nurses as members of the surgical team

8/13/2019 Nurses as Members of the Surgical Team

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NURSES AS MEMBERS OF THE SURGICAL TEAM

REYNALDO O. JOSON, M.D.


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PREFACE

This manual is intended for nurses who will be training and working in theoperating room.

I am a surgeon writing this manual for nurses. Over the years that I have beenworking in the various operating rooms in Metro Manila, I realized the need for a manualto be written by a surgeon for nurses who will be training and working in the operatingroom. This is so because since time immemorial, operating room nurses, have oftenbeen scolded, if not insulted, by the captain of the surgical team, who is none other thanthe surgeon. Why this prevalent scolding and insult My observations are ignorance onthe part of the nurses and idiosyncrasy on the part of the surgeons.

Ignorance on the part of the nurses.Many operating room nurses do not possessade!uate knowledge of the basic operating room techni!ue when they start participating

in operations. This ignorance is usually due to an inade!uacy of their training in theirundergraduate as well as postgraduate years. "ecause of this ignorance, they are oftentimes scolded by the surgeons in the operating room.

Idiosyncrasy on the part of the surgeons. #urses who are knowing of their rolesand functions in the operating room may still find themselves being scolded because oftheir inability to contend with or cope up with the idiosyncrasies of some surgeons. Theidiosyncrasies consist of personal peculiarities of surgeons in terms of their operatinghabit and behavior and in terms of their way of thinking especially as regards how theyshould be assisted by the nurses. More often than not, the nurses $ust strive to befamiliar with and to cope up with the idiosyncrasies of these surgeons in order to avoid

scolding.

I repeat I am a surgeon writing this manual for nurses. I am one among the manysurgeons who can scold operating room nurses, but only when this is necessary. I amwriting this manual not to insult the operating room nurses, but to help them becomebetter operating room nurses% to help them participate in an operation without having tobe scolded or insulted anymore by surgeons% to help them cope up with theidiosyncrasies of the surgeons% and most important of all, to help them stand up anddefend their rights and dignity as professional members of the surgical team.

This manual consists principally of three parts. The first part is the basicintroduction to an operation. This part consists of seven topics, namely% &' basicoperating room setup% (' aseptic and antiseptic techni!ue% )' basic surgical instruments%*' surgical needles and sutures% +' stitches and knots% ' e-posure and dissection% 'the operation and the surgeons.

The first part actually constitutes the manual which I wrote in &//+ with the title0"asic Introduction to the Operation1. 2lthough this manual was primarily intended for


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surgical trainees, I believe it should be read by all operating room nurses as well. Infact, this manual should be the first thing that these nurses should be ac!uainted with.

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3or to be able to !ualify as members of the surgical team and to be able to assist thesurgeons properly and efficiently in their operations, the operating room nurses shouldbe familiar with at least the basic things about an operation.

The second part consists of a description of cancer nursing in the operatingroom. Operations for tumors which are cancers or which may turn out to be cancers arebecoming more and more common nowadays. 4ence, the inclusion of this particulartopic.

The third and last part of this manual is on nurses as members of the surgicalteam. 5iscussed here are what the surgeons e-pect from the nurse, what the nursesshould do and what they should not do.

This manual is not all6inclusive. It can never substitute for the standard te-tbooksbeing used in nursing schools. It contains only the basic essentials that operating room

nurses should know from the standpoint of the surgeons, who is the captain of thesurgical team. The nursing students are advised to stick to whatever te-tbooks onoperating room procedures prescribed by their schools or instructors. 4owever, readingthis manual maybe a must before a nurse participates in an operation and has actualencounter with surgeons.

It is my hope that with this manual I will be able to improve the !uality of theoperating room nurses. It is also my hope that with this manual I will be able to improvethe relationship between the surgeons and the nurses. If these two aims are achieved,then it will not only be me who will be happy. The nurse will not be scolded anymoreand will be treated professionally. The surgeons will have a better time operating and

will have better operations because of good assist from nurses. 7ome to think of it, thefinal beneficiary will be the patients in the operating room. This, in the last analysis, isthe ultimate aim of this manual.


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REYNALDO O. JOSON 1988; 2004

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NURSES AS MEMBERS OF THE SURGICAL TEAM

CONTENTS

Pr!"#

P"r$ I "asic Introduction to the Operation&. "asic operating room setup &(. 2septic and antiseptic techni!ue )). "asic surgical instruments (&*. 8urgical needles and sutures **+. 8titches and knots +(

. 9-posure and dissections :. The operation and the surgeons &

P"r$ II 7ancer #ursing in the Operating ;oom

P"r$ III #urses as Members of the 8urgical Team&. ;oles e-pected of operating room nurses :*(. 7ommon pitfalls of operating room nurses :). 4ow not to be scolded and what to do when scolded /&

E%&'()*


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P"r$ I

BASIC INTRODUCTION TO THE OPERATION


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BASIC OPERATING ROOM SETUP

The typical operating suite is constructed in such a way that there is a continuousprogression from the entrance, through zones that increasingly approach sterility, to the

operating rooms.

