( UTERINE FIBROID )

KURSUS PENGKHUSUSAN
PERAWATAN PERIOPERATIF
SESI 2/2006
15TH JULY 2006 – 14TH JAN 2007
Compiled by

PBS ZUBAIDAH @ SALMA BT

MOKHTAR
COLLEGE OF NURSING PENANG.
 TABLE OF CONTENT
NUM CONTENT PAGE
1. Acknowlegdements 1
2. Objective 2
3. Introduction 3
4. Anatomy and physiology of female 10
reproductive system
5. Introduction of case 19
6. Preparation of patient 21
7. Preparation of operation room attire 24
8. Preparation and Maintenance of the Operating 29
Room Environment
9. Preparation of Operating Room 32
10. Preparation of Operating Room Equipment 37
11. Receiving patient - responsibilities 49
12. Preparation of sterile team members 51
13. Induction of patient 66
14. Positioning of patient for surgery 72
15. Preparation of instrument trolley and Mayo’s 73
stand
16. Painting Procedure 80
17. Draping Procedure 81
18. Operation Procedure 85
19. Principle of Collecting and Fixing specimen 99
20. Concept of confine and contain 101
21. Reversal of patient 103
22. Cleaning and checking of instrument 104
23. Removal of gown and gloves 105
24. Post operative care in Recovery Room 108
25. Post Operative Visit 109
26. Nursing Diagnosis and Intervention 111
27. Bibliography 115
 ACKNOWLEDGEMENTS

I wish to express my gratitude to a few person for their

contributions during the preparations of this case study.

To my college principal Pn Dermawan Mohd Ismail, my tutor

Miss Yee Siew Fong, all Sister in Operating Department Penang
as sister incharge and Local Preseptors who always gave me a
lots of precious motivation, advice and unending support,
confidence and patience to me in making me to successfully
complete this case study.

Also a lots of thanks to all the doctors including the

anesthetist and surgeon and also Operating Department Staff
who generously spend their time and share their knowledge in
this case study.

And last but not least to my loving husband and daughter who
have been there for me through the transitions of life.

Again, thank you very much to all of you.

PBS ZUBAIDAH @ SALMA BINTI MOKHTAR

PERIOPERATIVE NURSING
GROUP 2/2006
 OBJECTIVES

GENERAL OBJECTIVE
~ To gain knowledge and understanding and practice skill to
provides high quality perioperative care to the patient
undergoing surgery.
~ To fulfill requirement of the post basic perioperative course.
~ To understand the principles of studies technique.

 SPECIFIC OBJECTIVE
~To understand the processes involved in preparing a patient
undergoing the operation of Total Abdominal Hysterectomy
Bilateral Salphingo-Oopherectomy.
~ To provide insight regarding patient care, instrument
preparation, instrument care and potential complication that
may arise.
~To documents all the relevant steps involved in the process
and reason why certain things are done in certain way.
~To shared my knowledge with colleague those are not
expose in Gynae Surgery.
~To provide better nursing care for patient undergoing for
Total Abdominal Hysterectomy Bilateral Salphingo-
Oopherectomy.
~To identified the phase of surgery, including the usage of
specialized instrument and supplies during the intraoperative
phase.
~To practice safety precaution for patient during pre, intra
and post operatively.
 INTRODUCTION
HISTORICAL DEVELOPMENT OF PELVIC
SURGERY.

The ovariotomy and myomectomy was performed

before the hysterectomy was attempted.

In 1843, Charles Clay of Manchester removed a

fibroid. The patient was doing well until the day 12th of the surgery,
but on the 13th day of the surgery, the patient was fell on the floor
while the nurse turning her to arrange the bed and died on the
morning of the 15th day of the surgery.

In 1853 - Massachussets, by Dr. Walter Burnham of

Lowell, the first successful removal of fibroid uterus was
performed. It was forced to removed the uterus without intending
to do so. The abdomen had been opened to removed what was
thought to be ovarian cyst, suddently the patient vomited and
extruded the fibroid uterus through the incision. The operator could
not replace it and was force to removed it. The patient survived
and Burnham was encouraged to attempt further hysterectomy.

In 1856 - On November, 13th William J. Baker and

associates performed the first successful abdominal hysterectomy
with bilateral salpingo-oophorectomy in Knoxville, Tennessee. The
patient recovered uneventfully and lived for 34 years after her
procedure.

( From the 1Department of Surgery, University of Texas Southwestern

Medical Center, Dallas, Texas; and 2Gynecologic Oncology Service,
Baptist Hospital of East Tennessee, Knoxville, Tennessee. )
UTERINE FIBROID
A uterine fibroid (known medically as a leiomyoma, or simply myoma) is
a benign (noncancerous) growth composed of smooth muscle and
connective tissue. The size of a fibroid varies from that of a pinhead to
larger than a melon. Fibroid weights of more than 20 pounds have been
reported.

Fibroids originate from the thick wall of the uterus and are categorized by
the direction in which they grow:

• Intramural fibroids grow within the middle and thickest layer of

the uterus (called the myometrium). They are the most common
fibroids.

• Subserosal fibroids grow out from the thin outer fibrous layer of
the uterus (called the serosa). Subserosal can be either stalk-like (
pedunculated) or broad-based ( sessile). These are the second most
common fibroids.

• Submucous fibroids grow from the uterine wall toward and into the
inner lining of the uterus (the endometrium). Submucous fibroids
can also be stalk-like or broad-based. Only about 5% of fibroids
are submucous.

