32,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Rapid
- Sprache: Englisch
Rapid Perioperative Care is an essential text for students and practitioners requiring up-to-date fundamental information on the perioperative environment. Covering a wide range of subjects related to perioperative practice and care, each chapter is concise and focused to guide the reader to find information quickly and effectively. This book uses a structured approach to perioperative care, starting with an introduction to the perioperative environment, anaesthetics, surgery and recovery, followed by postoperative problems and finally the roles of the Surgical Care Practitioner (SCP).
Covering all the key topics in the perioperative environment, this concise and easy-to-read title is the perfect quick-reference book for students and theatre practitioners to support them in their work in clinical practice, and enable them to deliver the best possible care.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 920
Veröffentlichungsjahr: 2016
Ähnliche
Table of Contents
Title Page
Copyright
Preface
Acknowledgements
Abbreviations
Section 1: Preoperative Preparation
Chapter 1: The Role of the Anaesthetic Practitioner
Preanaesthetic phase
Anaesthesia
Checking the anaesthetic machine
Monitoring responsibilities
Conclusion
Chapter 2: The Role of the Surgical Practitioner
Scrub practitioners
Circulating practitioners
Chapter 3: The Role of the Recovery Practitioner
The role of practitioners in recovery
Admission to recovery
Initial assessment of a patient
Discharge of patient
Chapter 4: Preoperative Assessment of Perioperative Patients
Introduction
Preoperative preparation
Reducing postoperative complications
Chapter 5: Perioperative Patient Care
Preoperative visiting
Patient preparation
Care during anaesthesia
Intraoperative care
Transferring the patient to recovery
Postoperative care
Discharge of the patient back to the ward
Chapter 6: Operating Theatre Attire and Personal Protective Equipment
Chapter 7: Surgical Safety Checklist
Team brief
Pre-anaesthetic SIGN IN
TIME OUT
SIGN OUT
Conclusion
Chapter 8: Teaching Students How to Use Operating Theatre Equipment
Anaesthetic equipment
Surgical equipment
Principles of the swab and instrument count (SIC)
Basic surgical instruments
Chapter 9: Perioperative Equipment
Initial equipment checks
Operating room equipment
Anaesthetic equipment
Equipment for resuscitation
Patient-monitoring equipment
Surgical equipment
Other operating room equipment
Conclusion
Chapter 10: Managing Perioperative Medication
Introduction
Principles of managing medication
Perioperative medications
Conclusion
Chapter 11: Interprofessional Learning and Collaboration
Providing interprofessional learning
IPL for students
Conclusion
Chapter 12: Preventing Surgical Site Infection
Surgical site infections
Risks associated with SSIs
Causes of SSIs
Perioperative care
Conclusion
Chapter 13: Skin Preparation for Surgery
Surgical skin preparation
Skin prep solutions
Summary
References and Further Reading
1. The Role of the Anaesthetic Practitioner
2. The Role of the Surgical Practitioner
3. The Role of the Recovery Practitioner
4. Preoperative Assessment of Perioperative Patients
5. Perioperative Patient Care
6. Operating Theatre Attire and Personal Protective Equipment
7. Surgical Safety Checklist
8. Teaching Students How to Use Operating Theatre Equipment
9. Perioperative Equipment
10. Managing Perioperative Medication
11. Interprofessional Learning and Collaboration
12. Preventing Surgical Site Infection
13. Skin Preparation for Surgery
Section 2: Anaesthesia
Chapter 14: Preoperative Evaluation of the Anaesthetic Patient
Identification of high-risk patients
Preoperative visits
Previous problems
Smoking
Alcohol and medications
Obesity
Bleeding problems
Conclusion
Chapter 15: Preparing Anaesthetic Equipment
Anaesthetic machine
Anaesthetic equipment
Chapter 16: Checking the Anaesthetic Machine
Checking the anaesthetic machine
Checking the anaesthetic machine
Manual Ventilation
Conclusion
Chapter 17: Anatomy and Physiology: The Cardiovascular System
The heart
Blood vessels
Arteries and arterioles
Blood
Cardiovascular system physiology
Chapter 18: Anatomy and Physiology: The Lungs
Oxygen exchange
Lung problems
Conclusion
Chapter 19: General Anaesthesia
Premedication
Anaesthetic induction
Airway management
Maintenance of anaesthetic
Monitoring
Complications
Chapter 20: Local Anaesthesia
Pathophysiology
Action of local anaesthetics
Local anaesthetics
Administration of LAs
Allergic reaction to LAs
Chapter 21: Regional Anaesthesia
Examples of surgical procedures
Regional blocks
Chapter 22: Rapid Sequence Induction
Introduction
Airway protection
Steps taken for rapid sequence induction
Preparing for RSI
Drugs used for RSI
Undertaking RSI in different settings
Chapter 23: Total Intravenous Anaesthesia (TIVA)
TIVA actions
Main aims of TIVA
Conclusion
Chapter 24: Airway Management
Assessing the airway
Airway management techniques
Preparation for intubation
Airway emergencies
Conclusion
Chapter 25: General Anaesthetic Pharmacology
Premedication
Anaesthetic induction
Neuromuscular blocking agents
Maintenance of anaesthesia
Emergence from anaesthesia
Postoperative care
Chapter 26: Intraoperative Fluid Management
Body water distribution
Capillary fluid shifts
Distribution of crystalloid fluids
Distribution of colloid fluids
Administration of intraoperative fluids
Oesophageal doppler monitoring
Conclusion
Chapter 27: Monitoring Perioperative Patients
Setting up monitors before anaesthesia
Monitors during and after anaesthesia
References and Further Reading
14. Preoperative Evaluation of the Anaesthetic Patient
15. Preparing Anaesthetic Equipment
16. Checking the Anaesthetic Machine
17. Anatomy and Physiology: The Cardiovascular System
18. Anatomy and Physiology: The Lungs
19. General Anaesthesia
20. Local Anaesthesia
21. Regional Anaesthesia
22. Rapid Sequence Induction
23. Total Intravenous Anaesthesia
24. Airway Management
25. General Anaesthetic Pharmacology
26. Intraoperative Fluid Management
27. Monitoring Perioperative Patients
Section 3: Surgical Specialities
Chapter 28: Laparoscopic Surgery
Basic principles of laparoscopic surgery
Equipment
Difficulties for surgeons
Conversion to open
Further developments and innovations
