UNIT: Peri-operative nursing

CLASS: KECHN, ( YR 2, SEM 1)

LECTURER: Njeri Karienye

Objectives

By the end of this unit learner should be able to:

 Describe the historical background of theatre nursing
 Explain the legal requirements to be met by an operating theatre
 Describe the general layout of the operating theatre
 Describe the instruments used in a theatre
 Describe the methods of ensuring safety and infection prevention in the theatre
 Position patients on the theatre table for various surgeries
 Manage common anaesthetic emergencies
 Explain the Roles and functions of the theatre Nurse in the care of a patient while in
theatre
Introduction

 Staff in operating theatres is made up of multi-professional teams including surgeons,

anaesthetists, junior doctors, perioperative nurses, operating department practitioners
(ODPs) and perioperative support workers (PSWs).

 Perioperative nurses provide skilled care and support for patients undergoing either
major, intermediate and/or minor surgical procedures.

 Perioperative care encompasses all perioperative specialist areas, which include

surgery, anaesthetics and the Post Anaesthetics Care Unit (PACU), often referred to
as recovery.

 The fundamental role of a perioperative nurse is to:

 assess

 plan
 deliver high quality, safe and effective care as part of the multi-disciplinary
team.

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  The perioperative nurse must:

 be technologically able
 work effectively within a multidisciplinary team
 have good decision making abilities
 be compassionate
 be empathetic to deal with patients at their most vulnerable.
 One of the core roles of a perioperative nurse, working together with the
multidisciplinary team is to ensure patient safety and depending on which
perioperative speciality they work in, they will be responsible for a variety of
elements of care, including the management of specialist equipment, devices and
drugs.
 There are several drivers for standardising training and education in the perioperative
environment.
 ‘Surgery is an inherently risky process and surgical systems are highly complex’
(NHS England, 2015a; 2014:4).
 There is universal agreement on the need to protect patients from harm and therefore
it is essential that all registered perioperative nurses have met a minimum standard of
education for safe practice. A good example is setting up the taskforce following
the never events policy framework that concluded ‘that to achieve a continual
reduction in harm, they must reduce variation in practice, promote learning from
our mistakes and inform improvement activities, and continue to promote
organisational and professional responsibility’. It also proposed a strategy of three
interlocking elements namely:
 Standardisation of generic operating department procedures
 Systematic education and training for operating theatre environments
 Harmonising activity to support a safer environment for patients ((NHS England,
2014:4)
History of theatre nursing

 Theatre nursing has developed alongside the history of surgery

 Surgery is an old form of treatment that can be traced back through the history of
man.

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 In the past, there were no theatres, no trained personnel, no anaesthesia and no
equipment.
 Operations were performed at home.
 Problems during this time included infection, bleeding and pain. However, with time,
efforts were made to solve these problems.
 E.g, in 17 B.C, alcohol and opium were used to relieve pain by Napoleon who
performed an amputation while the patient slept for 24 hours.
 By 1772, Joseph Priestly discovered the use of nitrous oxide as anaesthesia
 In 1842, Dr Crawford discovered the use of ether.
 In 1847 James Young began to use chloroform.
 In the 18th century a great breakthrough was made with the use of trilene,
thiopentone, clytopopaine and curare, which are muscle relaxants.
 By the end of 19th century, pain relief was an integral part of surgery.
 In order to control haemorrhaging, the ancient Greeks and Romans as far back as the
16th century BC, used strings as ligatures. Later on, during the Middle Ages, they
came up with the use of hot iron
 This idea has been developed into the use of cautery to control bleeding.
 By the beginning of the 20th century, many types of ligatures were available,
prepared from metal, nylon and cotton.
 The control of infection dates back to the efforts of Louis Pasteur, who proved that
bacteria caused infections.
 In 1865, Joseph Lister used carbonic acid to reduce the growth of bacteria in wounds.
 In 1886 Von Bergemen introduced sterilisation of dressings.
 Gloves were introduced in surgery in 1890.
 Theatre nursing is as old as nursing
 A theatre nurse is a member of a bigger team, all of whom work together to provide a
safe passage through the operating theatre for every patient.
 Theatre team includes ( the nurse, anaesthetist, surgeon, theatre assistant)
 However small or insignificant the task to be performed, the theatre nurse is
responsible for the success of the procedure
 They must, therefore, be highly skilled and trained, in order to be able to ensure a
successful outcome for the patient

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Aims of theatre/perioperative nursing

 To prepare conscientiously by study to adapt to the changing world of medicine

 To allay the fears of the patient
 To integrate the patient care during their period in theatre
 To become highly skilled in theatre techniques
 To be able to impart knowledge to others

Preoperative evaluation

 Complete history and Proper documentation; ie menstrual , reproductive ,

sexual ,allergies ,chronic conditions etc
 Clinical examination-general head to toe, vital signs, weight, height and systems
review.
 Investigations, Full Haemogram, Urea and electrolyte ,LFT’S, Blood cross-
match ,RBS,etc.
 You should make sure that the surgeon explains clearly to the patient what will
happen to them.
 The surgeon should obtain an informed consent from the patient or
parent/guardian/next of kin for those under age 18 in Kenya or not in a position to
sign (e.g. unconscious person, mentally ill ).
 The nurse ensures that the patient has signed an informed consent, after the surgeon
has explained the advantages and outcomes of the operation.
 Make sure that the patient observes a ‘Nil by oral’ rule.
 The fasting should usually start six hours before the operation.
 Blood works: All should be within the acceptable ranges e.g. full Haemogram
including HB, urea, electrolytes and creatinine.
 The patient should be counselled and reassured especially those receiving operations
such as amputation, or mastectomy
 The site to be operated on should be shaved of hair and cleaned with warm soapy
water, to reduce the bacteria on the patients skin. The area shaved should be larger
than the incision site.
 Catheterisation and IV branula insertion may be necessary depending on the surgery.

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  Observations of vital signs, urine testing for sugars, proteins and acetone should be
done, some of the requirements form some of the legal aspects before surgery.
 Manage and treat/stabilize any pre- existing medical condition
 Give up smoking 6/52 or at least over 48 hours to reduce carboxyl haemoglobin
 Pre anaesthetic review
 Drug history

Preoperative counseling

 Patient has a right to know the extend and risks of any intended surgery,
 An outline of the immediate postoperative recovery

Surgery
This is a planned alteration of physiologic processes within the body in an attempt to arrest or
eliminate disease or illness

Purpose of surgery

 Diagnostic (Removing a tissue for testing in the lab. to determine whether cancerous
or not
 Curative (performed to remove e.g cancer from the body
- Ablative( e.g destruction of tissue that is allowing incorrect electrical signals hence
causing abnormal heart rhythm)
- Restorative ( used to follow-up to other surgeries to change/restore patient’s
appearance or of an organ/body part)
- Reconstructive( e.g restoration of normal function, appearance and deformity
correction)
 Palliative( help alleviate discomfort and minimise problems arising from the tumor
itself or CA treatment but not to cure)
 Debulking ( removing as much of the cancerous tumour as possible, then radiation
and chemotherapy follow for the remaining part. Done in situations when removing
the whole tumour may cause too much damage to the organ or surrounding areas)
Classifications of surgery

 Elective
 Urgent

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  Emergency
Variables affecting surgical outcome

 Age
 Nutrition
 Fluid balance
 Life-style habits
 Medical conditions
 Medication history
 Family history
 Prior surgical experiences
 Spiritual and/or cultural beliefs
 Anxiety and coping mechanisms
Core competency domains of perioperative nursing

Competence:

 The word competence means the proven ability to use knowledge, skills and personal
and/or methodological abilities.
The core competencies are based on the following 5 aspects:

Core domain 1: Professional, legal, ethical practice

General aim

 The perioperative nurse will analyse situations and events, understand and make
professional clinical judgment, uphold ethical practice, and maintain respect for the
patient. This competency requires knowledge of:

 Legislation
 Perioperative care
 Professional ethics
 Professional regulations
 Policies and guidelines
 Perioperative philosophy
 Concept of perioperative practice

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Core domain 2: Perioperative care and practice

General aim

 The perioperative nurse will provide quality care by the adoption of a holistic and
individual approach to the patient in accordance with relevant legislation, policies and
guidelines. This competency requires knowledge of:

 Philosophical and perioperative practice concepts

 Assessment, planning, implementation and evaluation of care
 Situational management in operating theatres for both routine procedures and clinical
emergencies
 General principles of perioperative practice
 Anatomy and physiology
 Pharmacology
 Surgical and anaesthetic techniques
 The preoperative process
 Principles of surgical care
 Principles of anaesthetic care
 Principles of Post-Anaesthetic Care
 Principles of hospital hygiene, asepsis and sterilisation
 Infection prevention and asepsis
 Environmental conditions of the perioperative area
 Pain management
 Physiological and behavioural responses to pain
 Assessment and management of a patient’s pain status
 Technology use in perioperative care
 Waste management strategies
 Risk management strategy
 Specific aspects of safety
Core domain 3: Interpersonal relationships and communication

General aim

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  The perioperative nurse will establish an efficient communication system with the
patient/family/significant others, the multidisciplinary team and other relevant
departments. This competency requires knowledge of:
 Communication technique
 Non-technical skills
 Human Factors
 Nurturing respectful relationships
 Psychological and communication skills
 Health education and promotion;
 Problem solving techniques;
 Communications and interpersonal skills
 Inter-professional pedagogy
 Professional behaviour and discipline
Core domain 4 : Organisational, management and leadership skills

General aim

 The perioperative nurse will lead and manage a group of equals and other
professionals, bearing in mind the subsystem, the organisations purposes, and the
results of the activity. This competency requires knowledge of:

 Principles of organisation
 Problem solving strategies
 Emotional intelligence
 Financial/budgetary implications
 Quality assurance auditing
 Materials management
 Personal and resource management
 Principles of organisation and management
 Inter-professional pedagogy
 Professional behaviour and discipline
 Stress and conflict management
Core domain 5 : Education, professional development and research

General aim

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  The perioperative nurse will further develop an enquiring mind regarding his/her
work and profession and have a working knowledge of research, to assist him/her in
building his/her professional portfolio, in order to personally develop and meet the
knowledge and skill requirements of a constantly evolving specialisation. This
competency requires knowledge of:

 Team work
 Self-learning
 Development and personal growth
 Theories on self-motivation and methods of self-respect
 Foundations/ principles of the perioperative practice
 Perioperative care approach within the operating theatre
 Applied research on perioperative care in the operating theatre
 The sources and places where information and documentation can be found
Peri-operative

 The perioperative period begins when the patient is informed of the need for surgery,
includes the surgical procedure and recovery and continues until the patient resumes
his/her usual activities .
 The term peri-operative is used to encompass 3 phases and the perioperative nurse
provides nursing care during all these 3 phases

Peri-operative phases

Peri-operative nursing has the following 3 phases:

i) Pre-operative
ii) Intra-operative
iii) Post-operative

Goal of peri-operative nursing

 To prepare the client mentally and physically for surgery and to assist in full recovery
in the shortest time possible with the least discomfort
1. Pre-operative phase
This begins when a decision is made to perform a surgical procedure and ends when the
client enters the operating room

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Nursing goals

 Assessing for risk factors

 Emotional support of client
 Client teaching
 Physical preparation of client

Pre-operative nursing assessment

History

 Age
 Medication
 Medical history
 Allergies
 Prior surgeries and outcomes
 Anaesthesia history / personal & familial
 Lifestyle habits e.g alcohol / smoking/ exercise
Common pre-operative nursing diagnosis

 Anxiety related to situational crisis, change in health status, fear of unknown, fear of
pain and/or disfigurement
 Knowledge deficit related to pre/post operative procedures
 Disturbed sleep related to anxiety about upcoming surgery
Pre-operative nursing interventions
a) Emotional Support