There are basically three zones in a standard operating suite of any hospital


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ASEPTIC AND ANTISEPTIC TECHNI+UES

The term aseptic and antiseptic are often used interchangeably. 4istorically,sterile techni!ue was first carried out with chemicals such as carbolic acid and phenol,

which were used on instruments as well as on the skin. This was known as antiseptictechni!ue. With the introduction of steam autoclave and other techni!ues more effectivethan chemicals in sterilizing instruments and linens, the term aseptic techni!ue wasused to distinguish the newer methods from the older chemical methods. The distinctionhowever, has been lost. 7urrent sterilization techni!ues rely on both chemical andphysical methods.

2septic techni!ue then is a body of techni!ues for ensuring that all bacteria aree-cluded from the sterile field in which the procedure is done. 2lthough the goal iscomplete sterility, this is impossible to attain. 9very surgical wound is contaminated byat least a few bacteria. These bacteria can come from + sources=

&. The operating room physical environment(. The patient himself). The nonscrubbed personnel*. The scrubbed personnel+. The operative tools and instruments

9ven the most advanced aseptic techni!ue has not yet produced a completeabsence of bacteria from the operative environment. #evertheless, attention to aseptictechni!ue is still of utmost importance in minimizing the risk of infection in all surgicalprocedures.

The greatest source of contamination in a basically clean operation is theoperative environment, a term that covers every other element in the operating room,from the nonscrubbed personnel to the air over the surgical wound.

8tudies of operating room during periods of inactivity indicate that although thewalls, the floors, and the furniture may contain considerable numbers of bacteria, theseorganisms do not enter the air of the room. "acteria do not become airborne unlessthey are pushed into the air by blast of air or mechanical brushing.

4uman activity accounts for most of the organisms in the air of an operatingroom. Movement or talking leads directly or indirectly to the dissemination of the ma$orportion of bacteria6containing particles in the air. Thus, the rules of behavior in theoperating environment come down to simple common sense and strict 0surgicalconscience1. Movement should be restricted to those functions necessary to conductthe operation. Talking should be minimal. 2ny break in the aseptic procedures shouldbe reported and corrected immediately, no matter who does it.

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2septic techni!ue for the operating room environment

&. The operating room should be cleaned and disinfected regularly and as often asnecessary, such as after a dirty case. 7hemical fogging or fumigation is used aswarranted.

(. 2 supervisor should control the flow of traffic of people entering the operatingroom, especially visitors, laboratory, -6ray, pathology and other hospitalpersonnel.

). 2ll persons entering the middle and inner zones of the operating suite should bein proper operating room attire.

*. >roper operating room decorum should be observed, like no eating, no drinking,minimizing talking and unnecessary movement.

2septic techni!ue for instruments, sutures, linens, fluids, and other surgical materials

&. 8team autoclaving

6 under pressure6 normal sterilization cycle, &(?@7 at (?6(+ lb pressure for )?minutes

6 sterilization of drapes, gowns, sheets, towels, lap pads, andsurgical instruments not damaged by intense heat

(. 9thylene o-ide sterilization


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2septic techni!ue for the scrubbed personnel

&. >roper operating attire(. >roper operating room decorum

). >reoperative aseptic techni!ue6 scrubbing6 gowning6 gloving6 prepping and draping of operative field

*. Operative aseptic techni!ue6 use of sterile surgical instruments and materials6 maintenance of sterility of operative field

>roper operating room attire


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There are ( phases of scrubbing= &' the preliminary mechanical cleansing ofsurface dirt and oils and (' the scrubbing proper. "elow is a description of the importantsteps in scrubbing techni!ue=

&. Wet and lather both hands and arms with soap, e-tend wash about (inches above the elbows. This preliminary wash removes all surface dirt andoils.

(. ;inse off lather. Cather both arms and hands with soap again.

). "egin scrubbing the fingernails. The nails should have been cut shorteven before scrubbing and dirt underneath should have been cleansed duringthe preliminary wash. 4old ends of fingers and thumb evenly together. 2pply)? strokes with the brush. One stroke consists of one forward and onebackward motion of the brush.

*. 3rom the fingernails, proceed to the fingers, the webs, the hand proper,the wrist, distal )rdof the forearm, middle ) rdof the forearm, pro-imal )rdof theforearm, elbow, and lastly, the distal third of the arm.