Chapter 29: Vascular Surgery
Vascular risk factors
Aneurysms
Lower limb ischaemia
Amputations
Arterial disease of the upper limb
Carotid embolisation
Venous disease
Chapter 30: Cardiothoracic Surgery
Cardiac surgery
Acquired heart disease
Congenital cardiac disease
Valvular heart disease
Thoracic surgery
Chapter 31: Orthopaedics and Trauma
Investigations
Orthopaedic specialities
Conservative management
Operative management
Fractures
Joint replacements
Specialist equipment
Chapter 32: Gynaecology Surgery
Gynaecology presenting symptoms
Examination and diagnostic tests
Gynaecological infections
Pelvic floor dysfunction
Pelvic neoplasms
Chapter 33: Plastic Surgery
Scope of plastic surgery
Wounds
Grafts
Other grafts
Flaps
Tissue expansion
Burns
Reconstructive surgery
Congenital abnormalities
Chapter 34: Urology
Common urological symptoms
Investigations
Common diagnoses
Urological surgery
Chapter 35: Breast Surgery
Breast clinic
Specific evaluation of breast patients
Factors which increase the risk of breast cancer
Management of high-risk patients
Breast disease
Surgical procedures
Imaging
Tissue diagnosis
Complications of mastectomy
Risk factors for tumour recurrence
Chapter 36: Endocrine Surgery
Thyroid
Parathyroid
Adrenal disorders
Gastrointestinal endocrine tumours
Chapter 37: Colorectal Surgery
Investigations
Colorectal disorders
Colorectal cancer
Anal, perianal and rectal disorders
Procedures
Colon tests and investigations
Indications for resections
Factors to consider with anastamosis
Complications of colonic resection
Chapter 38: Upper Gastrointestinal Surgery
Oesophagus
Peptic ulceration
Gastric neoplasia
Miscellaneous disorders of the stomach
Miscellaneous disorders of the duodenum
Acute upper GI bleeding
Chapter 39: Hepato-Pancreato-Biliary Surgery
Liver disease
Liver tumours
Liver cysts
Liver infections
Liver trauma
Biliary tract
Biliary strictures
Gallbladder tumours
Biliary tract cancers
Pancreatic disease
Pancreatic carcinoma
References and Further Reading
28. Laparoscopic Surgery
29. Vascular Surgery
30. Cardiothoracic Surgery
31. Orthopaedic and Trauma Surgery
32. Gynaecological Surgery
33. Plastic Surgery
34. Urology
35. Breast Surgery
36. Endocrine Surgery
37. Colorectal Surgery
38. Upper Gastrointestinal Surgery
39. Hepato-Pancreato-Biliary Surgery
Section 4: Surgical Scrub Skills
Chapter 40: Basic Surgical Instrumentation
Introduction
Sharps/cutting instruments
Clamps
Haemostatic forceps (Artery forceps)
Grasping/holding instruments
Retraction
Accessory instruments
Chapter 41: Surgical Positioning
Supine
Trendelenburg
Reverse trendelenburg
Lithotomy
Prone
Jack-knife
Lateral
Lateral chest
Lateral kidney
Fowler
Semi-fowler
Knee–chest
Documentation
Postoperative assessment
Chapter 42: Thermoregulation
Ways the body loses heat
Assessment of patient's temperature
Inadvertent hypothermia
Patients at increased risk of inadvertent hypothermia
Complications of inadvertent hypothermia
Preoperative management
Anaesthetic care
Intraoperative management strategies
Postoperative management
Chapter 43: Skin Preparation
Rationale for skin preparation
General considerations
Antiseptic choices
Optimum method of skin preparation
Chapter 44: Surgical Draping
Basic principles of draping
Considerations when selecting drapes
Reusable versus disposable drapes
Chapter 45: Surgical Site Marking
Wrong site surgery
Steps to surgical site marking
Factors which increase wrong site surgery
Theatre staff responsibility
Chapter 46: Swab Counts, Sharps and Instrument Checks
What should be checked?
When they should be checked
Count board
Taking additional items
Swabs
Sharps and miscellaneous items
Instruments
Who should carry out the checks?
What happens if the count is wrong?
Documentation
Chapter 47: Measures to Prevent Wound Infection
Patient factors
Preoperative practices to reduce surgical site infection
Perioperative practices to reduce surgical site infection
Chapter 48: Electrosurgery
Monopolar diathermy
Monopolar settings
Bipolar diathermy
Hazards of diathermy
Laparoscopic diathermy hazards
Chapter 49: Wound Healing and Dressings
Introduction
Physiology of wound healing
Patient factors which inhibit wound healing
Environmental factors which inhibit healing
Types of wound healing
Wound classifications
Things to consider when selecting dressings
Types of dressings
Wound dressing contraindications
Chapter 50: Bladder Catheterisation
Steps of bladder catheterisation
Complications of bladder catheterisation
Documentation after bladder catheterisation
Indications for bladder catheterisation
Contraindications for bladder catheterisation
Chapter 51: Tourniquet Management
Types of tourniquet
Digit tourniquets
Steps to tourniquet application for limb surgery
Caution when exsanguinating a limb
Caution and contraindications when using tourniquet
Key points to remember when using a tourniquet on a limb
Complications of tourniquet use
Aftercare of limb following tourniquet use
Chapter 52: Haemostatic Techniques
Introduction
Contributing factors to surgical bleeding
Adverse effects of surgical bleeding
Methods of haemostasis
Chapter 53: Surgical Drains
Rationale for wound drains
Drain uses
Disadvantages to surgical drains
Closed drainage systems
Securing of wound drains
Other considerations
Drain removal
Documentation
Chapter 54: Handling of Specimens
Principles of specimens
Laparoscopic specimen removal
Documentation
Safety issues
References and Further Reading
40. Basic Surgical Instrumentation
41. Surgical Positioning
42. Thermoregulation
43. Skin Preparation
44. Surgical Draping
45. Surgical Site Marking
46. Swab Counts, Sharps and Instrument Checks
47. Measures to Prevent Wound Infection
48. Electrosurgery
49. Wound Healing and Dressings
50. Bladder Catheterisation
51. Tourniquet Management
52. Haemostatic Techniques
53. Surgical Drains
54. Handling of Specimens
Section 5: Surgical Assisting
Chapter 55: Legal, Professional and Ethical Issues
Accountability and responsibility for practitioners in advanced roles
Delegating responsibility
Record keeping
Informed consent
Risk assessment
Guidelines, policies and protocols
Chapter 56: Surgical First Assistant
Background to role
Role definition
Scope of practice
Experiences of the role
Professional and legal considerations
