1. Scrubbing, Gowning, Gloving and Arranging of Surgical Equipment

4. 5.2 sterilization process 5.3 anesthesia 5.3.1 types of anesthesia 5.3.2 stages of anesthesia 6. demonstrate beginning skills in: 6.1 filling-up the consent form and peri-operative checklist 6.2 opening the sterile pack 6.3 packing and sterilization 6.4 performing the following OR techniques a. surgical scrubbing b. gowning and closed gloving c. draping d. serving of instruments e. assisting in the operation f. circulating

6. e. Analgesia ~ a decreased or absent sensation of pain without the loss of consciousness. f. Anesthesia ~ The absence of all sensation, especially to pain, as induced by an anesthetic substance or by hypnosis or as occurs with traumatic or pathophysiologic damage to nerve tissue. ~ the total or partial loss of sensation, especially tactile sensibility, induced by disease, injury, acupuncture, or an anesthetic such as chloroform or nitrous oxide. ~ local or general insensibility to pain with or without the complete loss of consciousness. ~ anesthesia induced for medical or surgical purposes may be topical, local, regional, or general and is named for the anesthetic agent used, the method or procedure followed, or the area or organ anesthetized.

30. C. OPERATING ROOM ATTIRE

43. A. COMPONENTS OF ATTIRE HEAD COVER

44. Shoe cover

45. Mask

46. B. PERSONAL PROTECTIVE EQUIPMENT - Aprons

47. Eyewear: Face shield

48. Laser eyewear

49. Gloves: Latex

50. Lead

51. Utility Gloves

52. Surgical gown

53. Surgical gloves

54. PHYSICAL LAY-OUT OF THE OR OPERATING-ROOM SETUP SHOWING TABLES FOR INSTRUMENTS AND SUPPLIES DESIGNED TO FACILITATE THE WORK OF THE SURGEON, HIS ASSISTANTS, AND THE NURSES

55. PACU (post anesthesia care unit)

56. OR suite (operating room-central Processing area)

57. Preoperative Holding area – sterile supply room

58. Preoperative Check-in Unit – utility room

59. Induction room (for anesthesia) – instrument room

60. Dressing room and lounger – scrub room

61. Central Control desk

62. Anesthesia work and storage area

63. Housekeep ing storage A rea

65. Draped patient and operating bed Mayo stand 1 st assistant Scrub nurse Surgeon Kick bucket Instrument table Electrosurgical unit Suction container Kick bucket Anesthesia machine Anesthesia provider

79. The Eight “Ps” to consider when preparing for a Surgical Procedure Sterile Field Considerations for the Scrub Nurse Environment Considerations for the Circulating Nurse PROPER PLACEMENT -items should be placed so they will not need to be moved during the procedure. The Mayo stand should not be moved during the procedure. Drapes may not be moved on the patient’s skin. Suction canisters, tourniquet, and the electro-surgical unit (ESU) need to be stationary. The operating lights should be directed toward the field. PROPER FUNCTION -items should be tested for safety and usefulness before they are needed, to prevent delay in the case. Test the efficiency of instruments (e.g., scissors, needle holders, clamps) as they are needed. Test the ESU, tourniquet, laser, and other equipment before the patient enters the room.

80. PLACE IT ONCE -items should not be manipulated during the procedure. Energy and attention should not be diverted to resetting the field. When setting up the field, each item (e.g., a basin) should be placed where it will be used during the procedure with minimal handling. The operating bed should be at the right place for the procedure. The dispersive electrode should not be moved or displaced. POINT OF CONTACT -items used within the field could cause harm or be rendered useless if they do not reach the intended point of contact. The scrub nurse should be aware of the passing of the instruments and how they are securely placed in the waiting hand of the surgeon or first assistant. The circulating nurse should evaluate the delivery of items to the sterile field. Some items (e.g., staplers) should be handed; others can be transferred in other ways. POSITION OF FUNCTION -items should be positioned so they will be useable during the procedure. When passing instruments, they should be placed in the surgeon’s hand in a useable way. For example, the curve of the instrument should match the curve of the hand. The use of a laser with articulating arm, or microscope should be preplanned so they may be positioned while the procedure is in progress.

