SCRUBBING, GOWNING, GLOVING AND ARRANGING SURGICAL EQUIPMENT

SCRUBBING, GOWNING, GLOVING AND ARRANGING SURGICAL EQUIPMENT




Objectives: After 12 hours of varied teaching-learning strategies, the level 2 students will be able to :


1. Define following terms:
1.1 pre-operative nursing
1.1.1 pre-operative phase
1.1.2 intra-operative phase
1.1.3 post-operative phase
1.2 analgesia
1.3 anesthesia
1.4 antiseptic
1.5 asepsis
1.6 consent
1.7 disinfection
1.8 homeostasis
1.9 medical asepsis
1.10 resident bacteria
1.11 sterile
1.12 sterilization
1.13 surgery
1.14 surgical asepsis
1.15 surgical conscience
1.16 surgical team
1.17 surgically clean
1.18 transient bacteria
2. discuss the operating room as to its:
2.1 personnel
2.2 physical lay-out
2.3 attire
2.4 set-up
3. recognize the importance of the following:
3.1 scientific principles involved
3.2 basic rules of surgical asepsis
3.3 duties and responsibilities of scrub and circulating nurse
4. familiarize the following
4.1 basic instruments found in basic sets
4.2 major pack and minor pack
4.3 sites for skin penetration
4.4 operative operations
5. discuss the following:
5.1 classification of surgery
5.1.1 different layers of the abdomen
5.1.2 common abdominal incisions
5.1.3 different types of:
5.1.3.1 suture
5.1.3.2 suture needle
5.1.3.3 blades
5.2 sterilization process
5.3 anesthesia
5.3.1 types of anesthesia
5.3.2 stages of anesthesia (with nursing responsibilities)
6. show beginning skills in:
6.1 filling up the consent form pre-operative checklist
6.2 opening the sterile pack
6.3 packing and sterilization
6.4 perform the following OR techniques
6.4.1 surgical handwashing
6.4.2gowning and gloving
6.4.3 draping
6.4.4 serving instructions
6.4.5 assisting in the operation
6.4.6 circulating










DEFINITION OF TERMS

1.1 Pre-operative Nursing
- Wide variety of nursing activities carried out before, during, and after surgery. It incorporates the 3 phases of surgical experience.
1.1.1 Pre-operative phase
 Before the surgical procedure
 Begins when the decision is made to undergo surgical intervention and end up when the patient is transferred to the operating table
 Nursing assessment is done during this phase
1.1.2 Intraoperative phase
 During the surgical procedure
 Begins from the transfer of the patient to the operating table and extends to the time the patient is admitted to the recovery room
 The implementation component of the nursing process takes place during this phase.
1.1.2 Post-operative phase
 After the surgical procedure.
 Lasting from admission of the patient to the recovery room
 Evaluation takes place during this phase.

1.2 Analgesia
- Lessening of or insensibility to pain/ absence of pain.
- A condition in which nociceptive stimuli are perceived but are interpreted as pain.


1.3 Anesthesia
- A state characterized by loss of sensation
- Absence of normal sensation especially sensitivity to pain

1.4 Antiseptics
- An agent that inhibits the growth of some microorganisms

1.5 Asepsis
- A condition in which living pathogenic organisms are absent.

1.6 Consent
- Permission given voluntarily by a person in his own will.

1.7 Disinfection
- The act of destroying pathogenic microorganisms or to inhibit their growth and vital activity
- The destruction of pathogenic microorganisms including their toxins or vectors.

1.8 Homeostasis
- The process through which such bodily equilibrium is maintained.

1.9 Medical asepsis
- Practices that limit the transmission of microorganisms and their growth and spreading action.

1.10 Resident Bacteria
- Microorganisms that usually resides on the skin, mucous membranes, respiratory and gastrointestinal tract.

1.11 Sterile
- Aseptic; without microorganisms
- Free from microorganisms and their spores.

1.12 Sterilization
- refers to any process that effectively kills or eliminates transmissible agents from a surface, equipment, article of food or medication, or biological culture medium. Sterilization does not, however, remove prions. Sterilization can be achieved through application of heat, chemicals, irradiation, high pressure or filtration.

1.13 Surgery
- is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, or sometimes for some other reason.
- is a medical technology consisting of a physical intervention on tissues. As a general rule, a procedure is considered surgical when it involves cutting of a patient's tissues or closure of a previously sustained wound.