 Utilize positive communication techniques

E.g touch, eye contact , validating statements
 Active listening
 Encourage verbalization of fears/anxieties
 Avoid negative communication techniques
false-reassurance judgmental statements
b) Client teaching
i) Pulmonary exercises

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  Method for diaphragmatic breathing:
Hands on ribs, inhale through nose allowing abdomen to expand, hold 3-5 sec, exhale
through pursed lips, 10x/hr while awake
 ii) Leg exercises
Dorsi /Plantar flexion, ankle rotation, knee/hip flexion, 5x each leg/hr while awake
iii) Ambulation

 Discuss importance of early ambulation and method for getting out of bed
iv) Turning and positioning

 Use of side rails

v) Use of devices E.g External pneumatic compression devices (Sequential compression
device( SCDs). This is to increase blood flow through the veins of the legs hence prevent
blood clots which would lead to complication like DVT

2. Intra-operative phase
This begins when client arrives in surgical area and lasts until he/she is in the Post
Anaesthesia Care Unit (PACU)

Nursing goals
- Prevention of injury to client
- Maintenance/Promotion of: oxygenation, cardiac output, balanced input & output

The Intra-operative team

 Surgeon
 Surgical Assistants: surgeon, intern etc
 Anesthesiologist and/or Nurse Anesthetist
 Nurses: Circulating, Scrub
Intra-operative nursing diagnosis

 Risk for positioning injury

 Risk for fluid volume imbalance
 Risk for hyperthermia
 Potential for hypoventilation
 Risk for aspiration

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  Risk for impaired skin integrity
E.g “Pressure ulcers do occur in surgery”
3. Post-operative phase
This begins upon admission to the PACU and continues through entire recovery phase

Nursing goals

 Promoting physiological recovery of all body systems

 Prevention of complications
 Pain management
 Client teaching
 Emotional support
Focused Assessment in PACU

 Respiratory – patent airway, + O2 status (Most common PACU complication)

 CNS – monitor gradual return of function
 Surgical Incision site E.g bleeding, drainage
 Vital Signs – cardiac function, hypothalamus depression
 GI- nausea/vomiting common, aspiration risks
 GU- strict Intake and Output, check for retention
 Comfort – administer analgesia IV per prescription
Important factors in the care of the anesthetized c lient

 Use protective positioning techniques

 Handle gently
 Change positions slowly
 Keep client warm
Focused assessment for post-operative client upon arrival in Nursing Unit

 Vital Signs – compare against PACU data, take frequently until stable
 Respiratory status: auscultate, pulse oxygen
 Cardiac status: HR – peripheral pulses
 Level of consciousness
 Skin – surgical site and other areas
 Abdomen – listen for return of bowel sounds check for distension ( flatus , urine)

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  Tubes – IV, NG, Drains, Foley
 Comfort – Administer analgesics; check PACU record
Nursing diagnosis for post-operative clients

 Acute Pain
 Risk for Ineffective Tissue Perfusion related to hypovolemia, circulatory stasis
 Risk for Ineffective Breathing Pattern related to pain, effects of anesthesia/narcotics
 Risk for Infection related to invasive procedure, respiratory stasis
 Risk for Deficient Fluid Volume related to fluid losses during surgery
Post-operative nursing interventions

a) Prevention of complications
Respiratory:

 Assess for signs/symptoms of pneumonia, atelectasis, pulmonary embolus

 Encourage coughing & Deep Breathing and Incentive Spirometer (device that will
expand the lungs by helping to breathe more deeply and fully
 Position with Head of Bed elevated
 Encourage ambulation
Cardiovascular:

 Assess for signs and symptoms hemorrhage, shock, thrombophlebitis

 Encourage leg exercises and/or ambulation
 Position to promote venous return
b) Elimination
 Assess for s/s of constipation, urinary retention, ileus, UTI
 Encourage ambulation
 Maintain IV and/or PO fluid intake
 Provide privacy, proper positioning and other strategies to promote
elimination
c) Wound
 Assess for s/s of infection, dehiscence, evisceration
 Promote wound healing through careful aseptic handling
 Encourage balanced diet w/ sufficient protein, Vitamin C, Iron, Zinc
 Administer prescribed antibiotics

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 d) Comfort and Rest
 Pain management
 Keep linens clean and dry
 Provide for personal hygiene needs
 Keep environment quiet
e) Fluids and Nutrition
 Monitor Input & Output
 Provide good oral hygiene
 Ice chips / water sips
 Assess for return of peristalsis
 Assess for gag reflex
 Gradual diet progression – clear, full, soft
f) Emotional support
 Encourage expression of feelings
 Utilize positive communication techniques
g) Knowledge deficit
 Teach wound care, signs/symptoms infection, dietary recommendations,
activity restrictions, medication regime
Personal Protective Equipment (PPE)

Definition:

Is a device that is worn by a worker in order to prevent any part of his body from coming into
contact with hazards present at place of work

PPE

 Designed to protect employees from serious workplace injuries or illness resulting

from contact with chemical, radiological, physical, electrical, infective agents,
mechanical or other workplace hazards.

 Choice of PPEs should be guided by risk assessment and the extent of contact
anticipated with blood and body fluids, or pathogens

General principles when using PPE

 Perform hand hygiene before handling and putting on PPE

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  Immediately remove PPE after completing the procedure to avoid contaminating
other surfaces and areas
 Properly discard all single use PPE immediately after use
 Perform hand hygiene immediately after removing and discarding any item of PPE
Factors Influencing PPE Selection

 Type of exposure anticipated

 Splash/spray versus touch

 Category of isolation precautions

 Durability and appropriateness for the task

 Fit

Types of PPEs

i. Goggles
ii. Safety spectacles
iii. Respirators
iv. Safety shoes / boots
v. Gloves
vi. Aprons(plastic)
vii. Overalls
viii. Dust coats
ix. Head gear (helmets and caps)
x. Ear protectors or defenders (ear muffs and ear plugs)
xi. Face shields
Gloves

 Gloves shall be worn as an additional measure, not as substitute for hand washing.
 Gloves are not required for routine care activities in which contact is limited to a
patients intact skin
 Gloves shall not be worn while walking in the corridors

Main body protection

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  The main body is protected by use of overalls, dustcoats, gowns and aprons
 They protect the wearer’s home cloth against contamination by workplace hazards
 Launder reusable gowns after every use

Eye, nose and mouth protection

 Purpose of –

 masks: to cover nose and mouth

 eye wear: to protect eyes( e.g- face shields, goggles/mask with visor)
NB: DO NOT touch the front of the mask or eye wear when removing them

Face mask

 Cover the mouth and nose

 These provide some protection against air-borne pathogens and shield splashes
 During surgical procedures-dental procedures, conducting deliveries, endoscopies and
in other situations where splashing/ spattering is anticipated
Head gear/ Head cover

 Surgical caps (cotton made)

Shoe covers/boots

 Should be waterproof material

 Should be worn where applicable-heat resistance, corrosive chemicals

Key points about PPE

Don before contact with the patient, generally before entering the room

 Use carefully – don not spread contamination

 Remove and discard carefully, either at the doorway or immediately outside patient
room, remove respirator outside room
 Immediately perform hand hygiene
Sequence for Donning PPE

 Gown first
 Mask or respirator

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  Goggles or face shield
 Gloves
Sequence for Doffing PPE

 Gloves
 Face shield or goggles
 Gown
 Mask or respirator
How to remove gloves (first hand)

 Grasp outside edge near wrist

 Peel away from hand, turning glove inside-out
 Hold in opposite gloved hand
then, the second hand;

 Slide un-gloved finger under the wrist of the remaining glove

 Peel off from inside, creating a bag for both gloves
 Discard
Remove goggles or face shield

 Grasp ear or head pieces with un-gloved hands

 Lift away from face

 Place in designated receptacle for reprocessing or disposal
Removing isolation gown

 Unfasten ties
 Peel gown away from neck and shoulder
 Turn contaminated outside toward the inside
 Fold or roll into a bundle
Removing a mask

 Untie the bottom, then top tie

 Remove from face
 Discard
Limitation of PPE

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  They don’t remove the contaminants
 Protection given by PPE is limited(i.e efficacy and time factor must be considered)
 PPE often cause high extra physical load
 Sometimes it is difficult to get proper fit due to different anatomical features of the
wearer
 They may cause aesthetic problem
Theatre attire

 The purpose of theatre attire is to provide a barrier that protects the patient from
micro-organisms, which are shed into the environment from the skin and hair of
theatre personnel, and to protect the outside environment from theatre contaminants.

 All personnel entering restricted areas of the operating department wear

designated theatre attire, thus decreasing the potential for wound infections in
surgical patients.
 It is essential that all staff receive instruction as to the correct manner of
dressing within the operating department, including information about the
need for strict personal hygiene, good health and the implications of these to
patient care.

 Theatre attire is also a means of identifying theatre personnel.

 Theatre attire is designed to minimise the transfer of micro-organisms from the

mucous membranes, skin and hair of the surgical team to the patient.

 It also provides the surgical team with some protection from the patient.

 When selecting theatre clothing (reusable or single-use), it is important to consider the

quality of material in relation to the dissemination of airborne bacteria and bacterial
strike-through. All personnel who enter the restricted area of the theatre suite should
don the attire intended for use within the surgical environment.

 Sufficient supplies of theatre clothing should be provided daily and clean theatre
clothing should be protected from possible contamination during transfer and storage.

 Theatre attire should consist of a two-piece trouser suit. It should also be:

 made of a close-knit material with antistatic properties

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  resistant to bacterial strike-through
 flame resistant
 lint-free, as lint(tiny fibres of fabric that are shed from the edges of clothes)
can increase the number of airborne particulates
 coloured to reduce glare
 cool and comfortable with maximum skin covering
 professional in appearance
 Provided freshly laundered and in good condition
 Hands should be washed before and after donning theatre attire.

 Theatre attire should be removed when it becomes wet or soiled, and placed into
containers specially designed for contaminated laundry, to reduce the potential for
cross-contamination.

 Theatre attire should be changed following environmental cleaning of the operating

theatre and before the commencement of a new operating list.

Headwear

 All head and facial hair should be covered completely by a head cover/cap - surgical
site infections have been traced to organisms isolated from the hair and scalp.

 Disposable headwear is preferable, however cloth hats are permissible if laundered

and inspected for holes/imperfections in an approved facility.

 Headwear should be donned prior to donning the scrub suit.

 This eliminates the possibility of hair or dandruff being shed onto scrub clothing.

 Headwear should be changed daily, unless it becomes soiled, when it should be

changed immediately.

 Headwear should always be worn in laminar flow theatres during prosthetic implant
operations (ICNA 2002).

Jewellery

 Jewellery should be removed as it has been shown to increase surface bacterial

counts when left in situ.

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  Finger nails should be clean, short and free from nail varnish.

 Short nails are less likely to puncture gloves and therefore reduce the risk of harming
the patient through transfer.

 False finger nails, including acrylic or gel-coated nails should not be worn.

 These have been shown to harbour micro-organisms such as fungi and Gram-negative
bacteria even after hand washing; they can also inhibit hand washing (Hedderwick et
al 2000, McNeil et al 2000, NICE 2008).

Masks

 The rationale for wearing masks in a surgical setting is to contain the micro-
organisms expelled from the mouth and nose.

 They also protect the wearer from potential splashes of body fluids and blood.

 Masks may offer some protection from inhalation of surgical smoke and laser plume.
Filtration levels vary according to manufacturer’s specification and masks should be
selected according to the level of protection required, E.g exposure to mycobacterium
tuberculosis. The wearing of masks in theatre is questionable, except during prosthetic
implant operation (Hospital Infection Society 2002).

 Facilities should develop their own policies and guidelines in relation to the wearing
of masks.

