PERIOPERATIVE CARE AND

ANAESTHETIC NURSING
NJIRU
 Module Objectives
By the end of this unit you will 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;
Explain the Roles and functions of the theatre Nurse in the care of a
patient while in theatre;
 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.
• 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.
• For example, in 17 BC, 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
• 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.
 Aims of theatre 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 Care

Preoperative evaluation
1. Complete history and Proper documentation; ie menstrual ,
reproductive , sexual ,allergies ,chronic conditions etc
2. Clinical examination-general head to toe, vital signs, weight,
height ,and systems review.
3. Investigations Full Haemogram, Urea and electrolyte ,LFT’S
GXM,RBS, ETC.
 Preoperative Care
4. You should make sure that the surgeon explains clearly to the
patient what will happen to them.
5. 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 ).
6. The nurse ensures that the patient has signed an informed
consent, after the surgeon has explained the advantages and
outcomes of the operation.
7. Make sure that the patient observes a ‘Nil by oral’ rule.
 Pre-operative care
8. The fasting should usually start six hours before the operation.
9. Blood works: All should be within the acceptable ranges e.g.
full Haemogram including HB, urea, electrolytes and creatinine.
10. The patient should be counselled and reassured especially
those receiving operations such as amputation, or mastectomy
11.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.
 ct
12. Catheterisation and IV branula insertion may be necessary
depending on the surgery.
13.  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.
 PREOPERATIVE PREPARATION OF PTS
• 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
 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
1. Right to life/principle of justice
2. Respect of autonomy-respect to ones opinion
3. Principle of non maleficence –do no harm (beneficence)
COMMON ENCOUNTERED LEGAL ISSUES
Consent, Negligence, inadequate documentation, inexperience,
clinical errors, confidentiality, patients security.
1. 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
2. Negligence: clinician not providing adequate /reasonable
information about risks of proposed treatment.
3. Inadequate documentation: improper and incomplete notes,
lack of documentation.
4. Inexperience /inadequate experience/lack of experience: No
clinician is an expert of everything, clinician should seek
appropriate guide,/supervision and refuse to proceed.
5. 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.
6. The importance of confidentiality in nursing practice was
stressed. 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.
7. Security/Safety of the patient before, during and after
operation is vested in the theatre team.
 It has already been implied earlier that 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.
• 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.
• 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:
1. Any patient going to theatre must be properly prepared
preoperatively.
2. The patient must be well labelled.
3. The patient must sign an informed consent, obtained by the
surgeon.
4. The patient must be protected from any harm, falls or eventuality,
during the stay in theatre.
5. Confidentiality must be observed regarding the patient.
5. Measures must be taken to ensure that the patient taken to
theatre is the right one for the intended operation.
6. 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.
7. Theatre nurses must know where the exits are, for use in case of
an emergency.
8. 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.
9. All electrical machines must be checked to ascertain optimum
function before use on the patient.
 Theatre design considerations
• The design depends on the :
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- patients and size of the hospital.
7. Planned technology.
8. Future plans expansion.
 Design consideration
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.
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 unoperated patient
12. separate areas should be allocated for
use
Anesthetic room Staff lounge
Scrub area Dark rooms for x-ray
Changing room and
Sterile supply area
cleaners room
Dirty utility area
Laboratory
Sterilizing room
Unsterile stock and heavy Operating suite
equipment area Clean corridors
Plaster room Separation between
Receiving area restricted and semi
Recovery area restricted areas
 Design - Theatre light
13. Fluorescent lighting is best for general illumination, with provision
for emergency back up (portable light)
14. In patients areas , white light is preferred as blue light will make the
patient look cyanosed
15. Over head lights 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.
16. The lights should be dimmed and increased by turning a knob
17. The lights should have an autoclavable handle covers so that the
surgeon can adjust the position of the light on the operating site.
 size