1.14 Surgical Conscience
- awareness that develops from a knowledge base of the importance of strict adherence to principles of aseptic and sterile techniques.
1.15 Surgically clean
- mechanically cleaned but unsterile. Items are rendered surgically clean by the use of chemical, physical or mechanical means that markedly reduce the number of microorganisms on them.

1.16 Surgical Asepsis
- complete removal of microorganisms

1.17 Surgical team
- members of the surgical health care team include the surgeon, surgical assistants, the anesthesiologists or nurse anesthetist the circulating nurse, the scrub nurse and other allied support personnel.

1.18 Transient Bacteria
- are different from resident microorganisms in that they do not take up permanent residence in the gastrointestinal tract. Instead, they establish small colonies for brief periods of time before dying off or being flushed from the intestinal system via normal digestive processes, and/or by peristaltic bowel action.


Personnel

SUBDIVISIONS of OR team

Sterile Team members

1. Surgeon
- Must have the knowledge, skill and judgment required to successfully perform the intended surgical procedure and any deviations necessitated by unforeseen difficulties.
- Responsibilities include preoperative diagnosis and care and performance of the surgical procedure and post-operative management of care.
- Is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD), or pediatrist who is to perform surgical procedures

2. Assistants to the surgeon
- Under the direction of the operating surgeon, one or two assistant help to maintain visibility of the surgical site, control bleeding, close wounds and apply dressings. The assistant handles tissues and uses instruments.
- The role of and need for an assistant will vary with the type of procedure or surgical specialty, the condition of the patient and type of surgical facility. In determining this need, the characteristics of the surgical procedure should be evaluated:
 Anticipated blood loss
 Anesthesia time for the patient
 Fatigue factors affecting the OR team
 Potential complications

3. First Assistant in Surgery
- Ideally is a qualified surgeon or a resident in an accredited surgical evaluation program
- Should be capable of assuming responsibility for performing the procedure for the primary surgeon

4. Non-physician first assistant
- are required to complete a formal education program for first assisting according to their practice discipline

5. Physicians Assistant (PA)
- Is a generic term with 2 subcategories:
 Assistant to the primary physician (PCCA or PA) Physicians clinical assistant
 Assistant to the surgeon (SA or PSA) Physicians surgical assistant
- Under the direct supervision of a surgeon

6. Registered Nurse First Assistant
- A certified preoperative nurse (CNOR) who has successfully completed an approved program based on the curriculum for the Registered Nurse First Assistant of AORN (Association of Preoperative Registered Nurses), may seek a position as a registered nurse first assistant (RNFA) with a private surgeon, hospital or clinic. The RNFA functions solely as the first assistant and should not simultaneously perform the functions of a scrub nurse.

7. Surgical Technologists First Assistant
- A certified surgical technologists (CST) may also trained to first assist. After successfully passing a national examination, the CST first assistant may use the acronym CST or CFA

8. Second Assistant to the Surgeon
- qualified nurses and surgical technologists may be used as second or third assistant for surgical procedures in which the surgeon deems their assistance is adequate and for which they have been trained. Second and third assistants are not involved in the actual performance of the procedure but primarily work with minimally invasive procedures, such as holding the endoscopic camera

9. Scrub person
- is a patient care staff member of the sterile team
- the scrub role may be filled by a registered nurse (RN), a licensed practical or vocational nurse (LPN or LVN), or a surgical technologists (ST)

Unsterile Team Members

1. Anesthesia Provider
- Is an MD or DO, preferably certified by the American Board of Anesthesiology, who specializes to the art and science of administering anesthetics to produce various states of anesthesia
- An anesthetist (local not general) is a qualified RN, dentist or physician who administers anesthetics. He works under the direct supervision of the anesthesiologists or the surgeon

2. Circulator
- Vigilant; documents the chart
- Is preferably an RN. A qualified ST may assist with circulating duties under the supervision of a RN. The circulator plays a role that is vital to the smooth flow of events before, during and after the surgical procedure.
SCIENTIFIC PRINCIPLES INVOLVED
Anatomy and Physiology
epidermis is the term used to designate the outer surface layer of the skin

Chemistry
rubbing alcohol combines with the albumins of the skin tissue and make it more resistant to pressure.