 Protective face shields should be worn whenever activities could place personnel at
risk of splashes or aerosol contamination.

 Occasionally filtration masks may be required when dealing with certain patients such
as those with pulmonary tuberculosis .

 Masks should cover the nose and mouth, fitting the contour of the face and should be
tied securely. The user should avoid touching the mask once it is applied.

 A used mask should be handled by the tapes only.

 Used masks should be discarded into an appropriate container for disposal after each
case or if soiled.

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  Masks should not be left around the neck or put into pockets for future use. Hands
should be washed following mask removal.

Cover gowns/laboratory coats

 Ideally, all theatre personnel should change into outdoor clothing before leaving the
theatre environment; however AfPP recognises that this is not always feasible.
 If theatre personnel are required to leave the theatre environment without changing,
fully fastened and clean over jackets may be worn, as determined by the individual
practice setting. However, if this is accepted and authorised practice, then there must
be arrangements made to ensure that there is a sufficient supply of clean cover gowns
available.

 Theatre attire should be removed before leaving the theatre environment and placed
into an appropriate container.

 When leaving the clinical area, personnel should change into their outdoor clothes

NB:
 Fresh, clean attire should be donned on return to theatre

 .Used theatre attire should not be stored in lockers for further use.

 Theatre attire should not be worn outside the clinical area or in public places.

Footwear

 Footwear in theatres should provide adequate protection and a risk assessment should
be done to determine whether the type of footwear is suitable for decontamination.

 The purpose of such footwear is to provide antistatic properties in accordance with

WHO recommendations

 Footwear that is not supplied by the employer may not meet all the necessary
standards. Footwear should be well fitting, supportive and protective.

 Shoes should provide protection from spillages and accidentally dropped equipment.
Footwear worn in theatres should be for that use only and should be cleaned regularly
(using appropriate PPE) to remove any contaminants.

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  The use of washer-disinfectors or autoclaves is preferable for the decontamination of
footwear (ICNA 2002).

 Auto-clavable footwear should therefore be available to personnel. It is each

individual health

Laundering of theatre attire

 The home laundering of theatre attire is not recommended.

 The rationale for laundering in an approved hospital facility is to prevent soiled

clothing from spreading contaminants into the home environment and to ensure that
laundering of clothing is in accordance with relevant standards (DH 1995, AfPP
2011).

 Hospitals have approved laundry facilities or have contracts with laundry companies
in which laundry processes are monitored and assessed and laundry can be handled in
conjunction with standard precautions.

Take home message as PPE are concerned

In conclusion it is important to note that the material of PPE chosen must be able to withstand
the specific hazard prevailing in a specific workplace

Ethical/Legal aspects in Theatre Nursing

 ‘Legal’. The dictionary defines the word legal as 'required’ or 'permitted by law'.
 Therefore, when we talk of legal aspects in theatre nursing, we are referring to what the
law requires us to do in the theatre before, during and after the operation.

Important considerations

 Right to life/principle of justice

 Respect of autonomy-respect to ones opinion
 Principle of non- maleficence – do no harm (beneficence)

Common encountered legal issues

 Consent, Negligence, inadequate documentation, inexperience, clinical errors,

confidentiality, patients security.

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Consent:

Consent must be:

 Legally valid e.g. given by a person above 18 years, of sound mind and voluntary not
coerced
 Administered by a competent doctor
 Must be informed

1). Negligence:

 Clinician not providing adequate /reasonable information about risks of proposed

treatment.
 Inadequate documentation: improper and incomplete notes, lack of documentation.
 Inexperience /inadequate experience/lack of experience: No clinician is an expert of
everything, clinician should seek appropriate guide,/supervision and refuse to proceed.
 Clinical errors (not negligence) clinician need to be honest and apologetic for their
mistakes ,this is not admitting negligence. Patients accept apologies but not explanations.

2). Confidentiality: This is another legal requirement.

 In the definition of legal, the term ‘permitted by law’ implies that you can only carry out
patient care within what the law permits you to do.
 Therefore, the law gives the patient seeking medical, surgical and nursing care, rights
under which they are to be managed.

3). Security/Safety of the patient before, during and after operation is vested in the theatre
team. By signing the consent form, the patient takes some responsibility for the whole loss of
life or part of their body. However, this does not take away the responsibility of the theatre
team to ensure the security of the patient's life during the operation.

4). Consent: It is on this basis that those below the legal age of adulthood (18 years in
Kenya) are not legally bound to sign the consent form.

 It is signed by the parents/guardians on their behalf. In the same way, consent for the
mentally ill is sought from their parents/guardians/relatives.

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 It is also important to note that consent for an operation should be obtained from the
patient before they are pre-medicated, as pre-medication drugs have the potential of
affecting their reasoning capacity, hence making consent signed not legally binding.
 The legal aspect in theatre nursing involves the care of the patient from the time the
patient is accepted in theatre, until they are handed over back to the ward.
 For these reasons, the following procedure should be adhered to:
 Any patient going to theatre must be properly prepared preoperatively.
 The patient must be well labelled (identification)
 The patient must sign an informed consent, obtained by the surgeon.
 The patient must be protected from any harm, falls or eventuality, during the stay
in theatre.
 Confidentiality must be observed regarding the patient.
 Measures must be taken to ensure that the patient taken to theatre is the right one
for the intended operation.
 The items to be used for the operation must be counted and recorded before and
after operation to prevent loss of swabs, tubes, blades, forceps, abdominal pacts
and any instrument used.
 Theatre nurses must know where the exits are, for use in case of an emergency.
 Sockets in theatre should be covered during scrubbing to prevent risk of
conducting currents. They should also be one meter or more above the floor level.
 All electrical machines must be checked to ascertain optimum function before use
on the patient.
 Documentation/record keeping in theatre

Ethical and legal aspects of peri-operative nursing

 Perioperative nurses often find ethical decisions difficult to make, but necessary when
caring for surgical patients in practice.
 Perioperative nurses need to be able to recognize ethical dilemmas and take
appropriate action as warranted.
 They are responsible for nursing decisions that are not only clinically and technically
sound but also morally appropriate and suitable for the specific problems of the
particular patient being treated. The technical or medical aspects of nursing practice
answer the question, “What can be done for the patient?”

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  The moral component involves the patient's wishes and answers the question, “What
ought to be done for the patient?”
 The code of ethics expresses the moral commitment to uphold the goals, values and
distinct ethical obligations of all nurses.

An ethical dilemma involves the need to choose from among two or more morally
acceptable options or between equally unacceptable courses of action, when one choice
prevents selection of the other.

NB: Nursing is practiced in a changing social context/world, so the code of ethics has
become a dynamic document.

The perioperative nursing code

 The code for perioperative nurses provide the framework in which perioperative
nurses can make ethical decisions.
 The code establishes a non-negotiable ethical standard for the nursing profession.
 It demonstrates accountability and responsibility to the public, other members of the
health care team and the profession overall.

BIOETHICAL PRINCIPLES

 The term ethical refers to reasons individuals have for the decisions they make about
how they ought to act.
 The term moral overlaps the term ethical , but it is more aligned with an individual's
personal beliefs and cultural values.
 Underlying nurses' ethical actions are the principles of bioethics, which have a great
deal of influence on perioperative nursing practices and these principles include the
following:
1. Autonomy
 That is an individual's self‐determination, which is the principle that encompasses
respect for others and allows individuals to make voluntary, uncoerced decisions
about life situations
2. Beneficence
 This is the principle of doing good, benefiting, or acting in the best interests of the
patient , health care providers should strive to do this for their patients

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3. Non-maleficence
 This is the principle that directs health care providers to do no harm, it is often
not enough to do good for a patient, but non-maleficence t must be considered
proportionally when heath care decisions are being made
4. Justice
 This is the principle that states individuals should be treated according to what is fair
or owed to them (i. e, patients expect to be treated fairly and to receive equal care
despite of the colour, social status, religion etc)
5. Confidentiality / fidelity
 The principle refers to the keeping of promises, as patients expect health care
providers will keep their promises to maintain the confidentiality and privacy of
patient information
6. Security/Safety
 This refers to the safety of the patient before, during and after operation is vested in
the theatre team. By signing the consent form, the patient takes some responsibility
for the whole loss of life or part of their body. However, this does not take away the
responsibility of the theatre team to ensure the security of the patient's life during
the operation.
7. Truthful/ veracity
 This is the principle of truth telling, patients expect health care providers to be
truthful about their care
 Veracity is defined as being honest and telling the truth and is related to the
principle of autonomy. It is the basis of the trust relationship established between a
patient and a health care provider. This allows patients to use their autonomy to
make decisions in their own best interest.
8. Medical negligence :
 In general, negligence involves a person's failure to exercise care in a way that a
reasonable person would have done/exercised care in a/under similar
situation/circumstance.
 Medical negligence applies when a medical provider makes a “mistake” in
treating patient and that mistake results in harm to the patient
9. Medical malpractice:

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  Malpractice is a type of negligence that specifically relates to licensed
professionals who fail to provide services that meet the required standard of care
 It also mean the breach of the duty of care by a medical provider or medical
facility).
10. Consent:
 It is on this basis that those below the legal age of adulthood (18 years in Kenya)
are not legally bound to sign the consent form.
 It is signed by the parents/guardians on their behalf. In the same way, consent for
the mentally ill is sought from their parents/guardians/relatives.
 It is also important to note that consent for an operation should be obtained from
the patient before they are pre-medicated, as pre-medication drugs have the
potential of affecting their reasoning capacity, hence making consent signed not
legally binding.

These principles often come into conflict with the values of those involved in ethical decision
making. It may be difficult for patients, nurses, and other health care providers to prioritize
between principles because the context of each situation may vary.

Code of Ethics for Nurses with interpretive statements

Respect for people

 The nurse, in all professional relationships, practices with compassion and respect for
the inherent dignity, worth and uniqueness of every individual, unrestricted by
considerations of social or economic status, personal attributes, or the nature of health
problems .
 This provision clarifies that perioperative nurses should have respect for human
dignity, especially in the context of their relationships with patients and taking into
account the nature of patients' health problems.
 Nurses also should respect human dignity in their relationships with their colleagues
and others in the health care setting. This provision also addresses the right of patients
and nurses to self‐determination. In terms of behavior, the overall concept expressed
is respect for people.

Supporting patient rights and choices

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 Perioperative nurses are obligated morally to respect the dignity and worth of
individual patients.
 Perioperative nursing care must be provided in a manner that preserves and protects
patient autonomy and human rights. Nurses have an obligation to be knowledgeable
about the moral and legal rights of their patients and to protect and support those
rights. Health care does not occur in a vacuum, so perioperative nurses must take into
account both individual rights and interdependence in decision making.
 By doing so, nurses can recognize situations in which individual rights to self‐
determination in health care temporarily should be overridden to preserve the life of
the human community. E.g, during a bioterrorism attack, victims infected with
transmissible organisms (E. g, small pox) require infection control measures to
prevent transmission to others. These infection control measures may require
isolation, resulting in restricting a patient's right to freedom of movement to protect
others.
 Perioperative nurses preserve and protect their patients' autonomy, dignity, and
human rights with specific nursing interventions, including supporting a patient's
participation in decision making, confirming informed consent and implementing
facility advance directive policies.
 Perioperative nurses explain procedures and the operating room environment before
initiating actions and they respect patients' wishes in regard to advance directives and
end‐of‐life choices.
 Perioperative nurses help patients make choices within their scope of care as
applicable. They also provide patients with honest and accurate answers to their
questions, especially related to perioperative teaching, and formulate ethical decisions
with help from available resources (eg, ethics committee, counselors, ethicists).
 Patients have the right to self‐determination (ie, the ability to decide for oneself what
course of action will be taken in various circumstances). The nurse, as a moral agent
for the patient, must be ready and able to advocate for the patient's rights and needs
whenever necessary while providing care.
 Assuming such a stance involves acting on ethical principles and values. Nurses must
be prepared to identify advocacy issues and take action on them as needed. The nurse‐
patient relationship not only allows the nurse to support the patient, but it also
supports the nurse.