• 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
1. Walls and ceilings should be solid without windows,
2. Finishes of all surface material should be hard, non porous, fire resistant,
waterproof, stain proof, seamless, non reflective and easy to clean .
3. The ceiling should be a minimum of 10 feet high and have seamless
construction
4. The ceiling colour should be white to reflect at least 90% of the light in even
dispersion.
5. 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.
6. The walls should have stainless cuffs at collision corner to prevent damage.
 Floors
1. The floor should be made of antistatic materials.
2. It should be probably made of terrazzo or seamless polyvinyl
chloride that is continued up the sides of the wall for about six
inches.
3. The material should not degrade or wear out with aging and
cleaning.
4. They should be slip-proof when wet
5. It should be easy to clean by flooding or wet vacuum cleaning.
 Doors and ventilation
Doors:
1. Should about 4ft wide
2. Sliding doors, that can be swung open when necessary
3. They should not remain open during surgical procedures
Ventilation:
4. Air movement and air conditioning in the operating theatre are
regulated so that the patient and theatre staff are comfortable.
5. Air flow in the operating room is directed clean to less clean areas.
6. Relative humidity is maintained at between 50-55%
7. Heat and water loss can occur in small babies during prolonged
operations in cool air conditioning, hence humidity needs to be
adjusted
 Recirculating air
• A certain amount of the exhaust air is filtered to remove bacteria and
is then re introduced to the operating room.

Control of pollution and traffic

1. Anesthetic gases are scavenged from the expiratory valve of the
anesthetic machine to the atmosphere via tubing
2. Traffic of personnel is restricted in the operating room
3. A limited number of staffs should be present
 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.
4. The flow of supplies should from clean core area through
the operating rooms to the peripheral corridor.
5. Soiled materials should not re-enter the clean core area
 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.
 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
 Members Of The Surgical Team
• The surgeon
• Anaesthesiologist
• Nurse manager
• Receiving area nurse
• Circulating nurse
• Scrub nurse
 Theatre equipment’s
1. The operating table 10. heart-lung machine
2. The operating lights 11. Diagnostic imaging systems
3. The anaesthetic machines such as MRI and cardiac
catheterization
4. The anaesthetic cart
5. Sterile instruments 12. Instruments and patients
trolleys
6. Electronic monitor
13. Drip stands
7. The pulse oximeter machine
14. Laryngoscopes
8. Automated blood pressure
machine 15. Suction machines
9. An electrocautery machine 16. autoclave
(Diathermy machine)
 Basic general instruments
1. Cutting instrument’s- scalpel, scissors
2. Holding instrument’s- dissecting forceps, sponge holding forceps,
towel clips, babcock’s tissue holding forceps, tissue forceps, kockers.
3. Clamping instruments- artery forceps.
4. Exposing instruments- Retractors.
5. Suturing instruments- needle holders, suturing forceps toothed and
non toothed and ligature scissors.
 Maintaining a sterile field/Principles of
aseptic technique
1. Placing sterile items within sterile field and only sterile items are used
within sterile field
2. Opening, dispensing or transferring sterile items without contaminating
them.
3. Not allowing sterile personnel to reach across unsterile areas and touch
unsterile items
4. Not allowing unsterile personnel to reach across the sterile field or to
touch sterile items.
4. Whatever is sterile for one patient can only be used for that patient.
5. You must pour sterile fluids from a point high enough to prevent
accidental touching of the receptacle, but this should not produce
splashing.
6. If there is any doubt about the sterility of an article or area, it is
considered unsterile
7. Sterile objects become unsterile when touched by unsterile objects.
8. Sterile items that are out of vision or below the waist level of the
nurse are considered unsterile.
9. Sterile objects can become unsterile by prolong exposure to
airborne microorganisms.
10.The edges of a sterile field are considered unsterile.
11. 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.
12. 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.
13. A tear or puncture of the drape permitting access to an unsterile
surface underneath renders the area unsterile. Such a drape must
be replaced.
14. Sterile fields should be prepared as close as possible to the time of
use.
15. The movements of the surgical team are from sterile to sterile areas
and from unsterile to unsterile areas.
16. Scrubbed persons and sterile items contact only sterile areas;
17. Circulating nurses and unsterile items contact only unsterile areas.
18. Movement around a sterile field must not cause contamination of the
field.
19. Sterile areas must be kept in view during movement around the area.
At least a 1-foot distance from the sterile field must be maintained to
prevent inadvertent contamination.
20. Whenever a sterile barrier is breached, the area must be considered
contaminated.
SAFETY AND INFECTION PREVENTION IN
THEATRE
Safety and infection prevention are of utmost importance in
the operating theatre. To ensure this, in this section you will
consider the:
1. preparation of the operating theatre,
2. theatre nurse,
3. patient and equipment.
4. The equipment used in theatre and types of
anaesthesia.
 1. 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.
5. 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:
10.After the operation you should ensure:
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