Microbiology
sterility is maintained throughout the procedure. Thorough hand washing should be done for protection of patient as well as the nurse and other sterile team members.

Pharmacology
drugs that act in the skin maybe classified as demulcents, protectives, astringents, antiseptic and disinfectants

Psychology
isolated patient must be well instructed.

Sociology
attitude of the isolated patient may depend on knowledge of the disease or problem.

Body Mechanics
proper body mechanics in order to prevent muscle strains for the nurse.

Responsibilities of scrubbed and circulating nurse
- These responsibilities may be divided into those who assumed and performed by the scrubbed members of the team and those assumed and performed by the circulating ones. They may further classified into those performed before the operation, during the operation and after the operation.

A. Responsibilities of scrubbed nurse before the operation

1. Physical attire
a. cap – all hair must be covered
b. mask – must cover the mouth and nose
c. dress – sleeves well above elbows
d. shoes – conductive rubber soles or shoe covers
e. Fingernails should be trimmed preferably without polish

2. Surgical scrub
There is much variation in this technique, but all methods are based upon the basic principle: namely, to remove bacteria from the skin. However, the surgical scrub only removes as many bacteria as possible from the hands and arms by mechanical washing or friction and chemical disinfection.

3. Procedures for dressing the person scrubbed vary as far as the gown and especially the glove technique are concerned.

a. Drying the hands and arms after scrubbing
b. Gowning and gloving: the sterile gown is worn to permit the wearer to come within the sterile field and carry out sterile technique during the operation.

4. prepare the sterile field for the operation

B. responsibilities of scrubbed nurse during the operation

1. pass the instruments
2. have all materials ready for use
3. anticipate the needs of surgical team
4. keep field neat, clean and dry
5. count sponges when necessary
6. prepare the sterile dressing which will be applies when the operation is complete

C. Responsibilities of scrubbed nurse after the operation

1. care for instruments- open used ones for the washing process
2. care for the immediate rinsing of rubber gloves
3. remove scalpel blades
4. care for tissue specimen
5. care for special instruments and equipment used
6. care for used basin
7. dispose of waste material properly

The circulating nurse must know all supplies, instruments and equipment as well as their location, use and care. They are responsible for the technique in their unit and must anticipate the needs of all persons functioning in that area.

D. Responsibilities of circulating nurse before the operation

1. prepare the operating room or unit
2. assist scrubbed personnel
3. count sponges before the operation begins
4. care of the patient during anesthesia
5. tie surgeon’s gown
6. assist with preparation of the patient

E. Responsibilities of circulating nurse during the operation

1. keep check to see that all equipment is in good working order
2. keep room neat and tidy
3. count sponges at appropriate time
4. take care of needs of the entire operating team throughout the operation
5. make out necessary forms

F. Responsibilities of circulating nurse after the operation

1. take care of the needs of the patient first
2. care of the tissue specimen
3. disconnect all special equipment and see that it is cared for
4. assist with general cleaning equipment and rearrangement for the operating room in preparation for the next operation in that room

Principles of surgical asepsis
-when beginning a surgically aseptic procedure, the nurse follows certain principles to ensure maintenance of asepsis. Failure to follow these principles places clients risk for infection. The following principles are important:

1. A sterile object remains sterile only when touched by another sterile object. The principle guides the nurse in placement of sterile objects and how to handle them.
2. Only sterile objects may be placed on a sterile field. All items are properly sterilized before use. Sterile objects are kept in clean, dry storage areas. The package or container holding a sterile object must be intact and dry.
3. A sterile object of field out of the range of the vision or an object held below a person’s waist is contaminated. Nurses never turn their backs on a sterile tray or leave it unattended.
4. A sterile object or field becomes contaminated by prolonged exposure to air. The nurse avoids activities that may create air currents, such as excessive movements or rearranging linen after a sterile object of field becomes exposed.
5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object of field becomes by capillary object. If moisture seeps through a sterile package’s protective covering, microorganisms travel to the sterile object.
6. fluid flows in the direction of gravity. A sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the object’s surface.
7. the edges of a sterile field or container are considered to be contaminated. Frequently a nurse places sterile objects on a sterile towel or drape. Because the edge of the drape touches an unsterile surface, such as a table or bed linen, a 2.5 cm border around the drape is considered contaminated.