Chapter 57: Surgical Care Practitioner
Background to role
Benefits and challenges of the surgical care practitioner role
Definition of role
Practitioner background
Scope of practice
Educational requirements
Surgical speciality pathways
Professional and legal considerations
Chapter 58: Pre and Postoperative Visiting
Introduction
Preoperative visits
Postoperative visits
Patient-centred communication
Things to consider
Barriers to pre and postoperative visits
Chapter 59: Retraction
Handling of tissues
Considerations when retracting
Choice of retractor
Alternative methods of retraction
Placement of the retractor
Chapter 60: Cutting of Sutures
Communication with the surgeon
Importance of having the right tools
Handling the scissors
Knowledge needed
Potential risks
Chapter 61: Suture Materials
Selecting suture materials
Patient factors
Wound support
The ‘perfect’ suture
Disadvantages of suturing
Absorbable and non-absorbable
Natural versus synthetic
Monofilament versus multifilament
Chapter 62: Surgical Needles
Needle selection
Needle classification
Handheld needles
The main aspects of a surgical needle
Different types of needles
Chapter 63: Wound Closure
Rationale for wound closure
Patient factors for consideration
Selection of wound closure materials
Consideration of different wound closure methods
Chapter 64: Suturing Methods
Simple interrupted
Horizontal mattress
Subcuticular
Continuous
Chapter 65: Alternative Methods of Wound Closure
Skin clips
Surgical glue
Chapter 66: Injection of Local Anaesthetic for Wound Infiltration
Ideal local anaesthetic
Delivery of local anaesthetic
Types of local anaesthetic
Local anaesthetic additives
Communicating with the patient
Guidelines and documentation
Chapter 67: Injection of Local Anaesthetic for Wound Infiltration – Caution and Complications
Toxicity
Allergies to local anaesthetics
Signs and symptoms of toxicity and allergic reactions of local anaesthetic
Patient factors to consider
Local factors to take into account with toxicity
Caution when using local anaesthesia
Contraindications of local anaesthesia
Chapter 68: Camera Holding
Introduction
Laparoscopic surgery
Laparoscopic equipment
Telescopes
Camera set-up
Light intensity
Skills necessary for camera holding
Poor camera holding
Challenges for the camera holder
Training and learning curve of camera holding
References and Further Reading
55. Legal, Professional and Ethical Issues
56. Surgical First Assistant
57. Surgical Care Practitioner
58. Pre and Postoperative Visiting
59. Retraction
60. Cutting of Sutures
61. Suture Materials
62. Surgical Needles
63. Wound Closure
64. Suturing Methods
65. Alternative Methods of Wound Closure
66. Injection of Local Anaesthetic for Wound Infiltration
67. Injection of Local Anaesthetic for Wound Infiltration – Caution and Complications
68. Camera Holding
Section 6: Recovery
Chapter 69: Recovery Room Design
Recovery bays
Recovery room facilities
Recovery room equipment
Conclusion
Chapter 70: Patient Handover
The patient's handover
Effective handovers
Effective handover process
Conclusion
Chapter 71: Postoperative Patient Care
Airway care
Pain relief
Mental health
Wound care
Deep venous thrombosis
Fever
Other problems
Conclusion
Chapter 72: Postoperative Patient Monitoring and Equipment
Monitoring equipment
Respiratory monitoring
Cardiovascular monitoring
Neuromuscular monitoring
Psychological monitoring
Temperature monitoring
Pain monitoring
Nausea and vomiting
Fluid monitoring
Urine output
Drainage and bleeding
Discharge
Chapter 73: Maintaining the Airway
Patient assessment
Basic airway management
Conclusion
Chapter 74: Diagnosis and Management of Postoperative Infection
Preoperative infection prevention
Intraoperative infection prevention
Management of postoperative infection
Postoperative care
Conclusion
Chapter 75: Postoperative Pain Management
Pain assessment
Side effects of pain
Systemic opioids
Nonsteroidal Anti-inflammatory Drugs (NSAIDS)
Regional techniques
Two effective drugs
Conclusion
Chapter 76: Fluid Balance in Postoperative Patients
Maintenance fluids
Fluid balance chart
Care of the infusion site
Conclusion
Chapter 77: Postoperative Medications
Antibiotics
Antifungals
Analgesics
IV Fluids and electrolytes
Anticoagulants
Diuretics
Antacids
Mouth care
Conclusion
Chapter 78: Managing Bleeding Problems
Postoperative haemorrhage
Actions to prevent haemorrhage
Conclusion
Chapter 79: Managing Postoperative Nausea and Vomiting
The physiology of PONV
The management of PONV
Risk factors associated with PONV
Anti-emetics
Rescue treatment for PONV
Conclusion
Chapter 80: Critical Issues in Postoperative Care
Managing sepsis
Immediate postoperative care
Postoperative care
Conclusion
Chapter 81: Enhanced Recovery
Introduction
Communication
Enhanced recovery
Summary
References and Further Reading
69. Recovery Room Design
70. Patient Handover
71. Postoperative Patient Care
72. Postoperative Patient Monitoring and Equipment
73. Maintaining the Airway
74. Diagnosis and Management of Postoperative Infection
75. Postoperative Pain Management
76. Fluid Balance in Postoperative Patients
77. Postoperative Medications
78. Managing Bleeding Problems
79. Managing Postoperative Nausea and Vomiting
80. Critical Issues in Postoperative Care
81. Enhanced Recovery
Section 7: Perioperative Critical Care
Chapter 82: Critical Care Nurses and Practitioners Roles
The roles of critical care nurses
The role of critical care practitioners (commonly used in the icu)
Conclusion
Chapter 83: Management of the Critically Ill Surgical Patient
Introduction to critical illness
Infection
Fluid balance
Organ dysfunction and failure
Actions for the critically ill
Conclusion
Chapter 84: Malignant Hyperthermia
Introduction
Causes of malignant hyperthermia
Symptoms of MH
Diagnosis
Prevention of MH
Treatment
Conclusion
Chapter 85: Inadvertent Hypothermia
Physiology of thermoregulation
Managing temperature during anaesthesia
Complications associated with inadvertent hypothermia
Temperature measurements
Postoperative care
Conclusion
Chapter 86: Congestive Heart Failure
Introduction
Congestive cardiac failure
Congestive heart symptoms and signs
Diagnosis of congestive heart failure
Congestive heart failure treatment
Conclusion
Chapter 87: Venous Thromboembolism
Introduction
Deep venous thrombosis (DVT)