81. POINT OF USE -items should be as close to the area of use as possible. Basins should be placed close to the edge of the table so the circulating nurse can pour without requiring the basin to be repositioned. The ESU pencil holder should be close to the field for safe containment of the tip. Pour solutions directly into the basins, open and hand sponges or sutures directly to the scrub nurse as they are needed. PROTECTED PARTS -items and surfaces should be rendered safe for the patient and the team. Apply jaw liners to instruments during setup. Hand instruments with care to avoid causing injury with the tip or sharp surface. Do not lay items on or against the patient’s body. Cords, cables, and tubing should be secured and appropriately directed away from the field. Pad the operating bed and patient as appropriate. Use safety belts. PERFECT PICTURE -items within and around the field should not be at risk for causing harm or becoming damaged. The environment should not be cluttered. The sterile field should remain neat and orderly, with instruments and supplies within easy sight and reach. Consistent setup fosters a sense of comfort and confidence in the scrub role. The entire room should appear neat and tidy. The door should be closed, and the temperature and humidity should be appropriate. Forethought to having a clear path for the crash cart or emergency equipment is essential.

88. After the surgeon and assistants scrub:

106. ABSORBABLE SUTURE

107. NONABSORBALE SUTURE

108. SUTURE NEEDLES

114. Depth of General Anesthesia From To Patient’s Responses Patient Care Considerations Induction of general anesthesia and beginning of inhalant and/ or IV drug Begins to lose consciousness; will have recall Bispectral state 100 Drowsy, dizzy, amnesic Close OR doors. Keep room quiet. Stand by to assist. Initiate cricoid pressure if requested. Loss of consciousness; excitement phase Relaxation, light hypnosis; low probability of recall Bispectral state 70 to 50 May be excited with irregular breathing and movements of extremities; susceptible to external stimuli (e.g., noise, touch) Restrain patient. Remain at patient’s side, quietly, but ready to assist anesthesia provider as needed.

115. Surgical anesthesia stage of relaxation Loss of reflexes: depression of vital functions Bispectral state 40: maintenance range Regular respiration; contracted pupils; reflexes disappear; muscle relax; auditory sensation lost Position patient and prepare skin only when anesthesia provider indicates this stage is reached and under control. Danger stage: vital functions too depressed Respiratory failure; possible cardiac arrest Bispectral state 0 Not breathing; little or no pulse or heartbeat Prepare for cardiopulmonary resuscitation.

116. Most Commonly Used General Anesthetic Agents Generic Name Trade Name Administration Characteristics Uses INHALATION AGENTS Nitrous oxide None Inhalation Inorganic gas; slight potency; pleasant, fruitlike odor; nonirritating; non-flammable but supports combustion; poor muscle relaxation Rapid induction and recovery; short procedures when muscle relaxation unimportant; adjunct to potent agents Halothane Fluothane Inhalation Halogenated volatile liquid; potent; pleasant odor; nonirritating; cardiovascular and respiratory depressant; incomplete muscle relaxation; potentially toxic to liver Rapid induction; wide spectrum for maintenance; depth of anesthesia easily altered; rapid reversal

117. Enflurane Ethrane Inhalation Halogenated ether; potent; some muscle relaxation; respiratory depressant Rapid induction and recovery; wide spectrum for maintenance Isoflurane Forane Inhalation Halogenated methyl ether; potent; muscle relaxant; profound respiratory depressant; metabolized in liver Rapid induction and recovery with minimal aftereffects; wide spectrum for maintenance INTRAVENOUS AGENTS Thiopental sodium Pentothal sodium Intravenous Barbiturate; potent; short acting with cumulative effect; rapid uptake by circulatory system; no muscle relaxation; respiratory depressant Rapid induction and recovery; short procedures when muscle relaxation not needed; basal anesthetic

118. Methohexital sodiuim Brevital Intravenous Barbiturate; potent; circulatory and respiratory depressant Rapid induction; brief anesthesia Propofol Diprivan Intravenous Alkylphenol; potent short-acting sedative-hypnotic; cardiovascular depressant Rapid induction and recovery; short procedures alone; prolonged anesthesia in combination with inhalation agents or opioids Ketamine hydrochloride Ketaject. Ketalar Intravenous, Intramuscular Dissociative drug; profound amnesia and analgesia; may cause psychologic problems during emergence Rapid induction; short procedures when muscle relaxation not needed; children and young adults