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  Nurses can empower patients by providing opportunities for them to make
autonomous decisions about their health care. They can support patient empowerment
through education about appropriate administrative protocols (eg, patients' rights,
hospital policies, procedures) that best meet individual patient's needs.
 When dealing with informed consent, the nurse's role is to validate that the patient has
been given the information and understands as much as is possible about the surgical
intervention. The nurse's assessment includes determining whether the patient has any
additional questions that might require another discussion with the physician. The
nurse also assesses the level of decision making the patient is able to demonstrate.
 The principle of autonomy provides for patients to make decisions freely, even if
those decisions are against medical advice.
 The criterion that must be met is that the patient is an adult who is capable of making
decisions and has been given the information necessary to make an autonomous
choice.
 Even if a surgeon and nurse believe that surgery is in the best interest of the patient,
the patient has the right to refuse the procedure at any time, regardless of whether he
or she signed a surgical consent form.
 Nurses ethically should support patients in their choices, regardless of whether they
agree with the patient's decision.
 Nursing assessment and care also applies to situations in which patients identify
advance directive choices or decisions related to do‐not‐resuscitate orders.
 It is the nurse's role to ensure that surgical team members are aware of a patient's
wishes in these matters. It is important that all team members and the patient discuss
and identify a plan of care before beginning the surgical procedure.

Respect for others

 Not only must nurses recognize the individuality of their patients, they also must
recognize the individuality of their colleagues and others.
 Nurses must be able to interact with a variety of other professionals and ancillary
providers in the perioperative environment. Treating others with professionalism and
respect enhances the performance of the health care team.

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  Perioperative nurses are obligated to treat all persons in a just and fair manner,
regardless of disability or economic, educational, cultural, religious, racial, age, and
lifestyle differences.
 Just as nurses have the right not to be abused or harassed in the workplace, so must
they treat others in the workplace with respect and compassion. The nurse recognizes
the contributions of each member of the health care team and collaborates to achieve
quality patient care.

Ethical dilemmas

 Perioperative nurses often are faced with an ethical dilemma when a patient is anxious
because he or she does not understand fully what is going to happen in surgery and
the nurse is being pressured for a fast turnover time.
 The nurse is faced with conflicting expectations (i.e, the patient's emotional needs,
expectations to be efficient). Nurses following the ethical principles of compassion
and respect would place a patient's emotional needs above expediting the surgical
schedule.
 In addition, there may be times when a perioperative nurse is told to get the patient's
signature on a consent form. Nurses must realize that they are not being asked to
provide informed consent for the patient. In cases such as these, the nurse merely is
acting as a witness to the identity of the patient and to the patient's signature on the
consent form.
 If a nurse is present at the time the patient signs the consent, it is a good opportunity
to once again assess the patient's level of understanding and see if he or she wishes to
further discuss the proposed intervention with the physician.

Treating patients equally

 Perioperative nursing care should be provided in a non-prejudicial manner that

preserves and protects patient free will, choice, and human rights.
 When providing patient care, nurses must take into consideration a patient's values,
religious beliefs, and lifestyle choices.
 These choices and beliefs influence nursing practice to the extent that they represent
factors the nurse must understand, consider, and respect in tailoring care to personal
needs and maintaining an individual's self‐respect and dignity.

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  The nurse does not have to agree with or condone the choices and beliefs of the
patient,
but he or she should not allow any such disagreement to preclude appropriate patient
care.
 Perioperative nurses may need to plan for appropriate substitute nursing care if their
personal beliefs conflict with required care; this respects the patient's health care
decisions.
 The principle of justice dictates that all patients receive the same care regardless of
personal attributes. A wealthy patient should receive the same perioperative care as a
patient from a lower economic status.

Privacy and confidentiality are to be maintained too, regardless of the personal

characteristics of the patient.

 Perioperative nurses apply ethical principles by using standards of nursing practice

consistently to all patients regardless of disability or economic, educational, cultural,
religious, racial, age, or lifestyle differences.
 Ethical perioperative nursing behavior also is demonstrated by refraining from
making derogatory comments about patients, family members, significant others,
colleagues, and other associates.

Age‐specific care

 As a part of respect for individuals, perioperative nurses must act ethically with regard
to age‐specific care and treatment. E.g sometimes it is difficult for nurses to
adequately assess pain in patients. As a result, they subjectively decide what is best
for the patient based on their depth of knowledge and individual assessment skills;
thus, some nurses may be more aggressive than others when managing pain.
 Nurses often use the principle of best interests, which allows them to act as most
reasonable people would act in similar circumstances. This principle is used most
often in cases in which patients cannot speak for themselves or cannot accurately
relate their feelings to the nurse, such as in the case of pediatric patients.
 It often is necessary to consult with a pediatric patient's parents when obtaining
assessment data. A nurse acting with the best interests of the patient in mind must
consider individual patient needs, parental preferences where applicable, and

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 professional standards of practice. In essence, the good of pain management has to be
balanced with the potential for harm to minimize or eliminate any harm that may
result.
 In this role, the nurse becomes the parental surrogate, advocating for the child,
assessing pain, and providing timely and effective relief. Understanding pain
management across the
 life span, therefore, becomes an integral part of the ethical practice of nurses. With an
understanding of the ethical principles and responsibilities inherent to nursing
practice, perioperative nurses will be able to more effectively manage preoperative,
intraoperative, and postoperative pain.

The changing face of culture

 Perioperative nurses provide nursing care directed to meet the comprehensive needs
of all patients, taking into consideration aspects of culture, language, perception of
pain, significant others, values, and beliefs. As individuals, nurses bring assumptions
from their own culture, as well as assumptions
 about the cultures of others, to their practice. To provide care that is relevant
culturally to a diverse patient population, it is vital that nurses recognize the
importance of being aware of and sensitive to the values, beliefs, and health practices
of different cultures.
 Culturally competent care has been defined as “a complex integration of knowledge,
attitudes, and skill that enhances cross‐cultural communication and appropriate and
effective interaction with others.” In many instances, nurses provide care across
cultures, so it becomes an ethical imperative for them to develop culturally competent
caring.
 To effectively care for patients from other cultures, nurses must be conscientious
observers and perceptive listeners and assessors. Acquiring information about a
patient's culture and gaining further personal insight provides nurses with an increased
understanding of culture and values as they relate to providing culturally competent
care from both the patient's and the nurse's perspective.
 Examples of this in perioperative practice occur when a nurse provides language
interpreters for spiritual comfort and care, regardless of the patient's health status.
Sometimes perioperative nurses can allow family members to be present at various

32
 times during the surgical experience to alleviate anxiety on the part of a patient from a
different culture.
 Sometimes all that is necessary is allowing a patient to bring an important cultural or
religious item (eg, a talisman, rosary) into surgery. The item often can be put in a
plastic bag so the patient still can have contact with it even as sterility is maintained in
the operating room.

CASE STUDY 1

A 44‐ year‐old woman, is brought into the operation theatre for a vaginal hysterectomy. She
speaks and understands english well and is in good health with no abnormal risks for the
procedure.

In the preoperative area, she tells the circulating nurse that she is very shy and concerned
about privacy issues, especially as related to her cultural beliefs. She would like as few
people as possible in the operation room during her surgery. The nurse assures her that all
efforts will be taken to ensure her privacy in surgery, but that there is a need for operation
room team members to be present.

As this patient is transferring to the operation room bed, the surgeon walks in with his 14‐
year‐old son, who is dressed appropriately for the surgical setting. The surgeon tells the
patient that it is take‐your‐ daughter/son‐to‐work week, and he has brought his son in to
see her surgical procedure. He asks the patient if it would be all right if his son were scrubbed
in at the field to observe her procedure. She stammers that she is uncertain about such
observers. The surgeon replies that it is only his son and he will be no trouble as he will just
stand by and watch. At this point, the patient appears unable to answer. She looks around the
room and locks her gaze onto the nurse's eyes.

The nurse, in this situation, needs to identify the ethical issues involved. The issues involve
patient autonomy, dignity, cultural beliefs and rights. To make an autonomous decision, a
person must have true freedom to refuse. If this freedom is eliminated, then consent is
meaningless. The patient in this case is being asked to consent to an additional observer in the
room. To ask a patient this immediately before she undergoes a procedure puts her in a
position of duress or coercion. The patient may not feel that she has a true choice or the
ability to refuse in such a situation.

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The nurse must help the surgeon identify that the patient feels uncomfortable with the
surgeon's son in the room and ask that he leaves. The patient on the other hand needs to feel
that her decision not to have the surgeon's son in the operation room will not in any way
prejudice her treatment from the surgeon or other members of the health care team. The team
members need to understand that certain cultures may value privacy and that this is an aspect
of human rights and dignity.

Additionally, the nurse must be aware of the element of risk that comes when any observer is
allowed into the perioperative environment. It is imperative for the safety of the patient and
the observer that any person coming into the operation room be trained appropriately in blood
and body fluid precautions and contamination.

In this case, some potential risks could occur. First, the surgeon's son may contaminate the
field and put the patient at risk and second, he may faint and injure himself or some else as he
falls. Thirdly, he also may become contaminated with blood or body fluids during the
procedure, because he is not trained in the proper protocols.

Most importantly, however, is the patient's right to refuse the observer. The patient should not
be put in such a last minute consent situation. Patients may feel compromised, coerced, or
violated by such a request.

Often patients are too worried about their procedures to even consider refusal as an option.
They do not want their surgeons to get angry with them for saying no.

In this example, the perioperative nurse should take immediate action to postpone the
anesthesia induction to explain the patient's concerns to the surgeon before proceeding. To
avoid a confrontation in front of the patient, the perioperative nurse should speak with the
surgeon privately.

The perioperative nurse and the surgeon then should reassure the patient that her wishes have
been honored and her privacy will be maintained throughout the procedure.

Conclusion

 The strength of the ethical perspective is its prescriptive nature. It promotes an action
guide for nurses to follow in the realm of patient care. Ethics, as a branch of
philosophy, incorporates multiple approaches to take when dealing with or applying
principles to real‐life situations.

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  Each perioperative nurse may experience a situation differently and also may address
the situation and identify the ethical conflict issues and his or her feelings, behaviors,
actions, analysis, and resolution of the situation differently.
 Health care delivery provided by a surgical team does not create ethical conflicts
necessarily, but it may highlight conflicts if the values of team members emphasize
different priorities.
 Additionally, new roles among health care team members may carry expectations
about how members should interact with each other and how standards of care should
be met.
 Perioperative nurses, by virtue of the nurse‐patient relationship, have obligations to
provide safe, professional, and ethical patient care.
 It is important that nurses know how to manage ethical decisions appropriately so
patients' ethical rights can be honored without compromising the nurse's own moral
conscience.
 Ethical practice, thus, is a critical aspect of nursing care and the development of
ethical competency is paramount for present and future nursing practice.

Theatre design considerations

The design depends on the following:

1. Number, type and length of the surgical procedure to be carried out.

2. Type and distribution of specialties of the surgical team and the equipment required by
each.
3. Staff, patients and other personnel safety during construction and renovation.
4. Equipment’s and surgical specialty
5. Scheduling policy
6. Volumes i.e patients and size of the hospital.
7. Planned technology.
8. Future plans expansion.
9. Systems and procedures for efficient patient, staff and supplies flow
10. Scheduling policies related to the number of hours per day and days per week the suit will
be in use.
11. Design , ventilation and control of pollution and traffic all need to be considered in the
design of the operating room.