BASIC INSTRUMENTS FOUND IN BASIC SETS
IRIS SCISSORS
are used for remove necrotic tissue.






BANDAGE SCISSORS
used to:
• to cut through custom-fit bandages.
• to cut through medical gauze.
• to cut through bandages already in place






SUTURE SCISSORS
used to close a wound. They are used in an attempt to improve and speed healing. Pulling the edges of a wound together and stitching help in healing process. Sutures are used to close cuts from injuries or surgery. They are commonly used on the skin, internal tissues, organs, and blood vessels.






TOWEL CLUMP
towel clamps are used to maintain surgical towels and drapes in the correct position during an operation.






MAYO
used to cut heavy tissues(muscle, uterus)









METZEMBUAM
used to cut delicate tissue.









ALLIS
used to grasp tissue








BABCOCK
used for grasp delicate tissue(intestine, fallopian tube and ovary)









BASIC INSTRUMENTS FOUND IN THE BASIC SET

• Towel Clips
• Kelly curve
• Kelly straight
• Allis tissue forcep
• Babcock forcep
• 3 Kidney basin(1 big and 2 small)
• 1 pair of army navy
• Toothed forcep
• non-toothed forcep
• metzenbuam
• Mayo
• Suture scissor
• Bandage scissor
• Iris scissor
• Stevens
• Cautery
• Yankauer


CONTENTS OF MAJOR AND MINOR PACKS

A) MAJOR
• ♂ 5 O.R GOWNS
• ♂ 5 HAND TOWELS
• ♂ 1 MAYO COVER
• ♂ 1 LAPARATOMY SHEET
• ♂ 6 DRAPING TOWELS
• ♂ 1 LAP SHEET
• ♂ 20 (4X8) OPERATIVE SPONGES
• ♂ 20 O.S
• ♂ 6 TOWELS
B) MINOR
• ♀ 5 O.R GOWNS
• ♀ 5 HAND TOWELS
• ♀ DRAPING TOWELS
• ♀ 2 PLAIN SHEET
• ♀ 20 O.S
• ♀ 6 TOWELS





PATIENT’S SKIN PREPARATION ON THE OPERATING TABLE

AREA
- After patient has been anesthetized and positioned on operating table, an extensive area surrounding it is mechanically cleansed again with an antiseptic agent immediately prior to draping.


SITES:

1. Abdominal Preparation
- The area includes breast line to upper third thighs, from the table line, with patient in supine position.

2. Lateral Thoracoabdominal Preparation
- Area includes the axilla, chest, abdomen, from the neck to the chest of the ilium. The area extends beyond midline, anteriorly and posteriorly.

3. Chest and Radical breast Preparation
- Area includes shoulder, upper arm down to the elbow, axilla and chest wall to the table beyond the sternum to the opposite shoulder in lateral position.

4. Rectoperineal and Vaginal Preparation
- Includes the pubis, vulva, labia’s, perineum, anus, and adjacent areas, including the inner aspect of the upper third of thighs.

5. Hip Preparation
- Abdomen of the affected side, thigh to knee, buttocks to table line, groin and pelvis.

6. Knee and Lower leg Preparation
- Includes the entire circumference of affected leg and extends from foot to upper part of thigh.








COMMONLY USED OPERATIVE PATIENT POSITIONS

SUPINE
Flat on back with arms at side, palms down, legs straight with feet slightly separated.

PRONE
Patient lies on abdomen with face turned to one side, arms at side with palms pronated, elbows slightly flexed; feet elevated on pillow to prevent plantar flexion.

TRENDELENBURG
Head and body are lowered into a head-down position and held in place with padded shoulder braces; knees are flexed by breaking table.

REVERSE TRENDELENBURG
Head is elevated and feet are lowered.

LITHOTOMY
Patient lies on back with buttocks to edge of table; thighs and legs are placed in stirrups simultaneously to prevent muscle injury; head and arms are secured to prevent injury.

LATERAL
Patient lies on side; table maybe bent in middle.




