Surgical Nursing Final

OR attire

Surgical scrubs, surgeon’s cap or bouffant, surgical mask

What is a surgical hand scrub?

Process of removing as many microorganisms as possible.

How many brush strokes should each surface get?

10 each, two times.

What is the traditional scrub?

Chlorhexidine or Provodine

How should a sterile hand towel be picked up?

Pick it up by a folded corner, step back, and unfold it

How should a sterile gown be put on?

1. 1.Pick up gown and step back

2. 2. Hold gown by shoulder and insert hands into armholes

3. 3. Let it unfold (do NOT shake)

4. 4.Advance both arms simultaneously (do NOT reach for the ceiling)

5. 5.Keep fingers inside the cuffs

6. 6.Have an assistant secure the closure

What is this called?

Closed gloving

What is this process?

Hand drying

What can you do after scrubbing to make it easier to glove?

Alcohol or Sterillium hand rub

What are the responsibilities of a surgical nurse?

Maintaining sterility, instrument/sharps count, sponge count, and passing of instruments

How should instruments be handed over?

“Snap”/place firmly into hand of surgeon

What are the 7 ways to accomplish hemostatis?

Sponge - blotting

Suture - ligate

Hemostatic agents (gelfoam)

Vascular clips - clamp

Forceps - crush

Electrosurgery - burn

Chemical cauterization - silver nitrate

What is the ideal surgical patient?

Clean, dry, and recently groomed

What are the 3 types of surgical clips?

Soft tissue, neurology, and orthopedic

What are examples of soft tissue procedures?

Ovariohysterectomy (spay - pyometra or c-section), Orchiectomy (castration - testicular or prostate cancer), onychectomy (declaw), Caudectomy (tail amputation)

Abdominal surgery shaving landmarks

Cranial: mid-sternum

Caudal: pubis

Lateral: last rib or flank

Spay shaving landmarks

Cranial: Xiphoid

Caudal: Pubis

Lateral: last rib or flank

Castration shaving landmarks

Cranial: mid prepuce

Caudal: cranial edge of scrotum

Lateral: 3 cm past nipple line

Soft tissue surgery examples

Anal sacculectomy, perianal fistula/hernia, inguinal mass, perineal urethrostomy, scrotal urethrostomy, urethral prolapse repair

Soft tissue limb procedures

Amputation of forelimb

Soft tissue head/neck procedures

Total ear canal ablation (TECA), ventral bulla osteotomy (VBO), salivary mucocele, pinnectomy, thyroidectomy, parathyroidectomy

Soft tissue thoracic procedures

Intercostal thoracotomy, median sternotomy, lung lobectomy, heart procedures

Dorsal hemilaminectomy shaving landmarks

Cranial: 2 vertebral spaces cranial to site

Caudal: 2 vertebral spaces caudal to site

Lateral: 2 clipper widths (9 cm) lateral to dorsal midline

Ventral slot (ventral hemilaminectomy) shaving landmarks

Cranial: ventral bola

Caudal: 2 cm caudal to manubriums

Lateral: lateral midline

Craniotomy shaving margins

Cranial: nose

Caudal: base of skull

Lateral: lateral to globe of eye & pinna

Orthopedic general landmarks

Joint above to joint below intended surgical site

Orthopedic forelimb procedures

Arthrodesis, arthroscopy, ORIF (fracture open reduction & internal fixation), Ex-fix (fracture external repair), Incongruity (elbow malalignment)

Orthopedic hindlimb procedures

TPLO (Tibial Plateau Leveling Osteotomy), MPLR (medial patella luxation repair), THR (total hip replacement), TKR (total knee replacement), CCLR (caudal cruciate ligament repair)

What is this technique for orthopedic cases called?

Hanging leg technique

What is used to scrub the patient?

Chlorhexidine (2% or 4% solution)

What is this scrubbing technique and what is it used for?

Target, used for soft tissue and neuro procedures

What is this scrubbing technique and what is it used for?

“Barber pole”, used for orthopedic procedures

Initial/preliminary scrub

Scrub clipped area to remove majority of debris, alternate scrub then rinse at least 3 times

Traditional sterile patient scrub

Sterile open gloving, sterile scrub (sterile sponges, saline/chlorohex), scrub in chosen pattern (scrub & rinse x3)

One-step prep

Chloraprep or duraprep, clean exam cloves, paint in chosen pattern (overlap each pass by 50%), allow to dry prior to draping

What is the inflammation process also called?