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12. A proper design of the operating theatre allows a one way flow of traffic and prevents the
return flow of contaminants in to the clean area.
13. Operated patient should not meet with the un-operated patient

Separate areas allocated for use

 Anesthetic room
 Scrub area
 Sterile supply area
 Dirty utility area
 Sterilizing room
 Unsterile stock and heavy equipment area
 Plaster room
 Receiving area
 Recovery area
 Staff lounge
 Dark rooms for x-ray
 Changing room and cleaners room
 Laboratory
 Operating suite
 Clean corridors
 Separation between restricted and semi restricted areas

Theatre light

Fluorescent lighting

 This is best for general illumination, with provision for emergency back up (portable
light)
 In patients areas , white light is preferred as blue light will make the patient look
cyanosed

Over head light

 These should be shadow less and made of tungsten lamps and incandescent bulbs with
heat filters that act as reflectors to prevent over heating of patients and theatre staff.
 The lights should be dimmed and increased by turning a knob

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 The lights should have an autoclavable handle covers so that the surgeon can adjust the
position of the light on the operating site.
 The lights should be dimmed and increased by turning a knob
 The lights should have an autoclavable handle covers so that the surgeon can adjust the
position of the light on the operating site.

Size of theatre

 Theatres should be of equal sizes if possible.

 They should measure 20 by 20 by 10 ft. (L W H, or 400 sq.ft
 Larger rooms for complicated procedures like cardiac surgery

Wall and ceiling

 Walls and ceilings should be solid without windows

 Finishes of all surface material should be hard, non porous, fire resistant, waterproof,
stain proof, seamless, non reflective and easy to clean .

 The ceiling should be a minimum of 10 feet high and have seamless construction

 The ceiling colour should be white to reflect at least 90% of the light in even
dispersion.

 Walls should be pastel colour (soft, neutral e.g. baby blue) with paneling made of
hard vinyl materials that is easy to clean and maintain.

 The walls should have stainless cuffs at collision corner to prevent damage.

Floors

 The floor should be made of antistatic materials.

 It should be probably made of terrazzo or seamless polyvinyl chloride that is

continued up the sides of the wall for about six inches.

 The material should not degrade or wear out with aging and cleaning.

 They should be slip-proof when wet

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  It should be easy to clean by flooding or wet vacuum cleaning.

Doors and ventilation

 Doors:
1. Should be about 4ft wide

2. Sliding doors, that can be swung open when necessary

3. They should not remain open during surgical procedures

 Ventilation:

1. Air movement and air conditioning in the operating theatre are regulated so that
the patient and theatre staff are comfortable.

2. Air flow in the operating room is directed clean to less clean areas.

3. Relative humidity is maintained at between 50-55%

4. Heat and water loss can occur in small babies during prolonged operations in
cool air conditioning, hence humidity needs to be adjusted

Traffic flow

1. Unrestricted area:

 Personnel may wear street cloths, and traffic is not limited.

2. In semi-restricted area:

 Such as processing and storage areas for instruments and supplies, as well as
corridors leading to the restricted areas of the surgical suite, personnel must wear
surgical attire and patients must wear gowns and hair coverings

3. Restricted area:

 This includes operating room and clean core and scrub sink areas.
 Surgical attire and mask are required in these areas when there are open sterile
supplies or scrubbed persons in the area.

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 4. The flow of supplies should be from clean core area through the operating rooms to
the peripheral corridor.

5. Soiled materials should not re-enter the clean core area

Traffic patterns

In the restricted areas there are:

 Open sterile supplies

 Scrubbed personnel
 All personnel should wear masks and caps
 Sterile procedures

Semi restricted area:

 Personnel to wear scrubs/theatre attire, and caps

 Patients hair should be covered
 Only authorized personnel

Location

1). Theater should be located in an area accessible to the:

 Critical Care Unit

 Sterile Supplies Area
 Laboratory Department
 The Radiology Department

2). A terminal location is necessary to prevent un related traffic from passing through the
suite.

Members of the surgical team

 The surgeon

 Anaesthesiologist

 Nurse manager

 Receiving area nurse

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  Circulating nurse

 Scrub nurse

Some theatre equipment

 The operating table

 The operating lights
 The anaesthetic machines
 The anaesthetic cart
 Sterile instruments
 Electronic monitor
 The pulse oximeter machine
 Automated blood pressure machine
 An electrocautery machine (Diathermy machine)
 heart-lung machine
 Diagnostic imaging systems such as MRI and cardiac catheterization
 Instruments and patients trolleys
 Drip stands
 Laryngoscopes
 Suction machines
 Autoclave

Basic general instruments

 Cutting instrument’s- scalpel, scissors

 Holding instrument’s- dissecting forceps, sponge holding forceps, towel clips,
babcock’s tissue holding forceps, tissue forceps, kockers.
 Clamping instruments- artery forceps.
 Exposing instruments- Retractors.
 Suturing instruments- needle holders, suturing forceps toothed and non toothed
and ligature scissors.

Maintaining a sterile field/Principles of aseptic technique

 Placing sterile items within sterile field and only sterile items are used within
sterile field
 Opening, dispensing or transferring sterile items without contaminating them.

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  Not allowing sterile personnel to reach across unsterile areas and touch unsterile
items
 Not allowing unsterile personnel to reach across the sterile field or to touch sterile
items.
 Whatever is sterile for one patient can only be used for that patient.
 You must pour sterile fluids from a point high enough to prevent accidental
touching of the receptacle, but this should not produce splashing.
 If there is any doubt about the sterility of an article or area, it is considered
unsterile
 Sterile objects become unsterile when touched by unsterile objects.
 Sterile items that are out of vision or below the waist level of the nurse are
considered unsterile.
 Sterile objects can become unsterile by prolong exposure to airborne
microorganisms.
 The edges of a sterile field are considered unsterile.
 Gowns of the surgical team are considered sterile in front from the chest to the
level of the sterile field. The sleeves are also considered sterile from 2 inches
above the elbow to the stockinette cup.
 Sterile drapes are used to create a sterile field. Only the top surface of a draped
table is considered sterile. During draping of a table or patient, the sterile drape is
held well above the surface to be covered and is positioned from front to back.
 A tear or puncture of the drape permitting access to an unsterile surface
underneath renders the area unsterile. Such a drape must be replaced.

Safety and infection prevention in theatre

Safety and infection prevention are of utmost importance in the operating theatre. To ensure
this, some of the things considered are the following :

 Preparation of the operating theatre`

 Theatre nurse
 Patient and equipment
 The equipment used in theatre and types of anaesthesia
 Operating room

41
  Setting sterile trolley

Preparation of the operating room

1. The theatre and equipment must be cleaned thoroughly every morning to minimise
the number of micro-organisms.

2. Ensure high dusting of walls and clean trolleys, drip stand, operating tables and all
equipment there in.

3. You should also ensure that the floor is scrubbed with soapy water to remove dirt and
then mopped with a disinfectant recommended by the hospital.

4. After cleaning and drying the theatre floor, all the equipment must be returned to
its proper place and ensure they are working.

5. Prepare the operating table by drying it after cleaning and placing it in the right
position directly below the overhead operating lights. Theatre table should then be
draped with a clean sheet ready to receive the patient.

6. You should then set the anaesthetic tray ready

7. Check the diathermy machine to ensure it is in working order for use to cauterise any
bleeding vessel during operation.

8. The operating lights should be checked to ensure they are in good working order.

9. The required operating set of equipment should be ordered from the theatre sterilising
room/unit.

10. After the operation has been completed you should:

 Clean all fitments and equipment thoroughly

 Do high and low level dusting using the disinfectant
 Clean the floor and drains with the disinfectant
 Wipe the operating lights with a clean damp towel

Preparation of the Nurse

1. After entering the theatre unit, you should go straight to the changing rooms.

42
 2. Take a shower and change into your theatre suit and boots. Personal clothes should be
locked in a locker within the changing room.

3. Your head should be covered with a clean, sterile theatre cap.

4. If you have any respiratory infection you are advised not to enter the operating room.

5. A very high standard of personal hygiene should be maintained.

6. You should avoid movement in and out of the theatre and any time that happens you
should change into another clean theatre suit before re-entering the operating room.

7. It is advisable for you to visit the toilet to empty your bowels and bladder before
taking a shower and putting on the sterile theatre suit to minimise the need of using
this facility later during the theatre activities.

8. However, this is just a precautionary measure and you should change your theatre suit
any time the toilet facilities are used if you are to go back to the operating room.

Scrubbing

 This is done to remove micro-organisms from the forearm and arms by

mechanical washing and chemical disinfections before taking part in surgical
procedure.
 This helps prevent the possibility of the patient being contaminated by bacteria
from the hands and arms.

Preparation for this procedure involves the following:

1. The theatre suit should have the top/shirt tidily tucked in. Roll the sleeves up to at least
three inches above the elbow.

2. A cap should be worn to cover all the hair, tie the tape at the back.

3. A mask should be worn with the short side above the nose and the long side under the
chin.
4. Remove all jewellery, wedding rings, dress rings, watches, earrings and necklaces.
5. Finger nails must be short and clean without nail varnish.
6. No cut wounds or septic wound on fingers. No upper respiratory tract infection.
7. No gastroenteritis.

43
 8. Wear a mackintosh apron to protect your scrub suit. Regulate temperature and flow of
water to suit you.
9. Scrubbing time varies according to the type of soap or chemical used.
10. E.G if using gamophen soap, which contains hexachlorophene disinfectants, you
should scrub for five minutes; if using hibiscrub, two minutes; ordinary soap, ten to
fifteen minutes.

For the procedure refer to the nursing council procedure manual

Drying / gowning and gloving

1. Drying :

 Pick up the towel and step back.

 Start with the left hand and blot dry the fingers, the webs of the hand and the palm
well, then move to the back of the hand, and the forearm, using a circular
movement to the elbows.

 Change the towel to the left hand with the wet part against the left palm. Using the
dry part of the towel, repeat the same procedure on the other arm.

 When you get to the elbow, discard the used towel in the dispenser provided.

2. Gowning

The following procedure should be followed when gowning:

1. Pick a gown and step back.

2. Hold the neck-band and let the bottom hem drop.

3. Open the gown and slide both hands in through the arm holes.

4. Do not touch the outside of the gown with your bare hands.

5. The Runner Nurse will first tie the neck and shoulder bands then wastbands without
touching the gown.

3. Gloving
The following procedure should be adhered to:
1. Arrange gloves on the trolley with glove finger portion away from you.

44
 2. Pick the glove with left hand holding at the folded part and slip in your right hand.
Fold the tip of the sleeve on right hand and pass the glove over.
3. Using the gloved hand slip your fingers beneath the folded area of the remaining
glove and slip in the left hand into the glove.
4. Unroll the cuff of the glove covering the cuff of the sleeve.
5. Do the same for the opposite hand using the same technique.
6. Ensure you do not contaminate any area that will come in contact with the sterile
field.

Patients preparation

 Skin preparation depends on the area being operated.

 Preparation of the skin includes vigorous sponging of the skin with a sponge soaked
in strong disinfectant held in a sponge
holding forceps.

 Disinfectants used include centrimide and hibitine in spirit, After sponging, the
area is swabbed once with iodine in spirit or hibitine 5% in 70% alcohol.

After skin preparation the patient is draped:

 The purpose of draping is to maintain an adequate sterile field for the surgical
procedure.

 The scrub nurse gives the surgeon the sterile towel to cover the area above the
operation site and below and the sides.

 After draping, the scrub nurse brings the operation trolley and instrument trolley
next to the table.