+. 7onsider your fingers as having * planes% the hands, planes, two on thepalmar surface, two on the dorsal surface, and one on each side% theforearms and arms, * planes each. Bive each plane &+ strokes. 5o nothesitate to give each plane more than the minimum number of strokes. "esure to overlap from plane to plane.

. 2fter scrubbing one e-tremity, repeat the same systematic procedure onthe other e-tremity.

. 2fter the scrubbing has been completed, discard the brush. Dou are nowready to rinse your scrubbed hands and arms.

;insing after scrubbing


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These areas are the hands, that is, after the sterile gloves are worn, thesleeves up to the front of the gown $ust below the neck to the waistline ortable level. ropergloving not only entails proper aseptic techni!ue but also using the proper6sized gloves with absence of wrinkles.

2ll gloves must be immediately changed once punctured or unsterilized. 2circulating nurse should remove the unsterilized gloves making sure she doesnot touch the sterile surface of the gown of the surgeon.

If both gloves and gown need to be changed, the gown is always removedbefore the gloves.

>repping the operative field

The operative field is prepared through the following aseptic techni!ue= &'mechanical cleansing and scrubbing using detergents and (' sterilizationusing antiseptic solution like iodophors or benzalkonium chloride. "odysurface hairs encroaching upon the operative procedure should be removedeither by shaving or depilation a few hours or minutes before the operation.

The e-tent of preparing depends on the proposed operative field, as wellas the areas of possible e-tension. 2s a rule, it is better to overprep than tounderprep. 3ig. &? illustrates some e-amples of the area of prepping forseveral types of operation.

The duration or time that maybe considered as ade!uate prepping with anantiseptic solution is + minutes. ;esidual bacterial count drops markedly

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during the first minute and progressively less during the second and thirdminute. 2fter + minutes the count will be minimal.

The direction of prepping with an antiseptic solution begins at the areaswhere the incision will be made and gradually goes outward or peripherally


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THE BASIC SURGICAL INSTRUMENTS

There are so many surgical instruments that have been manufactured and thatwill be manufactured in the future that it is impossible to enumerate all of them. What is

done is to describe only the most basic instruments used in general surgery.

Cikewise, there are as many techni!ues in handling surgical instruments as thereare surgeons. 2gain it is impossible to describe all of them. What is done is to illustrateonly one or two techni!ues which every surgical trainee should know in the early stageof his training.

"asic surgical instruments can be grouped into + ma$or categories according tofunction= &' cutting instruments, (' grasping instruments, )' retracting instruments, *'suction devices, +' electrosurgery machines. 9-amples of instruments under eachcategory are shown in Table &.

The 8calpel

2 scalpel consists of handle and a blade lan incision before cutting. 9stablish starting and stopping landmarks.7onsider e-posure and cosmesis. >reliminary marking of the incision maybe made by scratching with the back of the blade or with the use of sterilepen or ink.

(. 8tabilize skin before and during the incision and cut with the blade alwaysperpendicular to the skin surface. This is to prevent $agged wound or abeveled skin incision.

). 4ave full control of the scalpel. Watch where you are going and where youare cutting.

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The following are some important guidelines in the use of the scissors=

5onEt cut unless&. Dou are in good position,(. Dou have full control of the scissors,

). Dou can see the suture or tissue to be divided, and*. Dou can see that you are not likely to cut any other structures.

In cutting sutures, the aforementioned guidelines hold true. The knot should notbe cut. The knot should be visible to the one who is going to cut the suture


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can be inserted accurately through the tissue. The instrument should be held in such away to facilitate the stitching following the curved of the needle.

There are several steps in making a stitch=

&. >ositioning the needle in the needle holder


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The most secure way of clamping tissues with the hemostat is the tripod grip


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The advantages of an electrocautery are an economy of blood loss, drier fieldand speed. The disadvantages and hazards are a poor depth control with damage tounderlying structures and unintentional burns. 9-plosion of anesthetic gases is rarelyseen nowadays with the use of nonflammable gases.

T"/' 1. B" S*r)"' I-$r*-$.

&. C*$$&-) &-$r*-$ 8calpels, scissors

(. Gr"%&-) &-$r*-$ 3orceps, needle holders, clamps, towelclips, 2llis forceps

). R$r"#$&-) &-$r*-$ 8kin hooks, rakes, 2rmy6navy ;ichardson,5eavers, self retaining retractors


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B. T5-"r )r&%

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SURGICAL NEEDLES AND SUTURES

8urgical #eedles

8urgical needles vary in shape, size, type of point, and suture attachment.


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continued strength is desirable, and if the suture will be removed subse!uently. Whenone gets down to fine points, the choice of suture becomes a matter of opinion.