Pulmonary embolism
Signs and symptoms of DVT and PE
Risk factors for DVT
Diagnostic tests for DVTs
Risk factors for PE
Diagnostic tests for PE
Treatment
Surgical interventions
Conclusion
Chapter 88: Latex Allergy
Introduction
Definition of latex allergies
Assessment of latex allergy
Management of latex allergy patients
Preventing contact with latex
Minimising contact with latex
Conclusion
Chapter 89: Pressure Ulcers
Intraoperative pressure ulcers
Risk factors for the development of pressure ulcers
Formation of pressure ulcers
Preventing pressure ulcers
Conclusion
Chapter 90: Managing Diabetes in Perioperative Patients
Introduction
Preoperative assessment
Intraoperative care
Postoperative care
Conclusion
Chapter 91: Smoking, Alcohol and Drug Abuse
People drinking alcohol
People smoking
People taking drugs
Conclusion
Chapter 92: Perioperative Care of Elderly Patients
Elective surgery
Emergency surgery
Care pathways for elderly patients
Postoperative delirium
Postoperative pain
Discharge of elderly patients
Conclusions
Chapter 93: Anaemia, Coagulopathy and Bleeding
Nutritional deficiency anaemia
Phlebotomy
Drug reactions
Bleeding complications
Coagulation abnormalities
Blood transfusion
Conclusion
Chapter 94: Care of Morbidly Obese Patients
Caring for obese patients
Staff training
Risk reduction
Specialised equipment
Preoperative assessment
Respiratory system
Cardiac disease
Metabolic disease
Thromboprophylaxis
Intraoperative care
Conclusion
References and Further Reading
82. Critical Care Nurses and Practitioners Roles
83. Management of the Critically Ill Surgical Patient
84. Malignant Hyperthermia
85. Inadvertent Hypothermia
86. Congestive Heart Failure
87. Venous Thromboembolism
88. Latex Allergy
89. Pressure Ulcers
90. Managing Diabetes in Perioperative Patients
91. Smoking, Alcohol and Drug Abuse
92. Perioperative Care of the Elderly Patient
93. Anaemia, Coagulopathy and Bleeding
94. Care of the Morbidly Obese Patient
Index
End User License Agreement
Pages
ix
x
xi
xiii
xiv
xv
xvi
3
4
5
7
8
9
11
12
14
15
16
17
18
19
21
22
23
24
25
27
29
30
32
33
34
35
37
38
39
41
42
43
44
46
47
49
50
52
67
68
70
71
72
74
75
76
78
79
80
82
83
85
86
87
89
90
91
93
94
96
97
98
99
101
102
104
105
106
107
109
110
112
113
115
116
131
132
134
135
136
138
139
140
141
143
144
145
146
148
149
150
151
153
154
155
157
158
159
161
162
163
165
166
168
169
170
171
172
174
175
176
178
179
180
181
193
194
196
197
198
199
201
202
203
205
206
208
210
211
213
214
215
217
218
219
221
222
223
225
226
227
229
230
232
233
234
236
237
238
239
241
242
243
244
245
246
247
259
260
261
263
265
266
267
269
270
271
273
274
276
278
279
280
282
283
285
287
288
290
291
293
294
295
297
298
299
301
302
313
314
315
317
318
320
321
322
324
325
326
327
328
330
331
332
334
335
337
338
340
341
343
344
345
347
350
351
352
354
355
357
358
359
360
377
378
380
381
383
384
386
387
388
389
391
392
393
394
395
397
398
399
400
402
403
404
406
407
408
409
410
412
413
414
416
417
419
420
421
423
424
426
427
428
429
54
55
56
57
58
59
60
61
62
63
118
119
120
121
122
123
124
125
126
127
183
184
185
186
187
188
189
248
249
250
251
252
253
254
255
304
305
306
307
308
309
362
363
364
365
366
367
368
369
370
371
372
373
431
432
433
434
435
436
437
438
439
440
441
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
Guide
Cover
Table of Contents
Preface
Begin Reading
List of Illustrations
Chapter 2: The Role of the Surgical Practitioner
Figure Photo 1 Carrying out the WHO checklist. Courtesy of Aintree Hospital, Liverpool
Chapter 5: Perioperative Patient Care
Figure Photo 2 Admitting a patient to the operating department. Source: Courtesy of Liverpool Women's Hospital
Chapter 17: Anatomy and Physiology: The Cardiovascular System
Figure 17.1 The cardiovascular system
Chapter 18: Anatomy and Physiology: The Lungs
Figure 18.1 Anatomy of the lungs
Chapter 19: General Anaesthesia
Figure Photo 3 Preoperative anaesthetic induction. Courtesy of Aintree Hospital, Liverpool
Chapter 40: Basic Surgical Instrumentation
Figure Photo 4 Basic instrumentation: scissors
Chapter 48: Electrosurgery
Figure Photo 5 A diathermy machine
Chapter 52: Haemostatic Techniques
Figure Photo 6 Ligature equipment
Chapter 59: Retraction
Figure Photo 7 Self-retaining retractor
Chapter 72: Postoperative Patient Monitoring and Equipment
Figure Photo 8 Monitoring the patient's temperature. Courtesy of Liverpool Women's Hospital
Chapter 73: Maintaining the Airway
Figure 73.1 Mallampati score.
Figure 73.2 The face mask is placed over the patient's open mouth and the balloon is attached to oxygen. The bag must be squeezed slowly by the recovery practitioner every 5 seconds to enable the patient to inhale oxygen and to remain alive.
Chapter 81: Enhanced Recovery
Figure Photo 9 Moving to the ward. Courtesy of Aintree Hospital, Liverpool
Chapter 82: Critical Care Nurses and Practitioners Roles
Figure Photo 10 Monitoring the critical care patient. Courtesy of Aintree Hospital, Liverpool
Chapter 85: Inadvertent Hypothermia
Figure Photo 11 Monitoring the patient's temperature. Courtesy of Liverpool Women's Hospital
Chapter 86: Congestive Heart Failure
Figure 86.1 Circulation of the blood throughout the body
Chapter 89: Pressure Ulcers
Figure 89.1 Main areas where pressure ulcers can occur.
List of Tables
Chapter 4: Preoperative Assessment of Perioperative Patients
Table 4.1 Care planning
Table 4.2 Deep venous thrombosis
Chapter 20: Local Anaesthesia
Table 20.1 Amides for infiltrative injection
Table 20.2 Esters for infiltrative injection
Chapter 22: Rapid Sequence Induction
Table 22.1 Induction agents
Table 22.2 Muscle relaxants
Chapter 23: Total Intravenous Anaesthesia (TIVA)
Table 23.1 Advantages of TIVA
Chapter 72: Postoperative Patient Monitoring and Equipment
Table 72.1 Adapted from: AAGBI (2013)
Immediate Post-anaesthesia Recovery 2013
. London, Association of Anaesthetists of Great Britain and Ireland
Table 72.2 Adapted from: AAGBI (2013)
Immediate Post-anaesthesia Recovery 2013
. London, Association of Anaesthetists of Great Britain and Ireland
Table 72.3 Adapted from: AAGBI (2013)
Immediate Post-anaesthesia Recovery 2013
. London, Association of Anaesthetists of Great Britain and Ireland
Chapter 89: Pressure Ulcers
Table 89.1 Risk factors (Pearce 1996, Brillhart 2006, Neighbors
et al.
