bader el safadi bsn, msc operating room nursing17 / 9/ 2013 skin preparation and draping of surgical...

Bader EL Safadi BSN , MSc Operating Room Nursing 17 / 9 /2013

Skin preparation and draping of surgical site

Basic preparation procedure for skin:

1. Expose only the skin area to be prepared.

2. Wear sterile gloves.

3. Place towels above and below to protect gloved hand

from touching the blanket.

4. Wet the sponge with antiseptic agent but squeezed out

5. Scrub the skin .

6. Discard the sponge after reaching the periphery


DrapingDraping is" The procedure of covering pt. and surrounding areas with a sterile barriers to create and maintain sterile field during operation."

1. Towels2. Laparotomy sheet 3. Stockinet4. Ortho pack sheet

types of Drapes:


Positioning/Surgical PositionsPosition and Explanation Illustration

1. Supine/Dorsal Recumbent In the supine position, the patient lies face up on the padded table with arms tucked in at

the sides (using the lift sheet), or extended on (padded) arm boards

Uses: Employed for procedures on the

face ,the neck, the abdomen, the upper

extremities and the lower extremities.

2. Trendelenburg's position The patient is on the back on a table or bed whose upper section is inclined 45 degrees so

that the head is lower than the rest of the body; the adjustable lower section of the

table or bed is bent so that the patient's legs and knees are flexed. There is support

to keep the patient from slipping.

Uses: Employed for abdominal hysterectomy

and other procedures in the pelvic area



3. Reverse Trendelenburg's

Supine position with the patient on a plane inclined with the

head higher than the rest of the body and appropriate safety

devices such as a footboard.

Uses: Employed for neck procedures as thyroidectomy, Para thyroidectomy, It is also used to perform laparoscopic procedures as cholecystectomy.

4. Fowler's position a position

In which the head of the patient's bed is raised 30 to 90 degrees

above the level, with the knees sometimes also elevated.

Uses: Employed for posterior craniotomy, selected shoulder, and ear, nose, and throat ,(ENT) procedures.



5. Lithotomy position

The patient lies on the back with the legs well separated, thighs

acutely flexed on the abdomen, and legs on thighs; stirrups

may be used to support the feet and legs.

Uses :Employed for low rectal resections, for some vaginal surgeries..

6. Sims’ (Semi-Prone) position

The patient lies on the left side with the left thigh slightly flexed

and the right thigh acutely flexed on the abdomen; the left

arm is behind the body with the body inclined forward, and

the right arm is positioned according to the patient's comfort.

See illustration. Called also lateral position

Uses : Employed for procedures requiring access to the vagina, anorectal, and perineum.



7. Prone Position

The patient lying face down with arms bent comfortably

at the elbow and padded with the arm boards

positioned forward.

Uses : Employed for anorectal procedures.

8. Lateral Kidney position

The patient is placed in the lateral position

and the iliac crest positioned over the “kidney”

elevator .The head is placed on a padded

donut, protecting the face and ear on the unaffected side

from undue pressure.

Uses : Employed for procedures on the upper urinary tract (e.g., kidney),and structures in the retroperitoneal space.



9. knee-chest position

The patient rests on the knees and chest with

head is turned to one side, arms extended

on the bed, and elbows flexed and resting

so that they partially bear the patient's

weight; the abdomen remains

unsupported, though a small pillow may

be placed under the chest.

Uses : Employed for rectal examination


Some considerations for OR staffs:A . General Important considerations 1. Persons in sterile attire touch only sterile articles.

2. Persons in sterile attire preparing a sterile field or draping an un-

sterile surface always face the area being prepared.

3. Persons in sterile attire do not turn their backs to a sterile field

4. Gloved hands are protected while draping by making a cuff with the drape.

5. Persons in sterile attire do not lean or reach over un-sterile surfaces

6.Persons in non-sterile attire only touch non-sterile

articles.

7. Persons in non-sterile attire avoid reaching over or touching the

sterile field when delivering sterile supplies to the sterile field.