The following factors may come into play in the final selection of the suture=

&. The needs of the tissues to be sutureda. absorbable or non6absorbableb. strength of suture needed to hold tissuesc. duration of continued strength neededd. infected or non6infectede. need for atraumatic needlef. amount of tissue reaction

(. 7ost). 2vailability*. 8urgeonEs bias or idiosyncracy

2lthough the choice of sutures may oftentimes be arbitrary, a few guidelines andsuggestions may help=

8kin 6 nonabsorbable eritoneum 6 absorbable

ascular repair 6 non6absorbable

Intestinal anastomosis 6 absorbable and non6absorbable


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Fnot tying consists of ( important steps= &' knot formation (' knot setting. Thefirst knot setting usually determines the tightness of the wound closure, the stitch or theligature. The second and subse!uent knot settings secure the knot.

Fnot tying can be done either with the use of the hands only or with an

instrument, usually the needle holder. Instrument tying


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When to remove skin sutures

The time to remove skin sutures varies according to the rapidity of woundhealings, the location in the different parts of the body, and the different situations

wherein it is up to the surgeonEs $udgment whether to remove or to retain the sutures.2s a rule skin suture are left in place until one is sure that the wound is well healed andthat the wound will not dehisce after the suture removal. On the other hand, one doesnot leave the suture too long unnecessarily, or else infection or permanent stitch marksmay result.

The following table lists the time when sutures are usually removed.

3279 2#5 #97F ) H + days

T;K#F H &? days

K>>9; 9LT;9MITI98 &? H &( days

COW9; 9LT;9MITI98 &( H &* days

8titch marks usually result when skin sutures are left in place for more than +days. 8titch marks on the trunks and e-tremities can be minimized by placingsubcuticular stitches so that the skin sutures can be removed earlier than usual.

4ow to remove sutures ull the cut sutures toward the direction of the wound.

This techni!ue of suture removal tries to eliminate pulling sutures that might becontaminated through the suture tract and pulling sutures that may disrupt the alreadyapposed wound edges.

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3or mobile structures like bowels and skin flaps, one may stabilize them withvisceral packs or sutures. This is another way of promoting e-posure.

5issection

There are two types of dissection. 2 sharp dissection separates tissues planesby cutting with the scalpel or scissors. 2 blunt dissection is done by inserting andspreading the blades of the scissors or the $aws of the clamps between tissue planes. 2peanut sponge or any other non6cutting instruments may also be used to separatetissue planes by blunt dissection.

2n accurate and safe dissection re!uires continuous and consistent e-posureand stabilization of the tissue to be dissected. Ways of promoting e-posure havealready been discussed above.

8tabilization of tissue for dissection can be achieved through traction andcountertraction. Most tissue planes remain flaccid and closed unless one appliestraction away from a fi-ed structure or from countertracting instrument. Thus, a tractionand countertraction techni!ue re!uires two opposing traction forceps or one tractionforce away from a fi-ed structure. The net effect is the stretching and stabilization offlaccid tissues for dissection.

Traction and countertraction may be done with the hands of the surgeon andGorhis assistants or with the use of instruments, especially the grasping instruments


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"elow is a checklist for the surgeon to consider prior to scrubbing=

>reoperative briefing of the surgical team

6 plan of operation

6 assignment of function6 operating tool re!uirement

>osition of the operating table

6 optimal access for work of the anesthesiologist, the surgeon andthe scrub nurse

>osition of the patients6 check pressure point6 optimal table height= operative field as at level of surgeonEs elbow

Intravascular lines6 ade!uate and properly secured

Cights

Operating tools6 check e!uipment table

Instruction for urethral catheterization, prepping, draping, etc.

Instructions for circulating nurse

>ositions of the scrubbed personnel

The position of the surgeon and his team members varies with each patient. Itdepends primarily on the area of the patientEs body to be operated on and on theposition by which the optimal access for work can be achieved by the surgeon and hissurgical assistants, the anesthesiologist, and the scrub nurse. 3or e-ample, a right6handed surgeon and a left6handed surgeon may occupy different positions for the samekind of operation, say abdominal surgery. The positions of the surgeon and theanesthesiologist in a head and neck procedure maybe different from the position takenby them in an abdominal or pelvic procedure. 3ig. * illustrates the usual positions of aright6handed surgeon and his assistants for abdominal and pelvic surgical procedures.

"elow is a general guideline in determining the position of the scrubbedpersonnel.

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>osition of the surgeon

6 depending on the area of the patientEs body to be operated on aswell as on the position of the patient on the operating table


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of functions among the assistants to avoid chaos which may hamper rather thanfacilitate the operative procedure.