2006)
Rapid Perioperative Care
Paul Wicker MSc, PGCE, BSc, RGN, RMN
Visiting Professor First Hospital of Nanjing, China; Fellow of the Higher Education Academy
Sara Dalby MSc, BSc (Hons), RGN, Dip HE
Surgical Care Practitioner Aintree University Hospital Trust; Associate Lecturer Edge Hill University; Winston Churchill Fellow
This edition first published 2017 © 2017 by John Wiley and Sons, Ltd
Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
111 River Street, Hoboken, NJ 07030-5774, USA
For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell
The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
Library of Congress Cataloging-in-Publication Data
[to come, includes 9781119121237]
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Paul Wicker
Preface
This book has been written by C. Paul Wicker and Sara Dalby for perioperative practitioners (students, nurses and ODPs) and junior doctors who work in anaesthetics, surgery and recovery. This Rapid series book covers a wide range of subjects related to perioperative practice and perioperative care, and each chapter is relatively short and concise so that practitioners can read the chapter efficiently and effectively, which will encourage them to learn how to undertake tasks and actions within the operating department. This book will provide practitioners with detailed knowledge and understanding of many aspects of perioperative practice which will support them in their work in clinical practice and enable them to deliver the best possible care to all perioperative patients.
This book will use a structured approach to perioperative care, starting with an introduction to the perioperative environment, anaesthetics, surgery and recovery, and critical care for patients who have serious health problems.
The first section is called ‘Preoperative Preparation’ which covers areas such as roles of theatre practitioners, preoperative assessment checklists, perioperative equipment, medication and several other chapters. This is an important area for junior theatre practitioners so that they know how to prepare the operating room prior to the patient arriving.
The second section is called ‘Anaesthesia’ and is related to anaesthetic procedures, which are very important to patients because, basically, anaesthesia maintains their homeostasis and physiological status during surgical procedures. Chapters include checking anaesthetic equipment, general and local anaesthesia, rapid sequence induction, airway management and so on. The purpose of anaesthesia is to keep the patient unconscious during the surgical procedure, and maintain oxygenation, blood pressure, pulse, and fluid levels throughout the surgery. The use of anaesthetic drugs also helps to prevent postoperative pain and can help prevent problems such as low blood pressure or malignant hyperthermia.
The next three sections are related to surgery – ‘Surgical Specialities’, ‘Surgical Scrub Skills’ and ‘Surgical Assisting’. The first two sections cover many areas of surgery, including all aspects of surgery such as vascular, breast, orthopaedics, laparoscopic and colorectal surgery, as well as skin preparation, electrosurgery, wound healing, dressings, haemostasis and so on. These two sections cover most surgical specialities and also all aspects of actions taken during surgery by both the surgeons and the scrub practitioner. The final section on surgery covers the actions taken by surgical assistants, including legal issues, suture materials, wound closure, camera holding, retraction and so on. This chapter will provide you with detailed information about the role of the surgical assistant, which will help you to understand fully the ability to assist surgeons, for those practitioners who have undertaken appropriate first assistant training.
The sixth section is called ‘Recovery’ and is related to recovery care of patients. Chapters include recovery room design, patient handover, monitoring, assessment, medications, bleeding problems and so on. When the patient enters the recovery room, he or she recovers from the anaesthesia and surgery. Recovery practitioners monitor patients carefully to ensure they don't suffer side effects and do recover from their anaesthesia and surgery safely. Monitoring includes respiration, breathing, blood loss, temperature, blood pressure, pulse and so on. Patients may also need supervising in case of postoperative problems caused by anaesthetic drugs, for example anxiety or delirium.
Postoperative problems include many areas such as postoperative pain, nausea and vomiting, electrolyte imbalance, low fluid balance, low blood pressure, malignant hyperthermia and so on. These problems may be resolved by recovery staff or may need an anaesthetist's or surgeon's actions. The 13 chapters regarding recovery should provide you with a good level of knowledge and skills in regards to caring for postoperative patients.
The final section is about ‘Perioperative Critical Care’ which covers areas such as management of critically ill patients, hypothermia, hyperthermia, deep vein thrombosis, latex allergies, pressure ulcers, diabetes, anaemia, morbidly obese patients and others. Critical care of patients is important and urgent when they are suffering from serious illnesses or conditions, and so these 13 chapters cover many areas which will be of interest to you when you need to deal with these patient conditions.
This Rapid series book on perioperative care will provide theatre practitioners with short, detailed and concise information about many aspects of their role. This will be useful for trained staff and for students and will help to ensure patient safety and effective working.
Enjoy this book and we hope that you like it!
Acknowledgements
Sara Dalby and myself have asked many people to review the chapters to ensure they are written correctly and clearly. This has taken some time to undertake; however, all chapters have been reviewed and updated which has been of great benefit to us both.
The reviewers who have checked over all the chapters which Paul Wicker has written include Africa Bocos (my wife), Rachel Simpson, Ashley Wooding, Helen Lowes, Laura Rowe and Natalie Lockhart. These reviewers are all qualified operating department practitioners, and they have read through the chapters thoroughly in order to ensure they are correct and well written. Some of the chapters were updated which has helped me in ensuring the chapters are read easily and contain the correct information. Paul Wicker gives his best and sincerest thanks to these reviewers for all the work they have done in updating my chapters.
Sara Dalby also asked several reviewers to look at all the chapters she has written in regards to surgery to ensure the chapters are accurate and concise. Sara would like to thank all these reviewers for their help and assistance, and their knowledge and skills in reading the chapters and updating them.
These people include:
Jill Mordaunt, Practice Education Manager
Jennie Grainger, Registrar General Surgery with Specialist Interest in Coloproctology
Elizabeth Clark, Consultant Anaesthetist
Kaylie Hughes, Speciality Registrar Urology
Tim Gilbert, Core Surgical Trainee General Surgery
Dave Ormesher, Speciality Registrar Vascular Surgery
Laura Ormesher, Speciality Registrar Obstetrics and Gynaecology
Claire Morris, Speciality Leader Orthopaedics and Trauma
Zoe Panayi, Senior House Officer General Surgery
Elizabeth Kane, Core Surgical Trainee General Surgery
Helen Bermingham, Core Surgical Trainee General Surgery
Andrew McAvoy, Speciality Registrar Colorectal Surgery
Kristen Daniels, Physician Assistant Plastic Surgery
Photos have kindly been provided by Aintree University Hospital, Liverpool Womens Hospital, and from the Cadaveric Workshop at University of South Manchester.
Finally, we would also want to thank Karen Moore and James Watson for their help in developing our book from John Wiley & Sons Limited, and for their help and support in getting this book published.
Kind regards to all.