LAYERS OF THE ABDOMINAL WALL

1. Skin
a. Epidermis -- the part we shed.
b. Dermis -- contains nerves, capillaries, sweat glands, hair follicles.
2. Subcutaneous
- is the layer of fat that lies between the dermis of the skin and underlying fascia.
- This layer is important because it regulates the temperature of the skin itself and the body.
3. Fascia
- soft tissue component of the connective tissue system that permeates the human body.
- It interpenetrates and surrounds muscles, bones, organs, nerves and blood vessels and other structures.
a. Superficial Fascia
- Is found in the subcutis in most regions of the body, blending with the reticular layer of the dermis.
- It serves as a storage medium of fat and water
b. Deep Fascia
- Is the dense fibrous connective tissue that envelopes all bone, blood vessels and become specialized in muscles and nerves.
c. Subserous Fascia
- a layer of loose connective tissue that serves as a glue to hold the peritoneum to the deep fascia.
4. Muscles
- Three flat muscles plus the longitudinal rectus sheath muscle.
a. External Abdominal Oblique -- muscle fiber direction is antero-inferior (like external intercostals -- hands in pocket).
- Originate at border of Thoracic ribs T5 - T12
- Extends to midline and attaches on linea alba. Also attaches to the iliac crest.
- Also forms the superficial inguinal ring, which allows passage of the spermatic cord (male) or round ligament (female).
-
b. Internal Abdominal Oblique
- Also has fibers that attach along the inguinal ligament to the pubic crest.
- Direction of fibers tends to go outward, from medial to lateral and a little bit inferiorly (inferolaterally).
- Borders on ribs 7 - 12.
c. Transversus Abdominis Deep most layer of flat muscles.
- Also borders on ribs 7 - 12. Extends down to the pubic crest and medially to the linea alba.
- It creates a diagonal pathway for the spermatic cord or round ligament to pass through.
- Fibers run transversely! -- horizontally from lateral to medial.
d. Rectus Abdominis: Straight muscle.
- Passes from Xiphoid Process inferiorly to pubic symphysis (inferior center of pubic bone).
5. Peritoneum
- is the serous membrane that forms the lining of the abdominal cavity- it covers most of the intra-abdominal organs.
a. Parietal peritoneum
- The outer layer
- Attached to the abdominal wall
b. Visceral Peritoneum
- Inner layer
- Wrpped around the internal organs that are located inside the intraperitoneal cavity.

Common Abdominal Incisions

A. Vertical incision:
1. Midline incision
- universally acceptable incision
- in the upper abdomen, the incision is made in the midline extending from the area of xiphoid and ending immediately above the umbilicus.
- In the upper abdomen, it is widely used for gastric and duodenal operations and gives adequate exposure for biliary and pancreatic surgery.
- In the lower abdomen it is commonly used for gynecologic, urologic, and colonic operations.





2. Paramedian incision
- vertical incision about 4cm lateral to the midline on either side of the abdomen.
- Provide access to the lateral structures such as the spleen and the kidney.







B. Transverse and oblique incision

1. Kocher’s subcostal incision
- Started at the midline, 2-5cm below the xiphoid and extends downwards, outwards and parallel to and about 2.5cm below the costal margin.
- On the right, this incision is frequently used for operation on the biliary tree, on the left, for splenectomy.




2. Mc. Burney’s Grid Iron or Muscle splitting incision
- The level and the length of the incision will vary according to the thickness of the abdominal and the suspected position of the appendix.
- Classically, the incision is made at the junction of the middle third and outer thirds of line running from the umbilicus to the anterior superior iliac spine.
- This incision, or some modification, is the most popular for appendiceal surgery.







3. Pfannenstiel Incision
- used frequently by gynaecologists and urologists for access to the pelvic organs, bladder, prostate and for caeserian section.
- The skin incision is usually 12cm long and is made in a skin fold approximately 5cm above symphysis pubis.
- Offers excellent cosmetic results because the scar is almost always hidden by the patient’s pubic hair postoperatively.






C. Retroperitoneal Incisions

1. Retroperitoneal Approach to Lumbar Area
- the skin incision begins at the level of umbilicus at the margin of the lateral rectus sheath and it is extended into the flank toward the twelfth rib for 12 to 20 cm.
- this incision is most frequently used for vena caval ligation, lumbar sympathectomy, or ureterolithotomy.
Explanation: you can see there the lower pole of yhe kidney, vena cava and the ureter.
During the incision, the patient is positioned in supine position with the right side elevated approximately 30-45 degrees and the right knee and hip flexed.