Some considerations for OR staffs:

8. Tables draped with sterile drapes are sterile only at table level.

9. Scrub persons perform all work on the sterile surface of the table

10. Materials that hang over the edge of the sterile field are not

considered sterile and are discarded.

11. Items that fall below the level of the sterile field are not brought

back onto the sterile field.

12. The gown is considered sterile from the level of the umbilicus to the

axillary level in front.

13. Sleeves are considered sterile to two inches above the elbow.

14. The back of the gown is not considered sterile.


Some considerations for OR staffs:

15. Areas of the gown outside the specified boundaries do not touch the

sterile field or sterile articles.

16. Articles that drop below the umbilical level of the gown are discarded.

17. Hands are not placed under the arms in the axillary region.

18. The edges of containers enclosing sterile items are not considered

sterile once the container is opened.

19. Non sterile persons maintain a safe distance from sterile areas.

20. Corrective measures are to be instituted immediately if

contamination occurs. If there is any doubt as to the sterility of an

item or surface, it is considered contaminated.


C. Respiratory consideration

D.Circulatory considerations

E.peripheral nerves consideration:


Anesthesia concepts and considerations

Anesthesiology

Anesthesia

Branch of medicine that is concerned with the administration of medication or anesthetic agent to relieve pain and support physiological function during a surgical procedure.

Greek words means negative sensation.So it means “Loss of feeling or sensation” of pain with loss of protective reflexes.(Absence of sensation)


Analgesia Losing of pain sensation without producing loss of consciousness.

loss of memory.

Amnesia

Induction of anesthesia

Period from beginning of administration of anesthesia

agent until pt. loses consciousness.


BiotransformationMetabolism of anesthetic drugs by broken down in hepatic cells.

Individual tolerance for pain. Pain threshold

Endotracheal intubationInsertion of endotracheal tube.

LaryngospasmInvoluntary spasmodic reflexes action that partially or

completely closes the vocal cord.


Purposes of Pre anesthetic medication1) Decrease preoperative anxiety.

2) To produce some analgesia an amnesia .

3) Decrease secretions in the respiratory tract.

I . Anesthetic drugs made by anesthesiologist and

based on :1) Assessment of physical and emotional status.

2) Age, medical history , weight.

3) Lab test , X rays , ECG, smoking.


II. Classification of Pre anesthetic medication used:

1. Sedative and Tranquilizer :

To reduce anxiety, and produce amnesia to provide comfort.(Valium, Nembutal

2. Antiemetic :

To relieve nausea and vomiting Example : ( Pramine )

3. Narcotics:

To produce analgesia but depress respiration, and may lead to nausea,

vomiting and urinary retention.(Pethedine and Fentanyl

4. Anticholinergic :

To decrease mucus secretion and to relieve Bradycardia. (Atropine , Scopolamine)


III. Choice of anesthesia :• Factors to be considered by anesthesiologist • Some characteristics of an ideal anesthetic agent

1. Provides maximum safety for the patient

2. Provides optimal operating conditions for the surgeon

3. Provides patient comfort

4. Has a low index of toxicity

5. Provides potent, predictable analgesia extending into the postoperative period

6. Produces adequate muscle relaxation

7. Provides amnesia

8. Has a rapid onset and easy reversibility

9. Produces minimum side effects


Types Of Anesthesia1. General anesthesia :

. Pain is controlled by general insensibility with loss of consciousness.

The depth and duration of anesthesia depends on the type and

the amount of anesthetic employed of the agent(s) administered

3. Local or Regional block:

Pain is controlled without loss of consciousness

4. Spinal or Epidural anesthesia :

Sensation of pain is blocked at the level below the

diaphragm without loss of consciousness


General Anesthesia Anesthesia is produced as CNS is affected.

Unconsciousness is produced

Methods of administration general anesthesia:

1. IV injection:

a) Pre oxygenation : Ventilating the pt. by mask of 100 % oxygen for few

minutes

b) Loss of consciousness induced by IV administration of drug agent.