Paul Wicker Sara Dalby
Abbreviations
AAA
abdominal aortic aneurysm
AAGBI
Association of Anaesthetists of Great Britain and Ireland
ABG
arterial blood gas
ACL
anterior cruciate ligament (knee)
ACS
acute coronary syndrome
AF
atrial fibrillation
ARDS
adult respiratory distress syndrome
ARF
acute renal failure, acute rheumatic fever
AV
arteriovenous or arterial-venous
AVR
aortic valve replacement
BMD
bone mass density
BMI
body mass index
BMR
basic metabolic rate
BNF
British National Formulary
BP
blood pressure
C
centigrade, Celsius
C/S
caesarean section
CABG
coronary artery bypass graft
CAD
coronary artery disease
CBD
common bile duct
CBF
cerebral blood flow
CEA
carotid endarterectomy (vascular surgery)
CF
cystic fibrosis
CHD
congenital heart disease
CHF
chronic heart failure
CNS
central nervous system
CO
2
carbon dioxide
COPD
chronic obstructive pulmonary disease
CPAP
continuous positive airway pressure
CPR
cardiopulmonary resuscitation
CT
computed tomography
CV
cardiovascular
CVC
central venous catheter
CVD
cardiovascular disease
CXR
chest x-ray
DCU
Day Case Unit
DoH
Department of Health
DIC
disseminated intravascular coagulation
DL
direct laryngoscopy
DOB
date of birth
DVT
deep vein thrombosis
ECF
extracellular fluid
ECG
electrocardiogram; electrocardiography
ECT
electroconvulsive therapy
EEG
electroencephalography
ET
endotracheal
ETT
endotracheal tube
F
Fahrenheit
FEF
forced expiratory flow
fem-fem
femoral-to-femoral bypass (vascular surgery)
fem-pop
femoro-popliteal bypass (vascular surgery)
FFP
fresh frozen plasma
GA
general anaesthesia
GU
genitourinary
H&P
history and physical examination
H
2
O
water
HA
haemolytic anaemia
HAV
hepatitis A virus
Hb
haemoglobin
HBV
hepatitis B virus
HCPC
Health and Care Professions Council
HCV
hepatitis C virus
HR
heart rate
I&D
incision and drainage
ICF
intracellular fluid
ICP
intracranial pressure
IHD
ischaemic heart disease
IM
intramuscular
IP
inpatient
IPPV
intermittent positive pressure ventilation
ISF
interstitial fluid
IV
intravenous
IVC
inferior vena cava
IVF
in vitro fertilization
IVIG
intravenous immune globulin
K
potassium
kg
kilogram
L
litre
LIH
left inguinal hernia
LMA
laryngeal mask airway
LV
left ventricular
MD
muscular dystrophy
MH
malignant hyperthermia
MI
myocardial infarction
ML
millilitre
mol
mole
MS
multiple sclerosis
MVR
mitral valve replacement
NG
nasogastric
NICE
National Institute for Health and Care Excellence
NM
neuromuscular
NPSA
National Patient Safety Agency
NSAID
nonsteroidal anti-inflammatory drug
O
2
oxygen
ODP
operating department practice, operating department practitioner
OPD
outpatient department
P
pulse
Pa
Pascal
PaCO2
arterial carbon dioxide partial pressure (measured from a blood gas sample)
PACU
post-anaesthesia care unit
PAH
pulmonary arterial hypertension
PaO2
arterial oxygen partial pressure (measured from a blood gas sample)
PAP
pulmonary artery pressure
PAWCP
pulmonary artery wedge capillary pressure
pCO
2
partial pressure of carbon dioxide
PE
pulmonary embolism
PEEP
positive end expiratory pressure
PKD
polycystic kidney disease
PNS
peripheral nervous system
pO
2
partial pressure of oxygen
PONV
postoperative nausea and vomiting
RA
right atrium
RBC
red blood cell
RCT
randomised controlled trial
RHD
rheumatic heart disease
RSI
rapid sequence induction
SaO
2
saturation level of arterial oxyhaemoglobin
SBO
small bowel obstruction
SIRS
systemic inflammatory response syndrome
SOB
shortness of breath
SpO
2
oxygen saturation measured by a pulse oximeter
SVA
supraventricular arrhythmia
SVT
supraventricular tachycardia
T
temperature
TAH
total abdominal hysterectomy
TB
tuberculosis
TBI
traumatic brain injury
TGA
transient global amnesia
TIA
transient ischaemic attack
TIMI
thrombolysis in myocardial infarction
TIVA
total intravenous anaesthesia
TURP
transurethral resection of prostate
TVR
tricuspid valve replacement
TVV
tricuspid valve valvuloplasty (valve repair)
UA
urinalysis
UE
upper extremity
UFH
unfractionated heparin
UO
urine output
URI
upper respiratory infection
UTI
urinary tract infection
VCO
2
carbon dioxide production
VF
ventricular fibrillation
VHD
valvular heart disease
VO
2
oxygen consumption
VS
vital signs
VT
ventricular tachycardia
WB
whole blood
WBC
white blood cell
Section 1Preoperative Preparation
Paul Wicker
Chapter 1The Role of the Anaesthetic Practitioner
An anaesthetic practitioner is an essential member of the operating department team working alongside anaesthetists, surgeons, practitioners and healthcare support workers to ensure that anaesthesia for the patient is as safe and effective as possible. Anaesthetic practitioners provide high standards of patient care and skilled support alongside the other members of the perioperative team during the perioperative phases before, during and after surgery (Fynes et al. 2014). It is also essential that they continue with updates and attend current in-house training to maintain their skills and knowledge.
The role of the anaesthetic practitioner has nationally agreed standards and levels of practice, implemented by the Royal College of Anaesthetists (RCA 2006). An anaesthetic practitioner's roles are also covered by the College of Operating Department Practitioners and the Health Care Professions Council. Hospital regulations manage these standards appropriately and are implemented within a nationally recognised framework (Fynes et al. 2014).
The roles and responsibilities of anaesthetic practitioners include working by themselves to prepare equipment and providing care for the patient, as well as offering support to the anaesthetist during all stages of anaesthesia (Fynes et al. 2014). The main roles and responsibilities of the anaesthetic practitioner include:
To deliver psychological and emotional support to the patient
To check the anaesthetic machine
To prepare the anaesthetic equipment
To support the patient throughout the stages of anaesthesia
To support the anaesthetist during anaesthesia
To understand responsibility and accountability for the patient during anaesthesia, including patient documentation, for example the consent form and the World Health Organization (WHO) Surgical Safety Checklist.
Preanaesthetic phase
The anaesthetic practitioner assists the patient before surgery and provides individualised care. This will include supporting the patient by reducing anxiety, placing blood pressure cuffs, connecting electrocardiograph (ECG) electrodes and pulse oximeters, and preparing IV fluids and anaesthetic drugs (NHS Modernisation Agency 2005). The practitioner will also communicate effectively within the team to pass on problems, issues or any past adverse events, such as when catheterising patients and when preparing and assisting in the safe insertion of invasive physiological monitoring such as central venous pressure (CVP) lines and arterial lines.
The anaesthetic practitioner is also able to support the patient if he or she has any concerns. For example, most patients fear anaesthesia, because of fearing the risk of waking up too early or not waking up following surgical procedures. Many patients ask, ‘Will I wake up alright after surgery?’ and then become anxious if they don't receive a reply. One of the main roles is therefore to provide psychological support, which is something that practitioners can do on a face-to-face basis. This may include discussing problems, offering reassurance to the patient to let them know they are monitored safely, ensuring the patient is comfortable, talking to the patient and reassuring the patient throughout their time in theatre (Fynes et al. 2014).