The first assistant is usually the most senior in command among the surgicalassistants. 4e assists the surgeon closely. 2lthough he is directly responsible for

promoting e-posure and helping the surgeon in his dissection and in decreasing thework load of the surgeon, he may not be able to do all the things at the same time. 4emay delegate some of these $obs to the second and third assistant. 4owever, he shouldcontinue to oversee that these $obs are done properly by the other assistants for thesurgeon.

To provide some order and system in assisting, it has become a universalpractice that the first assistantEs role be involved primarily with the surgeonEs dissectionand that the second assistant primarily role be in the e-posure of the operative field. #oassistant should hamper the smooth flow of the operation by abandoning his primaryrole to do other assistive $obs. 3or e-ample, a second assistant should not let go his

retraction which is needed for continuous e-posure at the moment, to reach out for apair of scissor to cut a suture being tied by the surgeon. Only if the primary role of anassistant is not needed can he do other assistive $obs for the surgeon. The point is eachassistant should know his primary and secondary responsibilities. If he is free from hisprimary responsibilities, then he can do his secondary responsibilities.

Tying of sutures is usually done by the first assistant and the cutting of sutures bythe second assistant, that is, if these operative maneuvers are delegated by thesurgeon to the assistants and if their hands are free from their primary responsibilities.

2side from the above guidelines in assisting, the other responsibilities of the

assistants are as follows=

&. They should carry out specific instructions of the surgeon.(. They should anticipate needs and moves of the surgeons.). They should create optimal e-posure of the operative field for the surgeon

through ade!uate retraction, sponging, and suctioning.*. They should keep the sterile operative table clean and clear of

unnecessary instruments, sponges, sutures, etc.+. They should always maintain sterility of the operative field.

>roper conduct during the operation

>roper conduct during the operation should be observed by the surgical team.These include the following=

&. Feep talking to the minimum. One may use hand signals to ask the scrubnurse for instruments. 4and signals simulate the holding of theinstruments


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). 5o not reach for instruments on the tray, unless necessary.*. >ass instruments under the hands and forearms of anybody and in front of

everybody and not at the back.+. When itEs necessary to change positions, do so face to face or back to

back.

. Feep the operative field clean and sterile.. Work as a team.:. >romote a smooth, safe, and secure performance of the operation.

Table *. 4and signals.

4and signals stimulate the holding of instruments.

4emostat6 e-tend the hand supinated.

8cissors6 e-tend the inde- and middle fingers and adduct and abduct the fingers in shearing motion.

8calpel6 hold hand pronated with thumb apposed against the distal phalange of the inde- finger and fle- the wrist.


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fragments through an ordinary hypodermic needle. #eedle biopsy is done by obtaininga core of tissue through a specially designed needle. Incisional or section biopsy isdone by removal of a small wedge of tissue from a larger tumor mass. 9-cisional biopsyis done by e-cision of entire suspected tumor with little or no margin or surroundingnormal tissue. 2ll the specimens gotten through the various techni!ues are submitted to

the pathologist for histologic diagnosis. 2ll of these basic biopsy techni!ues are done bytransgression of the skin directly over the tumor or by prior opening of a body cavity ande-ploration, such as e-ploratory thoracotomy and laparotomy.

;ole of surgery in the treatment of cancer. There are forms of treatment thatsurgery can do for cancers. These are=

&. 5efinitive treatment of primary cancer. There are basically three types ofcancer operation= a' local resection, b' radical en bloc resection, and c' amputation. 2local e-cision, which takes out the whole mass with little or no margin of surroundingnormal tissue, is not done for cancers because of the high incidence of recurrence. 2

wide local e-cision or local resection is the minimum, ideal cancer operative techni!ue.It means that the whole tumor is removed with a wide margin of surrounding normaltissue. ;adical en bloc resection means wide removal of the tumor together with anyadherent ad$acent organs and the lymphatic drainage in one piece. 9-amples of radicalen bloc resection are the commando operations and radical mastectomies. 2mputationrefers to the radical treatment of cancers of the e-tremities.

(. 7ytoreductive surgery. This is done to reduce the bulk of the tumor leavingbehind either gross or microscopic residual. This type of cancer surgery should only bedone when this is to be followed postoperatively by other effective cancer treatmentmodality.

). Treatment of recurrence and metastasis. 8urgery can be curative in thetreatment of local recurrence especially if the cancer is slow6growing and has lowpropensity to metastasize. Cikewise, surgery may occasionally be curative for thosecancers with solitary hepatic, pulmonary, and brain metastases.