2. Retroperitoneal Approach to Iliac Fossa
- the incision extends from just medial to the iliac tubercle to just lateral to the pubic tubercle.
- The incision gives exposure to the pelvic ureter, iliac, hypogastric, and femoral vessels, and the bladder.

D. Abdominothoracic Incision
- either right or left, converts the pleural and peritoneal cavities into one common cavity and thereby gives excellent exposure.
- The right incision may be particularly useful in elective and emergency hepatic resection.
- The left incision may be useful effectively in resection of the lower end of the esophagus and proximal portion of the stomach.







Types Suture Needles
a. Points of needles
1. cutting point->may be preferred when tissue is difficult to penetrate (skin, tendon, tough, tissue in the eye). Degree of sharpness of cutting edge varies:
a) Conventional cutting needle -> have 2 opposing cutting edges with a 3rd edge configuration on the needle. The cutting edges are on the inside curvature of a curve needle.
b) Reversed cutting needle -> have triangular configuration that extends along the body of the needles.
c) Side cutting needle -> flat on top and bottom. Use primarily on ophthalmic surgery.
d) Trocar points -> sharp cutting tips are the points of tapered needles.
2. Taper points -> are used in soft tissues (intestines and peritoneum) which offer a small amount of resistance to the needle as it passes through. They tend to push the tissue aside rather than cut it.
3. Blunt points -> are designed with a rounded point at the tip. They are used for suturing pliable tissues (liver and kidney)
b. Surgical needles
• specification of needles
1. Strong enough that it doesn’t break easily
2. Rigid enough to prevent excessive bending, yet flexible enough to prevent from breaking after bending.
3. Sharp enough to penetrate tissue with minimal resistance, yet stronger than the tissue it penetrates.
4. Approximately in shape, size for the type, condition and accessibility of tissue is sutured.
5. Appropriate in shape, size for the type, condition and accessibility of tissue is sutured.
6. Free from the corrosion and burns to prevent infection and tissue trauma.
c. Eye of the needle
 Eyed needle -> the closed eye of an eyed surgical needle is like that of any household sewing needle. The shape of the enclosed eye may be round, oblong or square.
 French-eyed needle -> sometimes referred to as “spring eye” or “split eye”. It has a slit from the inside of the eye to the of the needle through which the suture strand is drawn.
 Eyeless needle -> a continuous until with the suture strand. The needle is swaged into the end of the strand in the manufacturing process. The diameter of the needle matches the size of the strand as closely as possible. The surgeon uses sharp needle with every suture strand.
 single armed attachment- has 1 needle swaged to the suture strand.
 double armed attachment-has a needle swaged to each end of the suture strand: the 2 needles are not necessarily the same size and shape.
 Permanently swaged needle attachment-is secured so that the needle will not separate from the suture strand under normal use
 Controlled release needle attachment-secured so that the suture strand doesn’t separate from the needle inadver but doesn’t rapidly when pulled off intentionally.



Types of Blades
A. cutting and dissecting
• scalpels
• knives
• scissors
B. Blades may vary by size and shape:
1. #10 blade
2. #11 blade
3. #12 blade
4. #15 blade
5. #23 blade
6.
Specification for suture materials
• Must be sterile when placed in tissue
• Must be predictably uniform in tensile strength by size and material
• Must be small in diameter and safe to use on each type of tissue
• Must have knot security remain tied and give support to tissue during the healing process.
• Must cause as little foreign body-tissue reaction as possible.

Types of suture material

1. Absorbable suture
• sterile strands prepared from collagen, derived from healthy mammals or from a synthetic polymer. They are capable of being absorbed by living mammallian tissue, but may be treated to modify resistance to absorption.
They may be colored by a color additive.
• are dissolved or digested by body enzymes hydrolyzed by body tissue
• types:
1. surgical gut (plain or chronic)
2. collagen
3. glycolic acid polymers
• -absorbable sutures are digested by enzymes first by losing their strength, then gradually disappearing from the tissue
>Natural sources of absorbable sutures
1. Surgical gult -> often referred to as catgut; is a collagen from submucosa of sheep intestine or serosa of beef intestines.
2. Collagen -> purest from of “gut”, are extruded from a homogenous dispersion of pure collagen fibrils from the flexer tendons of beef.
>Synthetic source of absorbable sutures
1. Polyglactin 910 (vircyl) -> the précised controlled combination of glycolide and lactide results in a copolymer with a molecular structure that maintains tensile strength longer that surgical gut, but not as long as polydioxanome
2. Polyglycolic acid (Dexon) -> the homopolymer of glycolic acid tensile strength more rapidly and absorbs significantly more slowly than polyglactin 910. Strands are smaller in diameter.
3. Polydioxanome (PDS) -> useful in tissues in which slow healing is anticipated as in the fascia, or when extended wound support is desirable. They may be used in the presence of infecton; they will not harbor bacterial growth beause of their chemical and nonfilament construction.