The anaesthetic practitioner will also undertake roles which will also involve many clinical skills, such as preparing a wide range of specialist equipment and drugs (Copley 2006). This includes:
Testing anaesthetic machines
Preparing anaesthetic equipment (AAGBI 2012)
Preparing intravenous equipment
Making devices available to safely secure the patient's airway during anaesthesia
Ensuring drugs such as propofol, local anaesthetics, anaesthetic gases and so on are available
Knowledge of the different operating tables, including positioning equipment, clamps and pressure-relieving devices.
Anaesthesia
There are three parts to anaesthesia:
Induction
: This is when the patient goes to sleep using anaesthetic drugs.
Maintenance
: This is maintaining the anaesthetic during surgery.
Reversal
: This is wakening the patient up by stopping the administration of drugs and anaesthetic gases, or by using specialist drugs to revive the patient (Goodman & Spry 2014).
Responsibility of the practitioner for the care of the patient throughout the stages of anaesthesia is vitally important (Fynes et al. 2014). The practitioner is responsible for ensuring the patient is positioned correctly to maintain safety and comfort, to ensure pressure areas are supported, and also to provide maximum access during the operative procedure. The practitioner also needs to follow legal and ethical considerations, and ensure that they are following the Health and Care Professions Council (HCPC) regulations and guidelines.
Checking the anaesthetic machine
Making sure the anaesthetic machine is working correctly is an essential part of the anaesthetic practitioner's role, in collaboration with the anaesthetist. Knowing ‘how’ it works is of course equally important (Goodman & Spry 2014). During induction of anaesthesia, the patient is at one of the most vulnerable points in his or her perioperative care. Equipment error can therefore put the patient at high risk of harm, for example through airway obstruction, circulatory problems, reduced blood oxygenation or even death, because of errors such as flow reversal though the back bar on the anaesthetic machine (Smith et al. 2007).
Practitioners should check the anaesthetic machines by using the Association of Anaesthetists of Great Britain and Northern Ireland checklist (AAGBI 2012) and the manufacturer's manual as guides to ensure the machine is safe to use. There is a joint responsibility between the anaesthetist and anaesthetic assistant for ensuring the correct functioning of anaesthetic equipment before patient use. Often, the anaesthetic assistant will assemble and check the equipment in preparation for the anaesthetist, who then ensures that he or she has the correct equipment for the anaesthetic procedure. The assistant's role is therefore to support the anaesthetist, check the equipment and ensure the patient's safety (Wicker & Smith 2008).
Errors during anaesthesia have often been associated with lack of proper equipment checks. However, checking an anaesthetic machine using a checklist can lead to a reduction of incidents. Patient safety can be increased by the use of the checklist for checking new anaesthetic machines which can highlight faults during their manufacture. For example, wrong assembly of the anaesthetic machine can lead to errors such as high dosages of volatile agents. The use of a checklist also needs to be carried out when equipment is returned from servicing – it cannot be guaranteed that a serviced or brand-new anaesthetic machine is working perfectly. A thorough check will therefore ensure the equipment has been returned in a working condition and is ready for use. However, it is not the ultimate responsibility of the anaesthetic practitioner to ensure the anaesthetic machine is in perfect working order; it is the anaesthetist who carries the main responsibility. Nonetheless, practitioners have a duty of care to identify and report any faults and are also responsible for their actions, including recordkeeping of anaesthetic machine checks (Fynes et al. 2014).
Monitoring responsibilities
The anaesthetic practitioner's responsibility is to attach two ECG electrodes to the patient's upper left and right-sided chest, and one ECG electrode to the lower left side of the chest, before anaesthesia so heart rate and rhythm are monitored by the ECG monitor during induction of anaesthesia. There are many other areas to monitor, and three of the most important are blood pressure, oxygen saturation and temperature.
Non-invasive blood pressure (NIBP) measurement
NIBP is measured by using a blood pressure cuff which is fastened around the arm or leg. The air tube is then attached to the monitor which inflates and deflates the cuff according to the time settings. The blood pressure reading is displayed on the monitor and registers the systolic, mean and diastolic pressures. Normally, the monitor records all measurements over time and provides a trend to indicate when the blood pressure has risen or fallen. Invasive blood pressure monitoring equipment is also used to provide a continuous record of blood pressure. This normally works by connecting a monitor to a transducer which in turn is connected to an intra-arterial line (O'Neill 2010).
Attaching the blood pressure cuff around the patient's arm monitors blood pressure and will ensure that blood pressure is maintained at the correct level. Anaesthetic drugs can reduce or increase blood pressure because of vasoconstriction, vasodilation or effects on the heart, so it is important that blood pressure is constantly monitored.
Pulse oximeters
A pulse oximeter measures the patient's oxygen saturation in their blood. Normal oxygen saturation is between 95 and 100%; anything less than 95% is seen as causing problems for the patient. Patients with chronic obstructive pulmonary disease (COPD) may also suffer from hypoxia. The pulse oximeter is normally attached to a finger, but it can also be attached to an earlobe or toe. The light source in the probe passes through the tissue, and the patient's oxygen concentration is measured via the absorption of the light, then recorded on the monitoring screen (O'Neill 2010). The light is detected by light sensors and is altered by the levels of oxyhaemoglobin and deoxyhaemoglobin. The pulse oximeter should be regularly checked to ensure that it is correctly placed on the extremity and also that circulation at that point is not impaired. Constantly observing the patient's oxygen levels is essential during anaesthesia, and using a pulse oximeter is one of the most important monitors used during anaesthesia as it can help to identify patient problems associated with low oxygen levels (Valdez-Lowe et al. 2009).
Conclusion
Anaesthetic practitioners have the potential to contribute to team working, and this results in enhancing patient care and patient access, improving operating room capacity and reducing cancellations and waiting times. Practitioners can also enhance the learning experiences of anaesthetic trainees and other junior anaesthetic practitioners.
Chapter 2The Role of the Surgical Practitioner
The surgical practitioner role includes preparing the operating room, scrubbing and circulating as well as contributing to the WHO checklist (see Chapter 7). Scrubbing involves working within the sterile field to assist the surgeon and being responsible for delivery of instruments and equipment. The circulator, or runner, provides the link between the scrub nurse and the non-sterile areas outside the surgical field. Circulators are also able to provide equipment needed for the surgical team such as sutures, swabs or prostheses. Circulating staff also assist in preparing the patient for surgery. This includes moving the patient onto the operating table, exposing the surgical site and connecting the patient to equipment that is necessary for surgery, such as the electrosurgery machine or suction machine. As the surgical team are unable to leave the operating table during surgery, the circulator provides communication between the surgical team and the rest of the theatre department, wards or laboratories (Conway et al. 2014).