119. Fentanyl Sublimaze Intravenous Opioid; potent narcotic; metabolizes slowly; respiratory depressant High-dose narcotic anesthesia in combination with oxygen Sufentanil citrate Sufenta Intravenous Opioid; potent narcotic, respiratory depressant Premedication; high-dose narcotic anesthesia in combination with oxygen Fentanyl and droperidol Innovar Intravenous Combination narcotic and tranquilizer; potent; long acting Neuroleptanalgesia

120. Diazepam Valium Intravenous, intramuscular Benzodiazepine; tranquilizer; produces amnesia, sedation, and muscle relaxation Premedication; awake intubation; induction Midazolam Versed Intravenous, intramuscular Benzodiazepine; sedative; short-acting amnesic; central nervous system and respiratory depressant Premedication; conscious sedation; induction in children

136. Comparison of Toxicity and Allergy Caused by Local Anesthetic Drugs Toxic Reaction Allergic Reaction Symptoms vary depending on the drug Immediate localized reaction followed by generalized body reaction SUBJECTIVE Dizziness, somnolence, paresthesia, nausea, visual/speech problems Sense of uneasiness, pruritus, agitation, paresthesia OBJECTIVE Decreased breathing rate and depth, muscle twitches, tremors, slurred speech, seizures, vomiting unconsciousness, coma Erythema, urticaria, wheals

137. VASOVAGAL Dysrhythmia, bradycardia, vasodilation, hypotension, myocardial depression, cardiac arrest Coughing, sneezing, wheezing, bronchospasm, hypotension, hypovolemia, vasodilation, cardiovascular collapse, cardiac arresr TREATMENT Supportive, airway management; need intravenous (IV) line; Trendelenburg position; muscular contractions are treated with diazepam (Valium) Especially with amino ester type: airway management, IV fluids, epinephrine, diphenhydramine, and steroids as needed

139. Advantages, Disadvantages, and Contraindications of Local Anesthetics:

143. COMPLICATIONS OF LOCAL AND REGIONAL ANESTHESIA:

149. Local and Regional Anesthetic Agents Generic Name Trade Name(s) Uses Concentration Duration of Effect (Hours) Maximum Dosage AMINO AMIDES Bupivacaine hydrochloride Marcaine Sensorcaine Local infiltration Regional block Surgical epidural 0.25% to 0.50% 2 to 3 400mg Dibucaine hydrochloride Nupercaine Percaine Cinchocaine Local infiltration Peripheral nerves 0.05% to 0.1% 3 to 3 ½ 30mg

150. Etidocaine hydrochloride Duranest Peripheral nrves Epidural 0.5% to 1% 2 to 3 500mg Lidocaine hydrochloride Xylocaine Lignocaine Topical Infiltration Peripheral nerves Nerve block Spinal Epidural 2-4% 0.5% 1-2% ½ to 2 200mg 500mg or 7mg/kg body weight Mepivacaine hydrochloride Carbocaine Infiltration Peripheral nerves Epidural 0.5-1% 1-2% ½ to 2 500mg

151. Prilocaine hydrochloride Citanest Infiltration Peripheral nerves Regional Block Epidural 1-2% 2-3% ½ to 2 ½ 600mg Ropivacaine Naropin Infiltration Field block Nerve block Epidural Postoperative pain management Not used for Bier block 0.2% 0.5% 0.75% 1% 2½ for surgical analgesia; 6 to 10 for surgical nerve block 200mg for analgesia; 300mg for nerve block AMINO ESTERS Chloroprocaine hydrochloride Nesacaine Infiltration Peripheral nerves Nerve block Epidural 0.5% 2% 2% 2-3% ¼ to ½ 1000mg

152. Cocaine hydrochloride Topical 4-10% ½ 200mg or 4mg/kg body weight Procaine hydrochloride Novocain Infiltration Peripheral nerves Spinal 0.5% 1-2% ¼ to ½ 1000mg or 14mg/kg body weight Tetracaine hydrochloride Cetacaine Pontocaine Topical Spinal 2% 1% 2 to 4 20mg

156. ADVANTAGES, DISADVANTAGES AND CONTRAINDICATIONS OF SPINAL ANESTHESIA

163. Care of the anesthetized patient:

166. BASIC INSTRUMENTS