*. Treatment of oncologic emergencies. 8ome cancers may give rise toemergency situations wherein surgery maybe lifesaving. 9-amples are e-sanguinatinghemorrhage arising from the tumor, perforation of a viscus secondary to a tumor, and amassive pleural effusion.

+. >alliative treatment. 8urgery may provide palliative treatment in cases wherethere is no hope for cure. The goals of such a treatment are to relieve suffering, toprolong life, and to provide better !uality of life. 9-amples of palliative surgicalprocedures are colostomy, enteroesterostomy, or gastro$e$unostomy, to reliefobstruction, amputation to relieve pain and control infection, and simple mastectomy forulcerated foul6smelling, tetanus6prone breast cancers.

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. ;econstruction and rehabilitation. 7ancer surgery is basically an e-tirpativeprocedure which leaves behind a defect which much be repaired, covered, orreconstructed. 2ny surgeon treating cancer must be able to reconstruct whateverdefect he has created. 3urthermore, he must be willing to accept the responsibility ofrehabilitating, especially those patients with head and neck reconstruction problem,

laryngectomies, ostomies, and amputated e-tremities.

The following are some of the basic principles of cancer surgery=

&. 2s much as possible, the surgeon should always aim for cure. 2 curativesurgery is one of that attempts to remove every cancer cell from the body.

(. The first treatment offers the best opportunity for cure. It is mandatory that theinitial treatment be that which will most likely cure the patient. 7ancers cells selected forrecurrence maybe more virulent than the initial tumor. 3urthermore, tissue planes in apostoperative recurrence may be indistinct from the tumor margin, making treatment

more difficult and thus, the high incidence of retreatment failure.

). The operative risk for cancer patients should be taken into consideration as inany patient for surgery.

*. The histologic diagnosis must be established with appropriate biopsytechni!ue. Minimum number of biopsy procedure, preferably one and amount of tissuesufficient for a pathological diagnosis should be taken. The greater the number ofbiopsy procedures done, the more the manipulation, and the greater the chances ofspread and contamination. The site of the biopsy incision should also be well plannedso as not to compromise the performance and the result of a future definitive surgical

procedure. >roper handling of the specimen like putting markings for anatomicalorientation and placement into appropriate fi-atives should be considered. In allinstances of biopsy procedure, the cardinal rule to follow is to avoid and minimizecontamination of normal tissues with cancer cells.

+. The principles of intraoperative cancer surgery consist of the following=

a. 9n bloc, encompassing surgery to avoid cutting into the tumor and toensure its complete removal.

b. 2voidance of spread by gentle handling of the tumor, early pro-imal anddistal ligation of bowel.

c. 2voidance of contamination of normal tissues with cancer cells. 2voidcutting into or rupturing the tumor. 2ll gloves and instrumentscontaminated with cancer cells must be discarded.

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7ancer 5issemination

7ancer begins when one malignant cell starts to multiply. When the tumor gets

large enough, cancerous cells from the tumor travel to other sites or organs by directe-tension, through the lymphatics, andGor through the bloodstream.

5uring an operation for supposedly localized cancer, dissemination of cancercells may occur through two principal mechanisms=

&. 4andling of the tumor, especially rough handling may cause cancer cells tospread out from the primary site to the regional lymph nodes andGor distant sites ororgans. Thus, gentle handling is one of the basic principles of intraoperative cancersurgery. 9arly ligation of the venous drainage and early pro-imal and distal ligation ofthe bowel are other suggested ways of preventing spread.

(. 7utting through the tumor andGor rupturing it may cause contamination ofad$acent normal tissues with cancer cells either through a drop implantation or throughimplantation via contaminated instruments, gloves, and drapes. Thus avoidance ofcutting through tumor andGor rupturing it and discarding cancer contaminated materialsare other basic principles of intraoperative cancer surgery.

2lthough the surgeons, as the captain of the surgical team, plays a pivotal role inthe overall control of cancer dissemination, his surgical assistants have as muchresponsibility in preventing the spread of cancer during an operation. The mostimportant function that the operating room nurses should do in this regard is to oversee

that all contaminated instruments, gloves, and drapes, are discarded and changed. 2cancer operation is like an operation on an infected field. Once the instruments arecontaminated, they are discarded.

7ancer Operation and 7ancer #ursing in the Operating ;oom

2 cancer operation consists basically of ( phases= &' the e-tirpative phase and ('the wound closure or reconstructive phase. 2ll instrument, gowns, gloves, and drapesused during the e-tirpative phase are considered contaminated and should bediscarded and changed prior to the wound closure or reconstructive phase. Thus,ideally, ( sets of surgical tools and instruments should be prepared for each phase ofthe cancer operation.

2n e-ample of sterile operative field e-tirpative phase is shown in 3igure *.