Setting up a Sterile Trolley

 Done by a theatre nurse after scrubbing, putting on the required operating room attire

 The runner nurse/circulating nurse assists the scrub nurse in setting up the trolley e.g.
opening the green towels drum, sterile gloves

 Several trolleys and packs are required while setting the trolleys for specific
operations

 Instruments, , drapes ,extra instruments are arranged according to the order of use

 Counts must be maintained

45
  When the trolley is fully set it should be covered with sterile towel till the operation
starts

 Extra materials e.g. consumables may be added according to the need by the
circulating nurse

Positioning patient in Theatre

 Positioning is done by the other team members who have not scrubbed up and
worn sterile gowns and gloves.
 Patients are positioned before the skin preparation and draping described
previously.

Goals of proper positioning

1. To maintain patients airway and avoid constriction or pressure on the chest

cavity

2. To maintain circulation

3. To prevent nerve damage

4. To prevent bed sores

5. To provide comfort and safety to the patient during the operation.

6. To allow the procedure to be done on the patient

46
NB: The nurse must be aware of the anatomic and physiological changes associated with
patient positioning, and any procedure being done.

2. Reverse trendelenburg
 The entire bed is tilted so the head is higher than the feet.
 Used for head and neck procedures.
 Facilitates exposure, aids in breathing and decrease blood supply to the area.

47
48
49
Sutures and Ligature

 A suture is a medical device used to hold skin, internal organs, blood vessels or other
tissues of a human body together after they have been severed by injury or surgery
until healing takes place.

 A ligature is a suture used for tying blood vessels to a or another hollow organ to shut
it off.

Classification of sutures:

1. Absorbable they are broken down in the tissue after some time

2. Non Absorbable the body tissues cannot digest the material used thus they are
removable.

The above suture can further be classified as :

 Natural or synthetic

 Monofilament or multifilament

 Multi-stranded

50
Natural absorbable suture e.g. catgut

 Natural absorbable suture are defined by the loss of most of their tensile strength
within 6o days after placement
 They are of materials that are degraded by the body tissues
 Originally they were made from sheep’s intestines
 Gut sutures are made of specially prepared beef and gut intestines and packaged
in alcohol to prevent it from dying and breaking
 It is multifilament

Examples:

 Plain catgut – untreated

 Chromic catgut turned with chromium salts to increase their persistent in the
body

 Chromic catgut tensile strength 10-21 days

Synthetic absorbable suture

Examples are:

1. Polyglycolic acid (DEXON) synthetic multifilament

2. Polyglatin (VICRYL) synthetic multifilament

3. Polydioxanone

4. Poliglecaprone Monocryl

5. Polyconate (MAXOM )

6. Poly trimethylene carbonate suture synthetic monofilament

NB: Advantage to catgut is that it takes longer time in tissues than chromic catgut

Non absorbable sutures

 They are resistant to degradation by living tissue, i.e they are not affected by the
biological activities of the body tissues hence permanent unless removed

Uses:

51
 1. Skin or wound closure where the sutures can be removed after a period

2. Can be used In inner tissues in which absorbable sutures are not adequate e.g. heart
and blood vessels who rhythmic movements requires a suture which stays longer than
three weeks to give wound enough time to heal

NB: Non absorbable sutures can be permanently implanted in the body or can be removed
after few days of surgery depending on the kind of surgery

1. Natural non absorbable sutures

a) Stainless steel

b) Silk

c) Cotton

d) Linen

2. Synthetic non absorbable sutures

 Synthetic monofilament sutures are commonly used in cutaneous procedures and

include

1. Nylon

2. Polypropylene

3. Polyester

Characteristics of sutures

Main characteristics to be considered in the selection of suture material :

1. Tensile strength

2. Elasticity

3. Plasticity

4. memory

5. Ease of passage through tissue

52
 6. Knot security

7. Pull of tissue by suture

8. Short and long term reactions of tissue

9. Handling, ease of use of suture and packing property ensuring suture

getting out of package with minimum memory.

1. Elasticity:

 It is a term describing elongation of suture material by means of pulling method then

returning to its original length when left free, in short its flexibility.

 Elasticity is a preferred characteristic sutures. Because after implanting the suture to

the wound, suture is expected to keep two parts of scar together in suitable position by
elongating without stressing, cutting tissues due to edema developed in the scar and
then, upon retraction of wound after re-absorption of edema to return to original
length.

2. Plasticity:

 Plasticity is a term defined as the capacity of a suture to retain its length and
strength after stretching.

 Sutures with high plasticity do not hinder circulation on the tissue by elongating
without stressing or cutting tissues due to developing edema on the wound.

 However, elongated suture upon retraction of wound after re-absorption of edema

cannot ensure correct approximation of wound edges.

3. Memory:

 It is a term defining incapability of suture to change shape easily. Sutures with

strong memory tend to return their former, packing form when they are removed from
their packing, during and after manipulation. This is because of their rigidity.

 Sutures with strong memory is hard to manipulate and thread, at the same time they
have poor thread safety.

53
4. Friction Surface:

 It defines slipperiness of suture. Suture surface should be smooth and uniform.

However, very slippery and smooth sutures are not preferred due to their unsecure
knotting.

 Uneven surface of sutures is a desired characteristic for knot security.

 Disadvantages of these types of sutures (uneven sutures) are their leading trauma
while passing through tissue and to thrombosis by scratching vein surface. Such
disadvantages are tried to be eliminated by coating such sutures with materials such as
silicone.

 Multifilament sutures have larger friction surfaces compared to monofilament sutures

and they cause more trauma while passing through tissues.

5. Tensile Strength :

 It defines the force needed to break the suture. Tensile strength of suture reduces after
implantation.

 Tensile strength is related with the diameter of suture and tensile strength increases as
the diameter of suture increases.

 Weakest point of suture is knot. Therefore tensile strength of sutures are measured in
knotted condition. Knotted suture has 2/3 strength of unknotted suture. Each applied
knot reduces tensile strength of suture by 30-40% and causes to leave more foreign
substance on the tissue.

6. Capillarity:

 It defines wicking of fluids by the suture and transmission of fluid wicked throughout
the suture.

 Sutures with capillarity property carry the serum and bacteria in the region of
implantation they have absorbed throughout the suture. Generally, capillarity of
multifilament sutures are higher than monofilament ones.

54
  Sutures with capillary characteristic used on skin allow passage of microorganisms
between external medium and internal medium and lead contamination.

 Capillarity characteristics of sutures are minimized by coating with materials such as

silicone, Teflon or resin.
7. Pliability:

This refers to the ease of handling suture material. So it is the ability to adjust knot tension
and secure knots (related to suture material, filament types and diameter)

Factors impacting suture selection

1. Field of specialism

2. Clinical tissue regeneration experiences

3. Surgery experience

4. Knowledge gained on healing process of tissue

5. Knowledge on biological and physical characteristics of various suture materials

6. Patient factors (age, weight, general health status, existence of infection)

Usage characteristics:

 It defines usage quality comprehensively. It includes all physical characteristics of

suture such as handling, knot security, friction coefficient and memory.

Suture sizes

 Suture sizes are classified according to USA Pharmacopoeia (USP) and European
Pharmacopoeia (EP) which is also called as metric system.

 Suture sizes commonly classified according to USP. USP classification is made

according to diameter, tensile strength and knot security of the suture.

 12/0 – 7/0 = Microsurgery (smallest in diameter, weaker)

 6/0 = Face and Blood Vessels

 5/0= Face, neck and blood vessels

55
  4/0 = Mucosa, neck, hands, arms, legs, tendon, blood vessels,

 3/0 = arm, legs, body, intestine, blood vessel,

 2/0 = Body, fascia, stomach, internal organs, blood vessel

 0-1 = Abdominal wall, strong fascia surfaces. ( largest in diameter, Strongest

Surgical needle

 Needles are necessary for placement of suture material in the wound.

They should be:

1. Made of high quality stainless steel

2. As slim as possible without compromising strength

3. Sharp enough to penetrate tissue with no trauma

4. Be rigid enough to resist bending

5. Malleable (flexible) enough to bend before breaking.

Sterile and corrosion resistant to prevent introduction of microorganism or foreign bodies into
the wound

Needle construction

The needle has 3 sections:

 The point: this is the sharpest portion and used to penetrate the tissue.

 The body: this represents the mid portion of the needle.

 The swage: this is the thickest portion of the needle and the portion to which the
suture material is attached

Types of needles

 Round bodied needles, which are round and smooth, cause less damage and make a
puncture. They are used in delicate tissues and organs e.g. uterus , intestines, ( all the
internal organs)

56
  Atraumatic needles, which are either cutting or round bodied whose traumatising
chance is minimal. These needles have no eye. Suture and needles are made joined-
together.

 Cutting needles, which have a sharp edge, cut a crack as they pass, and are used on
strong tissues, for example, skin, tendon, muscles.

Swabs

 Swabs are resources/any porous material used in an open wound during surgery
for absorbing blood and fluids, protecting tissues, applying pressure or traction
and dissecting tissue dur ing a surgical intervention.
 A radio-opaque thread or marker is incorporated into commercially manufactured
swabs.
 There are different types of swabs:

1. Gauze swabs 3" X 3" (7.6 x 7.6) cm which are used for small.
incisions;

2. 4" x 4" (10 x 10) cm; raytec swabs or dissecting swabs.

Other type of swabs are:

3. Large abdominal swabs; with attached tapes

4. Small abdominal swabs; usually used in the bladder

5. Peanut swabs or lahey swabs; small round gauze sponges used for blunt dissections
or to absorb fluid in delicate procedures e.g. thyroidectomy

6. Large and small tonsil swabs which are cotton filled gauze with cotton thread
attached.

7. Neuro - patties made of compressed rayon of cotton, used moist on delicate structures
such as the brain or spinal cord

Care of swabs, instruments and needles

Prior to Sterilization

 Use clean, uncontaminated, new swabs.

57
  Check all swabs and shake well before folding and packing; no wool, threads or
pieces of lint should adhere to the swab.

 Swabs must be X-Ray opaque and abdominal swabs must have 25cm tapes.

 The first and second checker must do a simultaneous check.

 Each bundle must contain five swabs, abdominal, raytec and tonsil swabs are kept
together with tape or a rubber band.

 Point balls are sewn together and each bundle must contain a signed document.

Before the operation

The scrub nurse holds the bundle up and checks that each swab has a

 Secured tape and a opaque indicator.

 He/she checks each swab separately into a bowl while counting audibly and
must not count one bundle on top of another.

 The scrub nurse must count audibly with the circulating nurse.

If extra swabs are required during the operation, the same procedure is to be followed with
number added on, e.g. 5 + 5 + 5 or according to hospital policy

 Small dissecting swabs (laheys) are counted by holding one secure between fingers,
counting that one and then pointing with the finger to the remaining four which are
then placed in a gallipot.

 Ensure that each has an X-Ray opaque indicator.

 If any bundle of swabs opened is found to be incorrect, the swabs and document
must be removed from the theatre to prevent later confusion.

 The incorrect swabs must be given to the unit manager who must follow up this
occurrence.

 No opened swabs are to be allowed in theatre if they are not counted. Swabs may not
be used for cleaning theatres.
 Before closure of the cavity, an audible check is done of the remaining swabs on the
rack and those in use on the trolley and operating field.

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Rules for counting swabs intra-operative

 The rules for counting swabs in theatre is according to the scrub nurse's specific
preference, complying with at least the following:

 There should be a minimum of three (3) counts of swabs, though this is not fixed. If
the scrub nurse is doing a long difficult procedure using many swabs she can do five
to six counts.

 It is up to the individual but the first swab count must be done before:

 The peritoneum is closed, the next count is done before fascia is closed and
the last count before the skin is sutured.

 Lahey swabs are not removed from the trolley, but checked into a gallipot / receiver.

 It is important that the correct swab count is reported to the surgeon who must
acknowledge this.

Procedure for lost swabs

 If the count is incorrect, inform the surgeon and do a recount.

 The missing item must be looked for in the surgical cavity as well as in the theatre.