Vasodilation

How many growth factors do platelets release?

10

Tissue trauma/cellular death

-Injury that inflicts damage, which compromises the cutaneous, mucous barriers and compromises circulation

-Potential for bacterial growth or infection

The healing process is supported by what?

WBC’s, neutrophils, monocytes - macrophages, epithelial cells, endothelial cells, fibroblasts

Pathology of wounds

1. Laceration

2. Puncture

3. Incision

4. Contusion/bruise

5. Abrasion

6. Burn

7. Avulsion

Surgical wounds

Damage to tissues occurring during pre, intra, or post-operatively, compromises cutaneous and mucosa barriers which compromises circulation, potential for bacterial growth/infection

Primary closure/first intention

Skin is closed immediately after wound, heals without complications (no infection, good blood supply), reserved for surgical incisions

Second intention

Wound edges are not approximated, left open to heal from “inside out”, similar to first intention but takes longer to heal - generally weeks

Healing takes place by formation of:

Epithelialization (rebuilding of epidermal layers), granulation tissue (growth of new connective tissue & blood vessels), contraction of wound edges

What are the 3 phases of wound healing?

Lag phase, repair phase, maturation phase

Lag phase

-Begins immediately after trauma (inflammatory process & vasodilation), clot contraction (scab formation)

-Debridement - begins 6 hours after injury (lysis, necrosis, exudation), white blood cells leaked into wound, “clean up”

Repair phase

-Begins around day 4

-Three major components: Epithelialization (divide & migrate), Fibroplasia (produce collagen, wound strength), Capillary budding (revascularization of tissue)

Maturation phase

-Collagen rebuilds over 18-24 month period

-Tissue never regains full strength

Delayed primary closure

-wound is managed open for several days

-closed before granulation tissue appears

-direct apposition of skin, or reconstructive procedure (skin graft)

Secondary closure

-wound is managed open until granulation tissue is established

-closed by direct apposition of skin edges or reconstructive procedure

What are the 4 surgical wound classifications?

Clean, clean contaminated, contaminated, dirty

Clean wound

no entrance into bacterial flora

Clean-contaminated wound

Starts clean, enter bacterial flora, close clean

Contaminated wound

Traumatic injuty, intra-op gross spillage

Dirty wound

Pus present

Contamination vs. Infection

-all traumatic wounds are contaminated

-only considered infected if bacterial numbers are at least 10^5 bacteria per gram of tissue/fluid

Second intention healing

-wound edges left open

-cellularly identical to primary

-develops granulation tissue, epithelialization, contraction of wound edges/scar

-takes weeks to close

Triage

Assignment of degrees of urgency to wounds or illness to decide the order of treatment

Coaptation

-Pulling together separated tissue, as in a fracture

-Application of external appliance, such as a splint or cast

Dressing

Material used to cover and protect open wounds

Bandage

Material used to bind a wound or body part

Splint

Rigid material used to hold body part in fixed position

Cast

Rigid material encasing body part to hold in fixed position

Sling

Soft material suspending body part

What are the benefits of bandaging?

-Prevent further contamination

-Stabilize hard and soft tissue structures

-Absorb exudate/debris

-Limit/reduce hemorrhage

-Minimize edema

-Prevent self-mutilation

-Provide better healing environment

Exudate

A mass of cells and fluid that has seeped out of blood vessels or tissue

Debris

Foreign material, dead tissue/cells or fluid

Edema

Swelling caused by fluid trapped in tissue

Lavage

Flushing out wound with warm sterile fluids

Types of dressings

-Adherent

-Non-adherent

• -Occlusive (impermeable to air = moist environment)

• -Semi occlusive (used to debride wounds mechanically)

• -Non-occlusive (ex. Xeroform, impregnated mesh)

Primary layer of bandaging

Has direct contact with the wound, ex. Telfa pad, adaptic dressing, stockinet, or nothing

Secondary layer of bandaging

-Protective padding and stabilization, limits movement, holds contact layer in place, aids in absorption

-Cast padding or roll cotton, 2-3 layers

-May also include fortification (ex. fiberglass, plaster, prefabricated splint)