 2. Preparation Of The Nurse
1. After entering the theatre unit, you should go straight to the changing
rooms.
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.
 3. 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.
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. For example, 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 which you
covered in the introductory block.
 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 wristbands 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.
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 Trolleys
• 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
• 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

The nurse must be aware of the anatomic and physiological changes

associated with patient positioning, and any procedure being done.
 POSITION USED IN SURGERY
1. Trendelenburg Position
Trendelenburg, which is most commonly used in pelvic operations, where the patient is
placed supine while the table is modified to a head tilt of 30-45 degrees and the table is
broken at the knee joint to lower the lower section slightly to flex the patient’s knees.
 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.
 Kidney position
Kidney position, where the bridge of the table is raised to elevate the
loins between the lower limbs and the iliac crest.
 Lithotomy
Lithotomy, which is used in perineum operation. The patient lies supine
position and the lower limbs are raised and abducted to expose
perineum, the legs and feet are on stirrups that support the lower
extremities, they should at even height. Both legs must be raised
simultaneously to avoid injury. The knees are flexed.
 Supine or laparotomy position
• Supine (laparotomy position), where the patient lies on the back
spinal column should be in a alignment with the legs parallel to the
bed, head in line with spin and face is upward, with arms on the
sides on arm boards.
 Prone position
• Anesthetized supine, usually on the stretcher prior to turning, Face down,
resting on the abdomen and chest, Head is turned to one side with
accessible airway, Forehead, eyes and chin are protected Access to the
posterior fossa of the skull, the posterior spine, the buttocks and perirectal
area, and the lower extremities
 Laminectomy Position
• Laminectomy position, where the patient is put in the prone
position with the head beyond the end of the table with the
forehead resting and supported on a horseshoe fixed six
inches below the level of the table.
 Sutures And Ligatures
• 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
multistranded
 1. 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
 2. 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
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
Uses:
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
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
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.
 Characteristic of sutures
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.
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.
• 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.
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.
 Size of sutures
• 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
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.
6. 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)
• 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 used for absorbing blood and fluids, protecting
tissues, applying pressure or traction and dissecting tissue during 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
a) Prior To Sterilization
• Use clean, uncontaminated, new swabs.
• 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.
 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.
• 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.
ROLE OF VARIOUS 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
 1. Role of receiving area nurse
1. Receive reports
2. Ensure cleanliness-floor, wall, furniture
3. Ensure availability of documentation charts preoperative check list,
consent form
4. Ensure resuscitation drugs are available and ready
5. Avail screens for patients
6. Ensure availability of patients trolley
7. Ensure that all the theatre list are available
8. Confirm about patients readiness for surgery
9. Send for patient from the award
10. Receive the patient from the ward and check for;
Identification ( name tag, file, theatre list)
Consent, investigation, blood, items ordered, premedication,
dentures, jewelry, nail polish (cutex), hygiene, theatre attire,
covering of hair, other documents.
11. Confirm surgical site
12. Transfer patient to theatre
13. Indicate in the theatre list
14. Inform concerned theatre, care for the patient till collection
15. Compile report.
 2. 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
8. Checks the instruments for correctness, and working conditions
9. Counts instruments, swabs and sharps, audibly which are then
recorded by the circulating nurse
10. Receives all the other items that are to be used during the operation
11. Wheels the trolley to the operating room and positions self and
trolleys creating a sterile field
12. Maintains the sterile field and anticipates the needs of the surgical
teem.
13. Maintain count of items used in the sterile field
14. Communicates with the surgical team members on the condition of
the patient.
15. Receives specimen from the surgeon and hands them over to the
circulating nurse.
16. Assists during the closure of the incision.
18. Remains sterile until the patient is out of the operating room
19. Moves the trolley and hands over patient to the circulating nurse.
20. Checks patient for diathermy burns,
21. Clears theatre, hands over instruments, and other items used in the
procedure to the sluice room attendant.
22. Un gowns, ungloves, washes hands and signs name in the register
23. Ensures that patients notes are written
24. Follows patient to the recovery ward
 3. 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
5. 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.