DRUGES USED :

1. Pentothal Sodium ( concentration 2.5% ) 5mg / kg short acting drug given for rapid

induction within 30 second.

2. Fentanyl :short acting drug to produce good analgesia.


Muscle Relaxant : drugs which given before intubation to relax jaw ,

larynx and body muscles.

1. pavlon --- long acting ( 30 -45 minutes ).

2. Scoline --- short acting ( 5 minutes. )

Performed after administration of general anesthesia.

It can however be performed in the awake patient with local or topical

anesthesia, or in an emergency without any anesthesia at all

Facilitated by using a conventional laryngoscope, or bronchoscope

Inhalation gases can be delivered from anesthetic machine through:

1) Face mask inhalation

2) Laryngeal mask inhalation

3) Endotracheal tub

2. Inhalation of anesthesia :


Advantages of ET tube:

1. Ensure patent airway and control of respiration.

2. Protects lungs from aspiration of blood, vomiting of gastric content.

3. Helps in minimizing scape of gas into room.

1. Trauma to teeth , larynx, vocal cord.

2. pulmonary aspiration of stomach contents

3. Hypoxia and hypoxemia intubation or extubation.

Complications of endotracheal tube :


Inhaled anesthetic agents:

1) Halothane : ( Fluothane)

1. Nonflammable

2. Produce rapid and smooth induction

3. Useful for pt. with bronchial asthma.

Advantages :

Disadvantages:

1. Cause hypotension and Bradycardia.

2. Potentially toxic to liver.

3. May cause hypothermia and limited abdominal muscle relaxation.



2) Enflorane : It is similar to halothane.

1. Rapid induction and recovery.

2. Muscle relaxant is produced.

Advantages :

Disadvantages:

1. Depression of BP and respiration.

2. Contraindication in renal failure.



3) Isoflurane:

1. Rapid induction and recovery.

2. More patent muscle relaxant.

3. Used for asthmatic pt.

Advantages :

Disadvantages:

1. Expensive

2. Respiratory depressant.



4) Nitrous oxide :

Rapid inhalation and elimination.

Advantages :

Disadvantages:

1. No muscle relaxant.

2. Hypoxia develop and should not use alone.

At the end of surgery:Muscle relaxant should be reversed by using Myostagmine combined with atropine to

manage Bradycardia which is caused by Myostagmine drug , and the ET tube should

be removed when the pt. is breathing spontaneously and semi or full awake.


Local , Regional Anesthesia 1.Local ( topical ) anesthesia :

o The anesthesiologist inject the drug to depress sensory nerves and

blocks conduction of pain impulses from their site and the pt. will

stay full awake.

o The duration of local anesthesia is 20 -30 minutes.

o Agents of local anesthesia could be : ointment , spray , or solution.

e.g. Lidocaine 0.5%–2%

o Local anesthesia is frequently used for lesser procedures,

e.g. Dentistry , Ophthalmic, and Anorectal procedures


Local , Regional Anesthesia 2. Regional Anesthesia o The drug is injected into or around a specific never or a group of

nerves to depress the entire pain sensation.

o There are many types of regional anesthesia that are performed

on the lower abdomen and lower extremities

A) Spinal Anesthesia

a) It is performed by anesthesiologist.

b) The drug is injected into or around a specific nerve or a group of nerves to

depress the entire pain sensation.

Note : The headache which caused by spinal anesthesia is caused by leaking through

the needle hole in Dura.


Local , Regional Anesthesia 2. Regional Anesthesia

B. Epidural anesthesia

a) The epidural space lie between Dura and vertebral column contain network of

blood vessels and spinal never roots.

b) The anesthetic is injected outside the spinal canal (no direct contact between

spinal fluid and anesthetic).

c) Agents of spinal , epidural and local anesthesia:

• Lidocaine 1.0%–2.0%/

• Tetracaine 0.5%–1.0%/

Note: In case of sever hypotension which caused by spinal anesthesia, Ephedrine is

the drug of choice.