Tertiary layer of bandaging

-Protection and stabilization of second layer

-Cotton stabilized with conforming gauze - Kling

-VetWrap or Elasticon

Anatomy of a bandage

Robert Jones bandaging technique

-Immobilizes injury distal to elbow or stifle

-Must include joint above and joint below injury

-Copious amounts of roll cotton

-Thumps like a watermelon

-Only for short term stability

Modified Robert Jones bandaging technique

-Temporary compression after surgery

-Reduces swelling

-Most common

-Less cotton than Robert Jones

-Less stability

Fortified Robert Jones bandaging technique

-Modified Robert Jones + splinting material (ex. spoon splint, fiberglass, popsicle stick)

-Stabilizes both hard and soft tissue

-Reduces swelling

-Must include joint above and joint below injury

Cast bandaging technique

-Most rigid stabilization

-Encompasses limb

-Needs oscillating saw to remove

Spica Splint bandaging technique

-Similar technique as Modified Robert Jones, extends to top of forelimb and encompasses thorax

-Immobilizes shoulder, humerus, and elbow

Sling bandaging technique

-Relieve stress on joints

-Often lack 3-layer technique

-Can be homemade or purchased

Ehmer Sling bandaging technique

-Partially immobilizes & stabilizes hip joint

-Prevents weight bearing on hind limb

-Limb held in flexion

-Most prone to tissue trauma

Velpeau Sling bandaging technique

-Partially immobilizes scapular joint

-Prevents weight bearing on forelimb

-Limb held in flexion

-Can cause respiratory distress if too tight

“Other” bandages

-Tail (wagging injury, bite wound, VERY hard to do)

-Belly wrap (abdominal pressure after surgery)

-Head/ear (aural hematoma, TECA, ear cropping, need to be careful with tightness around neck)

Bandage complications

-Too tight (cuts off circulation which can lead to necrosis, pressure sores, skin irritation)

-Too loose (stability is compromised, can exacerbate injuries)

-Left on too long (pressure sores, tissue necrosis, muscle atrophy from disuse)

-Wet +/- Dirty (skin irritation, infection, poor healing environment)

Ideal suture

-Sterile

-Swaged needle

-creates as little tissue trauma as possible

-high tensile strength retention

-knot security

Suture classifications

-Absorbable vs Non-absorbable

-Natural vs. Synthetic

-Monofilament vs Multifilament (braided)

Antibacterial suture

-”Plus” sutures, coated with Triclosan

Suture size

-size of suture denotes is diameter

-measured in metric units

-USP scale runs from 11-0 (smallest) to #7 (largest)

Absorbability

-ability to be degraded and eliminated by the body

-natural material: proteolytic degradation & inflammation

-synthetic material: hydrolysis & inflammation

-non-absorbable: encapsulation & inflammation

Tissue healing times

-Skin: 5-7 days

-Subcutaneous: 7-14 days

-Peritoneum: 7-14 days

-Fascia: 14-28 days

Needle types

-Taper point

-Taper cut tip

-Traditional cutting

-Reverse cutting

Suture packet information

What are the 3 types of information given when asked for suture?

-Size

-Type

-Needle type or code

How should you select a suture type and size?

-Patient size

-Area (tissue) of placement (skin vs. hollow organ)

-Strength required

-Healing potential of tissue

-Importance of cosmetic appearance

-Cost

Knot security

-Multifilament have better knot security

-Minimum of 4 throws

-Knot is weakest point of suture line

-Depends on tying technique and physical characteristics of the suture material

Throw

Motion of wrapping the strands of the suture around each other and pulling on the ends to tighten them

Simple knot

Consists of 2 throws, can untie under tension

Surgeon’s throw

Suture is wrapped around needle holders twice before pulling tight

Continuous Sutures

-Simple continuous, Purse string

-Advantages: rapidly placed, less foreign material, better air/watertight seal

-Disadvantages: over tensioning could lead to tissue strangulation, breakdown of one are disrupts entire line (dehiscence), can transmit infection along entire suture line

Interrupted Sutures

-Simple interrupted, Cruciate, Horizontal mattress

-Advantages: more secure closure, precise suture tension, easily applied, microorganisms less likely to travel along row of sutures

-Disadvantages: slower, more foreign material, excessive tension can cause wound inversion