"uckets are provided for the surgeon and his assistant surgeon for discardingcontaminated instruments and materials without having to pass them on to the scrubnurse.

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3or the circulating nurses H

&. 4elp prepare the patient for operation.

a. 4elp the anesthesiologist with his needs.b. 4elp the surgeon with his needs.c. 4elp the scrub nurse with his needs.

(. Once the operation has started H

a. Watch the progress of the case and keep the sterile members of theteam supplied with necessary items and their needs.

b. 8tay in the room as much as possible. 2sk permission to go out whennecessary.

c. 2d$ust and focus light on the site of the operation.d. 7onnect electrical e!uipments and suction apparatus.e. Watch the brows for perspiration and mop them before they drop to the

operative field.f. Feep the room tidy.g. 7ollect and weigh soiled sponges as necessary.h. 4elp scrub nurse count the sponges and instruments.i. 4elp maintain sterility of the operative field.

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COMMON PITFALLS OF OPERATING ROOM NURSES

It is impossible to list all the pitfalls committed by the operating room nurses.Cisted below are $ust some of the more common shortcomings of scrub nurses as well

as circulating nurses. Included also are suggestions for the nurses on how to avoidthese pitfalls and on how to assist.

3or the scrub nurses=

&. 2fter scrubbing, they think that their hands are sterile. "ecause of this, anerror is commonly committed during the gloving procedure. They use theirbare hands to open the cover of the pair of gloves that they will use. Theydo this in such a way that the cover of the gloves touched by their barehands touches the sterile instrument table. This is a break in the sterility ofthe instrument table, which they donEt realize because they think their

hands after scrubbing are sterile.

(. They are not familiar with the operative procedure that they are going toassist. There is no e-cuse for this ignorance if the nurses have beenworking in the operating room for more than months and if the operativeprocedures are ones that are commonly performed in the place wherethey are working. 2ll nurses should strive to familiarize themselves withthe operative procedures that they are going to assist either by reading orby asking the more e-perienced nurses or better, the surgeons. Thesurgeons understand the limitations of those nurses who are new in theoperating room. They also give leeway to the nurses in case they are

doing uncommon operative procedures. The only thing the surgeonse-pect from the nurses is the mastery of the basic assisting techni!ues.

). They donEt prepare all the necessary and usual instruments needed for aparticular procedure. There are several possible reasons for this. One,they are not familiar with the operative procedure that they are going toassist. Two, they are not familiar with the instruments needed for suchprocedure. Three, they donEt consult the procedure book in the operatingroom. 3our, they donEt consult the doctorEs preference cards, especially ifthe surgeon is a regular operator in the operating room where they areworking. 2nd lastly, they donEt communicate with the surgeon before theoperation. ;emedies here are to do and to be the opposite of the donEtsand notEs mentioned above.

*. They donEt anticipate the needs of the surgeons. #urses should be familiarwith the operative procedure and the operating habits of the surgeons theyare assisting for them to be able to anticipate the needs of the surgeons.In #os. ( and ) above, mentioned was made on the situations in whichunfamiliarity of the nurses constitutes an e-cuse or no e-cuse. If the

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unfamiliarity of the nurses is an e-cuse, then the other reasons which donot constitute an e-cuse are that the nurses have not mastered the basicsurgical instruments and the basic surgical techni!ues and that they donEtwatch the operative field. They have to watch the field and to know thebasic surgical techni!ues to fulfill the $ob of anticipation. 4ere are some

specific e-amples to illustrate this point.

a. If they see blood covering the operative field, they shouldrealize that either a sponge or a suction apparatus maysoon be asked by the surgeon. They should be ready withthese e!uipments.

b. If they see that the surgeon has clamped two sides of ablood vessel in preparation for transaction and ligation,they should get ready to hand the surgeon a cuttinginstrument and a suture for ligation.

c. The nurses should be familiar with the preference of the

surgeon in his choice of instruments. In the e-amplementioned here, they should be familiar with the cuttinginstrument preferred by the surgeon, whether a pair ofscissor or a knife.

d. If they sense that the surgeon is going to make a series of suture ligation or suturing, then they should be ready

with at least two needles with sutures threaded on them.e. If they sense that the surgeon is going to suture the skin,

they should be ready with the proper needle, a cuttingneedle.

Watching the operative field and being familiar with the basic surgicaltechni!ues as well as with the operating habits of the surgeons are allneeded for the nurses to be able to anticipate the needs of thesurgeons. The nurses should always be one step ahead of the surgeonin sponges, sutures, and instruments. This way, they facilitate theoperation, not only in performance but also in terms of operating time.