Spinal and Epidural Anesthesia


Wound healing and methods of hemostasisTypes of wound:

Open wounds

1. Surgical Incision

2. Lacerations wounds

3. Abrasions wound

4. Avulsions wound

5. Ulceration wound

6. Puncture wound

Closed wound

Contusion wound


Mechanism of wound healing

Types of wound healing:

1) First intention :

Healing occurs directly, without formation of granulation tissue with Minimal scar

formation

2) Second intention :

Healing occurs with granulation tissue. Scar formation is excessive.

3) Third intention :

A deeper and wider Scar usually result.


Factors influencing wound healing:

1. Age

2. Weight

3. Nutritional status

4. Fluid and electrolyte imbalance

5. General health

6. Drug therapy

7. Post-operative complication.

8. Physical Activity


Hemostasis : Is the arrest of a flow of blood or hemorrhage.

The mechanism is coagulation (clot formation ) .

When there is incision or traumatic injury , a blood vessel

constricted and platelets rapidly clump and adhere to

connective tissue at the cut end of constricted vessel.

In some cases, blood disease, or operation on blood vessel.

They use anticoagulant agent as heparin to depress blood

prothrombin and tendency of blood platelets to cling together.


Hemostasis : Is the arrest of a flow of blood or hemorrhage.

1. Chemical Method.

A. Biological dressing :

It is covering an open surface defect of skin to, and promote the production of granulation.

The biological dressing is a graft and has the following types:

1. Auto graft : Skin grafted from one part of pt. body to another part.

2. Homograft : Skin taken from one person to another.

3. Heterograft : Skin grafted between two different species(e.g. an

animal )

B. Oxytocin: used to get uterine contraction after delivery to control bleeding.

C. Epinephrine ( Adrenaline ) : vasoconstriction which decrease bleeding.

D. Tannic acid : Is used on mucous membranes of the nose and throat.

Methods of hemostasis:


2. Mechanical methods 1. Bone wax : It is used to control bleeding from bone in some orthopedic

surgery

2. Drain : As prophylactically or therapeutic during operation to evacuate fluids.

3. NG tube : To measure blood loss during gastric surgery

4. Urinary drainage (Urethral catheter ).

5. Heamovac drain.

6. Chest tub.

7. Dressing over incision.

8. Hemostatic clamps

9. Ligature

10. Pressure

3. Thermal methods

Diathermy :


Wound Closure Material • Suture : Is a material used to bring tissue together.

• Ligature : Is a material tied around blood vessel to occlude lumen and

attached to needle.

• Free tie : Is a single strand material handed to surgeon or assistant to tie

blood vessel.

Suture Material Must :

1.Be sterile when placed in tissue.

2.Be predictably uniform in tensile strength

3.Be small in diameter and safe to use

4.Have knot security , remain tied.

5.Cause as a little foreign body tissue reaction.


Classification of suture material I. Absorbable suture :

Prepared form collagen or synthetic polymer they are absorbed or digested by

the body cells and tissue fluids .

II. Non absorbable suture :

Effectively resist enzymatic digestion or absorption in living tissue.

Subdivision of suture material:

A.Monofilament suture :

Consisting of single thread that is non-capillary.

B.Multifilament suture :

Made of more than one thread held together, it is considered capillary.


I) Absorbable suture : 1) Surgical Gut:

Types of Surgical Gut :

Collagen derived from the sub mucosa or serosa of beef intestine

Ranging from the heaviest size 3/0 to finest size 7/0

Digested by body enzymes and absorbed by tissue.

a) Plain Surgical Gut : Digested quickly in 5 -10 days and is completely digested by

60 days.

It is used to ligate small vessels and to suture subcutaneous fat.

It is available in size 3/0 through 6/0 .

It has natural yellowish color.


I) Absorbable suture : B. Chromic surgical gut

From the sub mucosa of sheep intestine or serosa of beef intestine

treated with chromium salts to delay the rate of wound

absorption.