Scrub practitioners are operating department practitioners (ODPs) or post registration nurses. ODPs are now more common in the operating room because the BSc (Hons) ODP programmes educate and train practitioners in all three roles in the operating department – anaesthetics, surgery and recovery. Preregistration nurses often observe in operating departments as they may not have the skills and knowledge needed to work in anaesthesia or surgery. Following their qualification, nurses may undertake CPD modules in anaesthesia, surgery and recovery to gain the necessary perioperative skills and knowledge.
Scrub practitioners need an understanding of operating room procedures, including the instruments and equipment needed for surgery, and must remain calm and clear-headed, even when under pressure because of, for example, urgent surgery. Practitioners communicate well when working with surgeons and aiding them during the surgery (Wicker & Nightingale 2010).
Surgical practitioners provide patient care before, during and after surgical procedures. Surgical practitioners must therefore be registered by the HCPC or Nursing & Midwifery Council (NMC), and have the necessary surgical expertise. When scrub practitioners assist the surgeon, it can be demanding, challenging and sometimes exciting, but circulating practitioners are also essential to provide support to the surgical team.
Scrub practitioners
The role of scrub practitioners is to ensure the best, safest and most effective care for the patient by supporting and aiding surgeons during the surgical procedure (Smith 2005). To undertake this role, they must have knowledge and skills related to patient care, anatomy and physiology, surgery, and the instruments and equipment needed for the procedure. Experienced scrub practitioners prepare equipment and instruments before the start of surgery and support the surgeon throughout the procedure. Inexperienced scrub practitioners, however, need support from mentors or colleagues during surgery as inefficiency may lead to delays or serious errors with instrument handling and use.
Before surgery
Surgical practitioners clean and prepare the operating room before surgery, including organising instruments and equipment for surgery. Scrub practitioners preserve the sterile environment by scrubbing hands and arms with betadine or chlorhexidine, and putting on suitable sterile surgical garments which include a gown, mask and gloves (Gruendemann & Fernsebner 1995). The scrub practitioner will prepare, check the function of and count the instruments and equipment before the patient arrives in the operating room to ensure everything is ready for the surgeon to commence surgery. The surgical practitioner will ask the circulator to show them the consent form with the correct procedure and patient identification number. The circulator will also identify any patient allergies and the correct equipment, for example if they are operating on a specific limb that needs left or right-sided tools.
When the surgeons arrive and start surgical scrubbing, the circulating practitioners may help them don their gown and gloves before exposing the patient for the surgical procedure.
During surgery
The main role of the scrub practitioner during surgery is to provide a quick, safe and effective procedure by selecting and passing instruments and swabs ready for the surgeon to receive. The practitioner may also support the surgeon during surgery by cutting sutures or other minor tasks (Smith 2005). Scrub practitioners must have knowledge and understanding of the surgical procedure, the patient's anatomy and the instruments which are required for specific procedures so they can quickly pass them over to the surgeon (Conway 2014). The scrub practitioner also needs to watch the procedure carefully to prepare instruments in advance. The practitioner should also retrieve instruments that the surgeon has stopped using, as these can sometimes fall off the operating table onto the floor. Also important is the need to keep track of any samples of tissues, as the surgeon can hand out many samples from different parts of the surgical site in quick succession, which must be kept separate. The scrub practitioner will then clean the instruments after use and place each instrument back in its place on the instrument trolley. If required, the scrub practitioner will ask for other instruments or items from the circulating practitioners.
After surgery
Scrub practitioners count all instruments, sponges, swabs and other tools and verbally communicate to the surgeon in regards to the count once surgery is completed. It is essential that swabs are counted so that they are not left inside the patient (D'Lima 2014). Scrub practitioners then remove instruments and equipment from the operating area, assist the surgeon in applying a dressing to the surgical site and accompany the patient to the recovery area to inform recovery staff of the procedure, dressings, suction drains and so on (Wicker & Nightingale 2010). Scrub practitioners also complete necessary documentation about the surgery in the surgical record book and input relevant information into the computer.
Circulating practitioners
Circulating practitioners create and preserve a clean and sterile operating room environment in preparation for treating patients before surgery. Having a clean and safe environment will promote health for staff and prevent patients from acquiring infections following surgery (Goodman & Spry 2014). Perioperative practitioners may also undertake pre and postoperative assessments of patients, and it is also important that they support, care and educate patients about their surgical treatment before and after surgery.
The circulating practitioner is also responsible for setting up the operating room before a surgical procedure gets underway (Goodman & Spry 2014). This role includes checking disposables, such as pads, swabs and sutures; laying out instrument trays; preparing equipment, such as diathermy and suction machines; and preparing any other equipment needed. The circulating practitioner also checks all equipment needed during the procedure to verify that it is functioning properly. When the patient arrives in the OR, the circulating practitioner usually verifies the patient's identity and necessary consent forms. This includes showing the consent to the surgical practitioner, and then reviewing the site and nature of the procedure with the surgeon (Goodman & Spry 2014).
Theatre practitioners clean and maintain the operating room and inform the surgical team of anything that may be contaminated before the start of surgery. They are also responsible for opening sterile packages, so the surgical team may easily access the sterile equipment without becoming contaminated (Goodman & Spry 2014). However, they must always avoid touching the sterile field, for example the instrument trolley or the drapes covering the patient, because they do not scrub or wear sterile gloves or a gown. The circulating practitioners and other members of the surgical team also position the patient correctly and safely on the operating table. The circulating practitioner connects any necessary equipment, such as suction and diathermy, and liaises with the surgeon about his or her needs. During the operation, the circulating practitioner provides the surgical team with sterile fluids and medications as required and renews the surgical team's supplies if they need more sterile drapes or instruments. Each member of the surgical team has specific personal responsibilities, including maintaining an overview of the patient's condition. For example, if an arm or leg accidently falls off the operating table, then this is one of the circulating practitioner's responsibilities to prevent it from happening, or to replace the arm or leg in a safe position (Wicker & Nightingale 2010).
Outside of surgery, perioperative practitioners also play a role in patient care before and after procedures, including the initiation of the WHO checklist (Photo 1). Before surgery, a practitioner draws up the patient's plan of care and spends time to document and record any allergies or other health-related issues. After surgery, theatre practitioners complete the WHO checklist and patient care plan, and the circulating practitioner helps the scrub practitioner and other staff to clean the room and prepare it for the next surgical procedure (Wicker & Nightingale 2010).
Photo 1 Carrying out the WHO checklist. Courtesy of Aintree Hospital, Liverpool
Chapter 3The Role of the Recovery Practitioner
The three perioperative roles in the operating department are anaesthetic, surgery and recovery practitioners. The recovery practitioner is