+. They donEt watch the operation. This was mentioned in #o. * but it isbeing repeated here for emphasis. #urses should watch the operative fieldnot only to anticipate the needs of the surgeons but also to see thefollowing=

a. To see the hand signals of the surgeon. 2 lot of surgeonstry to minimize talking in the operative field by using handsignals. #urses should be familiar with these hand signals.

b. To see the type of an instrument that maybe needed for aparticular situation. 3or e-ample, if a surgeon is dissectingin a deep field and asks for instruments like retractors,clamps, scissors, and ligatures, the nurses should know

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very well to give long retractors, long clamps, longscissors, and long ligatures and not short instruments.

2daptability and common sense are needed of the nursesin such a situation.

c. To see to it that the operative field is maintained neat and

tidy.d. To watch for any break in aseptic techni!ue.e. To see the procedure itself and become familiar with it.f. To see the operating habit of a particular surgeon and

become familiar with it.

. They donEt work as fast as possible. It is either they are congenitally slowin body movement or they donEt know what to do or how to assist.

. They donEt hand the proper instruments. It maybe that they donEt hear thesurgeons. In which case, they have to tell the surgeons to speak

louder. It maybe that they donEt watch the operative field to get a clueas to what the surgeons needs% in which case, they have to watch thefield as discussed in #os. * and +. It may be that they donEt know thenames of the instruments. They have to know at least the basicinstruments and those commonly used. 3or the names of otherinstruments, they $ust have to ask the surgeons before or early duringthe operation.

:. They donEt hand the instruments properly to the surgeon. In handling aninstrument, the scrub nurses should place it in the surgeonEs hand in theposition in which the surgeon is going to use it, so he will not need to

make any read$ustments.

/. They donEt wipe blood or tissues from instruments before handlingthem to surgeons. They donEt always keep the instruments clean. #otonly that, they should always have a neat and orderly arrangement ofthe operative tools in their instrument table so that they can readilyhand to the surgeons whatever instruments is asked for.

&?.They donEt know which instruments are contaminated. They have to lookat the operative field or to ask the surgeons to know which instruments arecontaminated with bacteria and cancer and which instruments are notcontaminated. They have to know which instruments should be set aside,which instruments have to be discarded, and which instruments can beused again.

3or the circulating nurses, the main problem encountered by the surgeons is that

they donEt stay in the room as much as possible and they donEt inform the surgical teamwhen they go out of the room. They are always not around when they are needed most.

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7irculating nurses should always inform the surgeon when they go out of the operatingroom to do something other than run errands and to get the needed items for theoperation. The surgeon will understand their absence if he is informed ahead of time.

In this day and age, where the cost of operating e-penses has soared up, proper

economizing is needed for the sake of the patient. This proper economizing should be aconcerted effort of the surgeons and the nurses. 3or the nurses, here are some advices=

&. 8ave on sponges. 5onEt readily discard sponges not fully soaked and whichcan still be used.

(. 8ave on sutures. 5onEt discard sutures which can still be used.

). 5onEt open operating materials which may not be needed.

*. Open correct operating materials.

+. 7onsult the surgeons.

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EPILOGUE

With this manual, I have attempted to offer a solution to very common problem inthe operating room in which nurses are fre!uently being scolded by the surgeons, eitherrightfully or wrongfully.

2lthough this book is directed to the operating room nurses, this doesnEt meanthat they are the only part at fault. 8urgeons can be at fault too. That this is so is clearlystated in the preface and in the last chapter of this manual.

2s mentioned in the preface, this book is not meant to insult the operating roomnurses but to help them6 to help them become better operating room nurses and to helpthem uphold their dignity as professional members of the surgical team.

My being a surgeon, as the author of this manual will surely have implications,good and bad. I $ust hope that the readers of this manual will adhere to the following two

implications. One is that a book such as this is better written by a surgeon because I ama party directly involved in such a problem and that my views can very well representthe views of the surgeons in general. 8econd is that this manual can be used as areference, as a starting point, as a arbiter, or as a tool in promoting the surgeon6nurserelationship and in solving any conflict between the two parties in the operating room.

The implications that I donEt like to hear are one, who is he in the position to writesuch a book, and two he is inciting the nurses to stand up against the surgeons.

Whatever be the implication that maybe perceived by the readers of this manual,I stick to the ob$ectives with which I wrote this manual H better operating room nurses,

better nurse6surgeon or surgeon6nurse relationships, and better operations. I like to lookforward to the day when I revise this manual% I donEt have to mention the word 0scold1.

I e-pect and welcome comments and suggestions from nurses and surgeonswho happened to read this manual. >lease address them to= ;oom )?&, Medical 2rts7enter, Manila 5octors 4ospital, Knited #ations 2venue, Metro Manila.

nurses as members of the surgical team

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