 4. 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
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.
5. Role of the PACU ( post anaesthetic care
unit) 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
18. While fully awake hand over patient to the ward nurse
19. Document time and patient state on exit.
 6. 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.
 7. Role of sluice room attendant
1. Ensures cleanliness of the sluice room
2. Ensures availability of cleaning materials
3. Ensures availability of disinfectants and decontamination solutions
4. Receives instruments from the scrub nurse
5. decontaminates, cleans, dries the instrument and assembles them
ready for sterilization
6. Hands over instruments to the sterilization staff
7. Updates all the records in the sluice room
8. Prepares other waste for disposal
 ANAESTHESIA

• Anaesthesia ( Greek word meaning “ without sensation”)

• 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
a. epidural anaesthesia This A regional anaesthetic delivered to the lower
spine to nump 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.
b. Spinal anaesthesia like epidural it targets the nerves of the spine and is
given as a single dose used to numb the lower part of the body.
3. General anaesthetic: 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
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 anaesthetic methods
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.
3. Field Block:
Similar to nerve block but cover a larger area and may involve
more than one nerve.
3. Refrigeration Analgesia
It is administered by use of a vapouriser. Drugs used
include: Ethyl chloride or Diethyl ether.
4. 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.
5. 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.
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 procedures 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.
• Pethidine 50 - 100mg intramuscular for adults, which has an analgesic effect on the
patient; and 25 - 50mg for children depending on age and weight.
• Diaepam 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
1. 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.
• 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, milk of anaesthesia) best for short procedures and
hypertensive patient contraindicated in shock.
 Muscle relaxants
Muscle relaxants can be divided into two 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
• GA –a reversible state consisting of complete loss of
consciousness that provides analgesia ,muscle relaxation and
sedation
• Protective reflexes are lost
• Consists of 3 major phases ie induction, maintenance and
emergence others are 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
hypersecretions (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
• 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
 Intraoperatively (during the operation)
• Depends on type of surgery ,type and amount of anesthesia
The circulating nurse:
1. Transfer of patient to operating room table
2. Positions the patient in the operating table
3. Maintains functional alignment
4. Exposure of surgical site
5. Observe patient critically for effects of;
6. Excessive fluid loss or gain ,watch for inflicted injuries
7. Distinguishes normal from abnormal cardiopulmonary data
8. Reports changes in patients vital signs
9. Institutes measures to promote normothermia
10. Mnx of bleeding ,reaction to anesthesia
 Discharge Of Patient From Post Anaesthesia Care
Unit (PACU)
Each facility may have an individual checklist or scoring guide to
include:
1. Stable vital signs
2. Adequate urine output (at least 30mls/hour)
3. Orientation to person , place and time
4. Satisfactory response to commands
5. Movement of extremities after regional anesthesia
6. Control of pain –minimal/tolerable
7. Control or absence of vomiting
General principle in post operative care
(after operation)
• The general principles in postoperative care include:
1. Ensuring clear airway
2. Supporting circulation
3. Controlling bleeding
4. Preventing infection
5. Monitoring any complications
6. Controlling pain
7. Ensuring return of gastro intestinal motility
8. Ensuring early ambulation
9. 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.
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.
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.
Preparing patient for discharge and home based care
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.
 Home based care concepts will be covered in another unit
 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.
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  Any extra procedure performed and the
 Elective/emergency procedure reason why it was performed.
Names of the operating surgeon and Details of tissue removed, added or
assistant altered.
Name of the theatre anaesthetists  Identification of any prosthesis used,
Name of the scrub nurse and circulating including the serial numbers of
nurse prostheses and other implanted materials
 Operative procedure carried out  Details of closure technique
Incision type Anticipated blood loss
Operative diagnosis  Antibiotic prophylaxis (where applicable)
Operative findings DVT prophylaxis (where applicable)
 Any problems/complications  Detailed postoperative care instructions
 Any extra procedure performed and the NAME AND SIGNATURE
reason why it was performed
 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
Avoid unnecessary building up of large stocks