Maintains strength for 10-14 days making it useful for mucosal

closures and absorbed completely within 120 days.

Rang size 3/0 to 7/0.

Reading the Suture Label

Company

Needle

SizeOrder Code

NameAlso:

LENGTH

NEEDLE SYMBOL

COLOR

Absorbable or Non


The rate of absorption is influenced by:

1. Type of tissue : The surgical gut absorbed much more rapidly in mucous

membrane, and absorbed slowly in subcutaneous fat.

2. Condition of tissue : Absorption takes place more rapidly in absence of

infection.

3. General health status of pt. : Surgical gut may be absorbed more

rapidly in well nourished tissue or healthy tissue, but in old pt. it may remain

for long time.

4. Type of surgical gut : Plain gut is untreated but chromic gut is treated

to provide greater resistance to absorption.


Handling characteristic of surgical gut and collagen suture:

1. Surgical gut and collagen suture are sealed in packets that contain

fluid to keep the material pliable, this fluid is alcohol and water,

hold packet over basin and open it carefully spilling fluid to your

eyes.

2. Surgical gut and collagen suture should be used immediately after

removal of their packets, you can put it into saline to soften it but

do not soak it.

3. Handle it as little as possible, never stretch it that weakens it

7 / 9 /2013Bader EL Safadi BSN , MSc Operating Room Nursing 43


2) Synthetic Absorbable polymers: Dyed or un dyed multifilament synthetic absorbable suture,

these sutures as absorbed by slow hydrolysis process in the

presence of tissue fluid.

a) VICRYLE®:

1. Absorbed rapidly within 90 days.

2. Multifilament braided, size range 2/0 through 7/0.

3. Monofilament, size rang 9/0 through 10-0 for ophthalmic

procedures.

Example


B. Monocryl®:

1. Monofilament maintaining 50-60% strength at 7 days with

complete absorption by 3 months.

2. It offers better handling and knot security than most other

monofilament sutures.

3. Less tissue reaction than Vicryl® and is therefore useful where

minimal tissue reaction is essential.


II. No absorbable suture

1. Surgical silk :

• An animal-product made from the fiber spume.

• Fiber are braided or twisted together to from Multifilament

suture.

• It is also dyed most commonly black, size range from 5/0

through 9/0.


Characteristics of silk suture:

Silk is not a true non-absorbable material, it loses much of it is tensile

strength after about 1 year and usually disappear after 2 or more years.

Silk suture are dry, they also lose tensile strength if wet, so do not

moisture before use.

If it is necessary to autoclave e silk suture, so at 121C for 15minutes,

but some of it is tensile strength is lost during sterilization.

It is used frequently in serosa of GI tract and to close fascia in the

absence of infection and it may be used in anastomosis of major vessels.


2. Synthetic non-absorbable polymers

a) Surgical nylon:

It is derived by chemical synthesis.

Inexpensive monofilament and has high tensile strength but lose it by

hydrolysis in tissue .

Has minimal tissue reactivity

Size range from 2/0 through 11/0.

It used to close skin and ophthalmology.

Disadvantages are its handling and knot security, but it remains one of

the most popular non-absorbable sutures in dermatological surgery.


B. Prolene®.

A monofilament polymer with a very low coefficient of friction

making it the suture of choice for running subcuticular stitches.

It has good plasticity but limited elasticity, poor knot security,

and it is relatively expensive.

Flavored by some for facial repairs


Factors that influence the choice of suture materials

1. Biologic characteristics of the suture material2. Healing characteristics of the tissue3. Location and length of the incision4. Presence or absence of contamination and/or

infection5. Patient problems such as obesity, debility,

advanced age and diseases6. Physical characteristics of the material such as ease

of passing through tissue, knot tying and other7. personal preference of the surgeon.

bader el safadi bsn, msc operating room nursing17 / 9/ 2013 skin preparation and draping of surgical...

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