 In the event of the missing article not being found, the scrub nurse must inform the
registered nurse in charge. X-Rays, must be taken and if the article is seen, the
surgeon must re-open the cavity.

 If no article shows on X-Ray the surgeon records on the patient's file stating the
missing article does not show on X-Ray.

 The scrub nurse will endorse the facts about missing items in red on the operative
form and in the operation register.

 The scrub nurse and check (circulating) nurse must write a statement and hand it to
the nurse in charge.

59
  The original statements are photo copied to distribute to the following significant
supervisors; Chief Nursing Service Manager, Clinical Manager, Theatre Nursing
Service Manager, Scrub Nurse and Floor Nurse.

NB:

Surgical count/ Swab count policy:

 Surgical count is the manual process to count the materials used in the sterile field to
prevent retained surgical items in patients during surgery
 The overriding principle for the count is that all swabs, instruments and needles
MUST be accounted for at ALL times during an invasive surgical procedure or
vaginal birth to prevent foreign body retention and subsequent injury to the patient.

Role of nurses in the operating room

1. Receiving area nurse

2. Scrub nurse

3. Anesthetic nurse

4. Circulating nurse

5. Role of the PACU (post anaesthetic unit) nurse

Role of receiving area nurse

 Receive reports

 Ensure cleanliness-floor, wall, furniture

 Ensure availability of documentation charts preoperative check list, consent form

 Ensure resuscitation drugs are available and ready

 Avail screens for patients

 Ensure availability of patients trolley

 Ensure that all the theatre list are available

 Confirm about patients readiness for surgery

 Send for patient from the award

60
Role of a scrub nurse

1. Checks the following day’s theatre list and makes the necessary orders for sterile
packs and other surgical supplies.

2. Ensures that the patients are ready for the operation.

3. Prepares the theatre for the days operation by:

 ensuring that the theatre necessary supplies are available

 Ensuring that the theatre is clean

 Checking the machines are in working order

 Checking the operating light

4. Receives the patient at the receiving area and confirms the right patient is received

5. Confirms the operation site

6. Scrubs, gowns and gloves and sets up the sterile field

7. Checks the instruments for correctness, and working conditions

8. Counts instruments, swabs and sharps, audibly which are then recorded by the
circulating nurse

9. Receives all the other items that are to be used during the operation

10. Wheels the trolley to the operating room and positions self and trolleys creating a
sterile field

11. Maintains the sterile field and anticipates the needs of the surgical teem.

12. Maintain count of items used in the sterile field

13. Communicates with the surgical team members on the condition of the patient.

14. Receives specimen from the surgeon and hands them over to the circulating nurse.

15. Assists during the closure of the incision.

16. Remains sterile until the patient is out of the operating room

61
 17. Moves the trolley and hands over patient to the circulating nurse.

18. Checks patient for diathermy burns,

19. Clears theatre, hands over instruments, and other items used in the procedure to the
sluice room attendant.

20. Un gowns, ungloves, washes hands and signs name in the register

21. Ensures that patients notes are written

22. Follows patient to the recovery ward

Role of the anaesthetic nurse

1. To prepare the anaesthetic machine

2. Tests machine and avails other anaesthetic equipment’s:

 Laryngoscope,

 Magillss forcep and

 Endotracheal tubes

3. Avails all the necessary anaesthetic drugs

4. Ensures that the patient is ready at the receiving area

. Assist the anaesthetist during :

 wheeling patient to theatre

 Induction

 Maintenance

 Reversal

 Wheeling the patient to PACU

6. Participates during resuscitation

7. Assists in clearance of theatre and preparation for the next patient.

62
Role of the circulating nurse

1. Prepares theatre for the days operations together with the theatre nurse

2. Assist is assembling needed supplies

3. Admits patients to the operating room

4. Assists in positioning the patient

5. Assists during induction

6. Assist the surgical team during scrubbing

7. Performs catheterization and skin preparation

8. Assist during draping and connecting of machines

9. Maintains orderly in the operating room

10. Co ordinates the activities of the operating room, anticipating the needs of the surgical
team

11. Maintains records and supplies during the operation

12. Receives specimen and other body tissues from the scrub nurse and labels accordingly

13. Continuously monitors the aseptic technique and patients needs

14. Counts the swabs with the scrub nurse at intervals

15. Finalizes records and changing

16. Assist in applying tape on dressing

17. After surgery, removes drapes and puts them under the instruments trolley

18. Removes diathermy plate and checks area for burns

19. Assist in clearing the theatre after surgery

20. Assist in transfer of patient from the operating table, room to the recovery room

21. Disposes specimen and other body tissues accordingly

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 22. Assist in clearing theatre

23. Avails supplies for the next operation

24. Ensures that the next patient is ready and available

25. Reports to the charge nurse for the next assignment.

Role of the PACU nurse

1. Reports on duty

2. Changes from home clothes into theatre attires

3. Receives report from the night staff on machines, drugs, patients, records, incidences.

4. Ensure cleanliness of environment and equipment’s

5. Ensures all equipment’s , anaesthetic machines, suction machines, defibrillator, and

monitors are in good working conditions.

6. Ensures that the resuscitation trolley is complete

7. Arranges machines at their respective areas

8. Ensures that the anaesthetic drugs are available

9. Prepares all the relevant documents, charts and request forms.

10. Recieves the patient to PACU

11. Perform initial assessment for fitness to admit at PACU

12. Monitor vitals signs and consciousness levels

13. Administer analgesics

14. Handle any emergencies

15. ¼ hourly observations of vital signs

16. Maintain fluid and input and output

17. Document vital signs and any other relevant information

64
 18. While fully awake hand over patient to the ward nurse

19. Document time and patient state on exit.

Role of nurse manager

 Ensures that all staff have reported on duty

 Ensures that theatre is clean
 Ensures that all the machines are in good working order
 Ensures that all the necessary supplies are available
 Liaises with the overall in charge for smooth running of theatre
 Ensure that the patients are ready.
 Ensures all the surgical team members are ready
 Ensures that documentation is carried out.
 Performs all the activities aimed at promoting patient safety
 Maintains a conducive working environment among surgical team members.

Role of sluice room attendant

 Ensures cleanliness of the sluice room

 Ensures availability of cleaning materials

 Ensures availability of disinfectants and decontamination solutions

 Receives instruments from the scrub nurse

 decontaminates, cleans, dries the instrument and assembles them ready for
sterilization

 Hands over instruments to the sterilization staff

 Updates all the records in the sluice room

 Prepares other waste for disposal

Anaesthesia

 Anaesthesia ( Greek word meaning “ without sensation”)

65
  It is a state of temporary induced loss of sensation

 It may include, analgesia, paralysis, amnesia or unconsciousness

 A patient under the effects of anaesthetic drugs is refered to as being anaesthetized

Types of anaesthesia

1. Local anaesthesia: Used for minor procedures such as skin surgery and tooth
extraction. The person remains conscious (awake) but should not feel pain in the area
being worked on.

2. Regional anaesthesia: These are similar to local anaesthesia but cover a wider or
deeper part of the body by targeting specific nerves

Regional anesthesia is the use of local anesthetics to block sensations of pain from a large
area of the body, such as an arm or leg or the abdomen. Regional anesthesia allows a
procedure to be done on a region of the body without you being unconscious.

Major types of regional anesthesia include:

 Peripheral nerve blocks. A local anesthetic is injected near a specific nerve or

bundle of nerves to block sensations of pain from the area of the body supplied by the
nerve. Nerve blocks are most commonly used for surgery on the arms and hands, the
legs and feet, the groin, or the face.

 Epidural and spinal anesthesia. A local anesthetic is injected near the spinal cord
and major nerves that enter the spinal cord to block sensations of pain from an entire
region of the body, such as the lower abdomen, the hips, or the legs.

For regional anesthesia, the anesthetic is injected close to a nerve, a bundle of nerves, or the
spinal cord. Skill and experience are needed for the anesthesia specialist to inject the
anesthetic at the proper location, because the site of injection of the anesthetic has a
significant impact on its effect. Careful technique is needed to reduce the risk of rare
complications, such as infection or nerve damage.

The site of the injection also strongly affects how quickly the anesthetic is absorbed into the
rest of the body. People who receive regional anesthesia are carefully watched, because the
anesthetics used may affect the central nervous system, cardiovascular system, and

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respiratory system (airway and lungs). This is particularly important with spinal and epidural
anesthesia, because they may affect blood pressure, breathing, heartbeat, and other vital
functions.

Regional anesthesia may be given with other medicines that make you relaxed or sleepy
(sedatives) or relieve pain (analgesics). These other medicines are given through a vein
(intravenously, IV).

Regional anesthesia is most often used when the procedure:

 Is confined to a specific region of the body.

 Involves a large area of the body where injection of large amounts of an anesthetic
might cause side effects that affect the entire body.

 Does not require general anesthesia

3. Epidural anaesthesia: This is a regional anaesthetic delivered to the lower spine to

numb the lower half of the body. It is given through a tube that is left in place, so can
be topped up over a period of time if necessary. The drug is injected into epidural
space

4. Spinal anaesthesia like epidural, targets the nerves of the spine and is given as a
single dose used to numb the lower part of the body. The drug is injected into Dural
sac that contains CSF hence it gives direct immediate effects compared to Epidural

5. General anaesthethesia: This is used for major operations and when a patient needs
to be unconscious, also known as being anaesthetized.

Goals of anaesthesia

 Provide analgesia

 Reduce the level of anxiety and discomfort

 Control the autonomic nervous system

 Muscle relaxation appropriate for the type of operative procedure

Clinical manifestation of pain

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Autonomic

 Elevation of BP

 Increase in heart and pulse rate

 Rapid and irregular respiration

 Increase in perspiration

Skeletal muscle

 Increase in muscle tension or activity

Psychological

 Irritability , apprehension

 Increased anxiety , attention focused on pain

Local / regional anaesthesia

 Local anaesthesia induces analgesia in the region where it is administered, for

example, lignocaine, procaine hydrochloride, xylocaine and lidocaine.

 The local anaesthesia last for forty five minutes to three hours depending on the type
of anaesthesia used.

 It is given locally to the affected part of the body by one of the following methods:

 Infiltration, nerve block, field block, refrigeration analgesia, spinal analgesia, epidural
anaesthesia.

Local Anaesthesia Methods

1. Infiltration:
The drug is injected on and around (in various points of) the affected area.

2. Nerve Block:

 The nerve supplying of the affected area is infiltrated by the anaesthetic

drugs, inducing loss of sensation on the affected area supplied by that specific
nerve.

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 3. Field Block:

 Similar to nerve block but cover a larger area and may involve more than one
nerve.

Refrigeration Analgesia

It is administered by use of a vapouriser. Drugs used include: Ethyl chloride or Diethyl ether.

Spinal Anesthesia

Used for operations from the abdomen and below, e.g. caesarean section. A lumbar puncture
is done and the local anaesthesia introduced through the spine. The drug paralyses the area
below the puncture.

Epidural Anaesthesia

The drug is injected in the dura mater space of the spinal cord. Used for operations of the
abdomen and below.

General anaesthesia

 General anaesthesia causes the patient to lose consciousness, for example,

thiopentone, ketalar and halothane.

 Anaesthesia can be categorised into: pre-medication, preoperative and postoperative

procedures.

General anaesthesia Classification:

1. Parenteral e.g. propofol(Diprivan)

2. Inhalation e.g. sevoflurane, isoflurane, desflurane, halothane (among the first to be

invented but it is still in use in 3rd world countries)

Premedication

The following pre - medications should be adhered to prior to the operation:

 Atropine 0.6mg intramuscular (for adults) administered one hour before the
operation to reduce Respiratory Secretion (RS) and to prevent bradycardia; Children
should be given 0.3mg.