2. Non-absorbable Sutures
- Sutures when used in minimal inflammatory response is desired, as in skin sutures, also when the wound requires continuous support longer than 1-3 weeks.
Ex. With vascular anastomosis, abdominal closure and
intestinal anastomosis
● Natural sources of Non-Absorbable sutures
1) Cotton – infrequently used today, tends to split, used for muscle or fascia.
2) Silk – most commonly used, may be twisted or braided, compose of single filament and ties most easily and usually well-tolerated by patients
- used in ophthalmology, GIT, brain and
cardiovascular system and as skin closure.



STERILIZATION PROCESS

- process by which all pathogenic and non-pathogenic microorganisms, including the spores, are killed.
- this term refers only to a process capable of destroying all forms of microbial life, including spores.
- the sterilizer is a piece of equipment used to attain either physical or chemical sterilization.




ANESTHESIA

• the goals of anesthesia are to provide analgesia, sedation, and/ or muscle relaxation appropriate for the type of operative procedure, as well as to control the autonomic nervous system.

TYPES OF ANESTHESIA
1. General Anesthesia
- blocks the pain stimulus at the cortex of the brain and depress the central nervous system (CNS). Loss of reflexes and skeletal muscle tone ensues, along with analgesia, amnesia, and unconsciousness.
1.1 Intravenous Anesthesia
• gives simple, pleasant, and rapid induction.
• it is commonly used to induce unconsciousness before more potent inhalation anesthetics are given.
1.2 Inhalation Anesthesia
• is a mixture of anesthetic liquids in volatilized form or gases mixed with oxygen.
• Ether was one of the first inhalation anesthetics used, but now is seldom used.
• it is flammable gas and can irritate the eyes and skin, plus it causes considerable post-operative nausea and vomiting.

2. Regional Anesthetics
- is used when only one part of the body will be involved in surgery.
• the nurse's role is increased in the use of in the use of regional anesthesia because the patient is awake and may be alert throughout the surgical procedure.
2.1 Spinal anesthesia
• nerve blockage n the sub arachnoid space.
• is used for surgical procedures performed below the level of the diaphragm, such as hysterectomy, appendectomy, and hernia repair.
2.2 Saddle Block
2.3 Epidural Block
2.4 Caudal Block
2.5 Local Infiltration anesthesia
2.6 Local surface or Topical anesthesia

3. Balanced Anesthesia
- to obtain a desired general anesthetic effect, the combination of several drugs is commonly used. This “balanced anesthesia” should provide not only sleep but also analgesia, elimination of certain reflexes, and good muscular relaxation.

STAGES OF ANESTHESIA
Stage 1 – ANALGESIA
Is the onset of anesthesia and analgesia and is noted by loss of consciousness after the patient appears drowsy and wants to sleep. Sensations of smell and pain are abolished before the patient loses consciousness. He may experience dreams and auditory or visual hallucinations. Speech becomes difficult and incomprehensible. There may be a ringing in the ears and an inability to move(paralysis)sensation.



Stage 2- EXCITEMENT
is the excitement phase and is seen by an increase in autonomic activity (pulse increases), irregular breathing , and some struggling of the patient may shout, laugh, cry, swear or sing as autonomic activity increases.

Stage 3 – SURGICAL
is the surgical anesthesia phase and consists of four planes. The patient is completely unconscious and his muscles are relaxed, beginning with the small muscles and continuing to the point of loss of most muscle reflexes and depression of vital functions.

Stage 4 – DANGER
is called the danger or toxic phase and is exemplified by cessation of breathing and may lead to both respiratory and circulatory failure.