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  Pethidine 50 - 100mg intramuscular for adults, which has an analgesic effect on the
patient; and 25 - 50mg for children depending on age and weight.

 Diazepam can be given one night before to a very nervous patient. Effects of
amnesia, adjuvant for anaesthesia.

 Hyoscine 0.4mg for adults, which can also be given for pre-medication although it
has the potential side effect of amnesia. It is antispasmodic.

 Morphine 10 - 15mg intramuscular can also be used. Oral pre-medication is the best
for children and should be administered two hours before operation. Analgesic and
adjuvant for anaesthesia.

 Remember to make the patient observe nil by mouth for six hours prior to operation.

Induction agents

Volatile inhalation agents include:

a. Ether, which is highly inflammable in the presence of diathermy and irritates

the respiratory tract. On the other hand, it has the advantage of being cheap to
administer.

b. Halothane is very good as an induction agent but can cause halothane

hepatitis.

c. Trilene is not a very good induction agent but is a good maintenance

anaesthetic agent. Its side effects include tachypnoea and vomiting. However
it has a good analgesic effect postoperatively and it is cheap.

 A mixture of Oxygen and Nitrous Oxide and one of the volatile anaesthetic agents, is
the best way of maintaining anaesthesia.

Parenteral anesthetic agents

• Intravenous agents include barbiturates sodium thiopental (STP), which causes

sleep very quickly.

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 • Methohexitone can be used as an induction agent but cannot be used without
equipment for resuscitation and is contraindicated in epilepsy. These are mainly
sedative drugs thus they do not have any analgesic effect.

• Ketamine can be given IV or IM. It has an analgesic effect and can be used alone in
minor surgeries. Side effects include bad dreams and elevated blood pressure.
Ketamine is also used with diazepam. It is contraindicated in hypertension.

• Diprivan (propofol, the milk of anaesthesia) best for short procedures and
hypertensive patient and is contraindicated in shock.

Muscle relaxants

Muscle relaxants can be divided into categories;

1. Short acting (depolarising) relaxants include suxamethonium (scoline), which is

mainly used for intubation. Its main side effect is that it causes bradycardia.

2. Intermediate vecuronium and rohocuronium

3. Long acting (non-depolarising) relaxants include curare, flaxedil and

pancuronium. The action of these agents has to be reversed to revive the patient by
neostigmine atropine.

Analgesics

 Analgesics are used to relieve pain and include pethidine, sosagen, morphine and
fentanyl.

 The postoperative patient is given a drug for pain relief, for example, pethidine or
valium, and an anti-emetic for instance, plasil (metoclopropamide), stemetil or
phenergan.

Nursing care of the anaesthetized patient

 Patient is usually given e.g General Aneasthesia – a reversible state consisting of

complete loss of consciousness that provides analgesia, muscle relaxation and
sedation

 Protective reflexes are lost

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  Consists of 3 major phases, induction, maintenance, emergence, others phases are
the pre anaesthetic and recovery

Phases of Anaesthesia

1. Pre anaesthetic phase: This period start from the time decision of operation is made
up to the time of induction, history taking, physical examination, investigations are
done FBC, GXM, premedication counselling, observation of vital signs, the patient is
prepared for a safe operation

2. Induction phase: This is done in theatre it involves giving patient anaesthetic

medication as per the operation . Patient is give oxygen, parenteral or inhalation
anaesthetics, muscle relaxants and adjuvant anaesthetics.

3. Maintenance phase: This is done to prolong unconsciousness for the duration

required. this is the phase during the operation where by the patient remains
anaesthetized till the operation is over, drug used e.g. oxygen , nitrous oxide,
halothane, anaesthetics drugs like propofol, opioid such as morphine and sedative

4. Emergence / reversal: This is the period following completion of surgery and

anaesthesia is no longer needed and return to basic physiological functions of all
organ and systems, drug commonly used are 1.2mgs atropine mixed with
neostigmine in 1 syringe counteracts the effects of neuromuscular blocking agents
and oxygen. Atropine counteracts Muscarinic effects of neostigmine i.e. brandycardia
and hyper-secretions (parasymphathetic effect)

5. Recovery phase: This is the period after reversal when the patients regains
wakefulness, spontaneous respiration and mobility. Patients is on post operative
treatment other post operative management as per the patients condition

Nursing responsibilities - pre operatively (before surgery)

 Monitor blood loss ,urine output

 Obtaining fluids drugs and blood products as requested

 Sending blood specimen to the lab

 Identity and the relevant documents and charts and notes are validated

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  Check bedside rails, catheters, intravenous lines, check for drug allergies

 Position patient well,

 Apply padding to all pressure areas in cases of a long operation

 Maintain patent and clear airway-ensure adequate ventilation

 Continue physiological monitoring

Intra-operatively (during the operation)

 Depends on type of surgery ,type and amount of anesthesia

The circulating nurse:

 Transfer of patient to operating room table

 Positions the patient in the operating table
 Maintains functional alignment
 Exposure of surgical site
 Observe patient critically for effects of;
 Excessive fluid loss or gain ,watch for inflicted injuries
 Distinguishes normal from abnormal cardiopulmonary data
 Reports changes in patients vital signs
 Institutes measures to promote normothermia
 Management of bleeding ,reaction to anesthesia

Discharge of patient from PACU

Each facility may have an individual checklist or scoring guide to include:

 Stable vital signs

 Adequate urine output (at least 30mls/hour)
 Orientation to person , place and time
 Satisfactory response to commands
 Movement of extremities after regional anesthesia
 Control of pain –minimal/tolerable
 Control or absence of vomiting

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General principle in post operative care (after operation)

The general principles in postoperative care include:

 Ensuring clear airway

 Supporting circulation
 Controlling bleeding
 Preventing infection
 Monitoring any complications
 Controlling pain
 Ensuring return of gastro intestinal motility
 Ensuring early ambulation
 Preparing the patient for discharge and home-based care
1. Ensuring a clear air way:

 You should place the patient in recovery position (three-quarters prone,

or left-lateral).

 This allows secretions from the lungs and mouth to drain out.

 Suck the secretions using a suction machine if they are excessive.

2. Supporting circulation

 This is done in order to maintain the functions of the lungs, the heart
and the kidney.

 This is achieved through adequate blood volume.

 You should maintain the infusion running at the required rates.

 Monitor input and output

3. Controlling bleeding and wound care

 Monitor the wound for any signs of bleeding.

 Should this occur, apply a firm dressing and inform the surgeon.

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  After 24 hours, check for signs of infection, these include redness,
tenderness, oedema and low grade fever.

 If this occurs the sutures are removed to allow the pus to drain and the
wound cleaned three times a day with antiseptic lotion.

4. Preventing Infection

 Septicaemia is likely following an operation, due to peritonitis.

 Pneumonia may follow bed confinement.

 This is indicated by a rise in body temperature and should this occur,

you will need to administer antibiotic without delay.

 In some hospitals it is a common practice to cover the patient with

antibiotics following surgery, where septicaemia is likely.

. 5. Monitoring for complication:

 You should monitor pulse, blood pressure, and respiration rate and
body temperature until they are stable and within the normal ranges for
the age and sex of the patient.

 The recommended frequency is to observe the patient every 15 minutes

for the first two hours, followed by every 30 minutes for the next two
hours, then four hourly if they appear to be stable.

 Other important observations to make at the same time are level of

consciousness, and urine output.

6. Controlling Pain

 This is achieved by the administration of pain relief drugs once the

patient is conscious.

 You should administer an intermittent bolus of pethidine 50-100mg

intramuscularly or morphine 10-15mg for adult.

Other measures include correct positioning of the patient

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7. Ensuring return to normal gastrointestinal motility

 This is indicated by the return of bowel sounds and passing of flatus.

 Following abdominal surgery (laparotomy), gastro intestinal motility

returns to normal in three to four days.

 The patient should not take food orally before this period is over.

 The stomach is decompressed through nasal gastric tube suction. This

should be removed when the aspirate falls bellow 400mls per day.

 Should postoperative diarrhoea occur, reassure the patient, as this

clears in two to three days, but ensure adequate hydration.

 When bowel sounds are back give oral sips, fluid diet, light diet, then
resume normal diet.

Ensure return to normal gastro intestinal motility

 This is done by ensuring Early Ambulation

 Encourage the patient to move out of bed as soon as their condition allows.

 This will prevent deep venous thrombosis (the development of a blood clot in a
vein), which can complicate to pulmonary embolism (a circulating blood clot in
the veins of the lungs).

 The signs of thrombosis include, warm swollen painful limbs and low-grade
fever.

 If noticed, the affected limb should be elevated until the swelling subsides.
Heparin in a dose of 5000units, eight hourly, is administered subcutaneously when
the diagnosis is confirmed.

 The postoperative care should start from the recovery area of a theatre, and
continue in the postoperative ward where the patient is rehabilitated then
discharged.

8. Preparing patient for discharge and home based care

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  The postoperative patient needs to be made aware of the expected outcome of the
surgery as well as the medical and nursing care that they will require at home.

 This will reduce the possibility of last minute crises on the day of discharge.

 The patient should be given an opportunity to get ready to cope at home and in the
community as they ask you how to deal with a changed body image.

Record keeping in theatre

Record your work clearly, accurately and legibly

 Surgeons must ensure that accurate, comprehensive, legible and contemporaneous

records are maintained of all their interactions with patients.

In meeting the standards of Good Medical Practice you should:

 Be fully versed in the use of the electronic health record system used in your
organization and record clinical information in a way that can be shared with
colleagues and patients and reused safely in an electronic environment.

 Take part in the mandatory training on information governance offered by your

organization, including training on data protection and access to health records.

 Ensure that all medical records are accurate, clear, legible, comprehensive and
contemporaneous and have the patient’s identification details on them.

 Ensure that when members of the surgical team make case note entries these are
legibly signed and show the date, and, in cases where the clinical condition is
changing, the correct time.

 Ensure that a record is made of the name of the most senior surgeon seeing the
patient at each postoperative visit.

 Ensure that a record is made by a member of the surgical team of important events
and communications with the patient or supporter (for example, prognosis or potential
complication). Any change in the treatment plan should be recorded.

 Ensure that there are clear (preferably typed) operative notes for every procedure.

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  The notes should accompany the patient into recovery and to the ward and should
give sufficient detail to enable continuity of care by another doctor.

 Ensure that sufficiently detailed follow-up notes and discharge summaries are
completed to allow another doctor to assess the care of the patient at any time.

Patients records should include

 Date and time

 Type of procedure i.e Elective/emergency procedure
 Names of the operating surgeon and assistant
 Name of the theatre anaesthetists
 Name of the scrub nurse and circulating nurse
 Operative procedure carried out
 Incision type
 Operative diagnosis
 Operative findings
 Any problems/complications
 Any extra procedure performed and the reason why it was performed.
 Details of tissue removed, added or altered.
 Identification of any prosthesis used, including the serial numbers of prostheses
and other implanted materials
 Details of closure technique
 Anticipated blood loss
 Antibiotic prophylaxis (where applicable)
 DVT prophylaxis (where applicable)
 Detailed postoperative care instructions
 NAME AND SIGNATURE

Record keeping/supplies

 Sort to make best use of available space

 Set out on clearly labeled shelves
 Should be standardized for all store rooms
 Stocks should be regularly audited
 Should be matched to demand

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  Avoid unnecessary building up of large stocks

Common anaesthetic emergencies

 Cardiac arrest
 Anaphylactic shock
 Respiratory failure
 Asphyxia
 Hypothermia
 Hypovolemic shock

ASSIGNMENT

1. Describe the management of the following common anaesthetic emergencies

 Cardiac arrest
 Respiratory failure
 Anaphylactic shock
 Hypothermia
 Hypovolemic shock
 Asphyxia
2. Describe various complications of surgery
3. Describe how the operating team should scrub for a surgery

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