Figure 1

• Uterine fibroids (lelomyomas) are common

noncancerous (benign) tumors of the uterus. They
grow from the muscular wall of the uterus and are
made up of muscle and fibrous tissue, they may be
single or multiple. (refer figure 1)
• These tumors may grow into the uterine cavity
(submucous fibroids), they may be located in the
uterine wall (subserous).

• In some women, uterine fibroids may cause heavy

bleeding and pelvic discomfort. The other symptom of
uterine fibroids as following;
 Painfull periods

 Bleeding between periods

 Pain during sex

 Lower back pain

 Feeling ‘full’ in the lower abdomen-pelvic

pressure

 Reproductive problem, such as infertility and

multiple miscarriages.

• Submucous fibroids are the type that commonly

cause significant problems, even small tumors located
in or bulging into the uterine cavity may cause heavy
bleeding, anemia, pain, infertility or miscarriage.
• Because of their location on the endometrium,
submucosal fibroids place pressure on the uterine
lining that builds with each menstrual cycle. This, in
turn, can cause abnormal bleeding.

• Pelvic pressure from the size of a growing fibroids

present, can also bring on abnormal bleeding.
Excessive bleeding can cause anemia.

• Anemia occurs when there is a decrease in your blood

red cells due to blood loss. If anemia is confirmed
through a blood test, taking iron supplementation may
help.

• Constipation and hemorrhoids are additional symptoms

caused by the pressure of growing fibroids.
• Depending upon the individual, any one of these
solutions may bring some relief from the symptoms
experienced as a result of uterine fibroids. When
symptoms are resolved most women feel cured and
find no need to take additional action with their uterine
fibroids.

• There is no known cause for uterine fibroids. There is

also no known reasons as to why some women acquire
severely symptomatic fibroids while othera do not.

• There has been so little research on the risk factors for

developing symptomatic uterine fibroids, that almost
begs the issue to try and list what little we do know
here

• . Even so, age, race lifestyle and genetics may well

play part in the overall scheme of health and body
tendency to develop symptomatic uterine fibroids.

• Here the few known associative risk factors:

• African-americans are 2-3 times more likely to

present with symptomatic uterine fibroids and
typically will do so at a younger age than the rest
of the population of women with uterine fibroids.

• Average age range for fibroids to become

symptomatic 35-50.

• Asian women have a lower incidence of

symptomatic uterine fibroids.

• Obesity is associated with the presence of

uterine fibroids. ( of cause, which came first – the
weight or the fibroids- is still an unanswered
question.)
 • Consumption of beef, red meat (other than beef),
and ham has been associated with the presence
of uterine fibroids.

• In addition, we also know the following:

 Changes in a woman’s hormone levels may
impact fibroids growth

 Fibroids grow rapidly during pregnancy

when hormone levels elevated.

 Fibroids shrink after menopause when

hormone levels are decreased.

 Estrogen and progesterone play in fibroids

growth.

Mdm Aini was diagnosed as having the Multiple Intramural

Fibroid
Treatment for uterine fibroids.

• If treating the symptom of the uterine fibroids is ineffective

in bringing about relief and patient’s quality of life is
dwindling away, it may be time to move more aggressive
methods of dealing with the uterine fibroids. It may be
time to switch from treating the symptom to treating the
fibroids.

• There are a variety of treatment options for benign uterine

fibroids which allow patient to retain the uterus. These
include;
 Watch & Wait
 Medical Therapy
 Myomectomy
 Uterine Fibroids Embolization (UFE)
 Myolysis
 Hysterectomy

• Watch & Wait

• Many women choose to do nothing and simply treat the
symptom since fibroids often shrink in size and become
asymptomatic as a women goes through menopause.
The average age of menopause is 51. can we just
watch and wait?

• Medical Therapy
• One way to reduce symptom of uterine fibroids is using
one of a group of hormones called gonadotropin
releasing hormone agonists (GnRHa). These
hormones block the body from making the hormones
thatcause women to menstruate or have their periods.
• If women have symptoms, have health conditions that
make surgery less advisable, and are near menopause
or do not want children, they may receive GnRHa
therapy to treat the fibroids.

• Myomectomy
• Myomectomy is a type of surgery that removes the
fibroid without removing the uterus. For women over
the age of 35, this procedure may provide adequate
 relief until the age of menopause when fibroids shrink
naturally due to a decline hormones.
• There are numerous ways that doctors perform a
myomectomy. The type, size and location of the
fibroids determine which of the following
myomectomies might be recommended;
 Laparoscopic Myomectoy
 Hysteroscopic Myomectomy
 Laparotomy ( Abdominal Myomectomy)
 Laparocopic Myomectomy with Mini-Laparotomy
 Laparoscopic Assisted Vaginal Myomectomy
(LAVM)

• Uterine Fibroids Embolization (UFE)

• Uterine fibroids embolization also known as uterine
artery embolization (UAE) is a minimally-invasive, non-
surgical procedure performed by an interventional
radiologist (IR). This procedure involves placing a
catheter into the artery and guiding it to the uterus.
Small particles are then injected into the fibroids. The
whole procedure only takes about an hour.
• Within a minutes after the procedure the fibroids begin
dying. Generally, but not always, there is an overnight
stay in the hospital because many women feel intense
abdominal cramping and pain. Pain from this
procedure is usually controlled through the use of
narcotics.

• Myolysis
• Involves surgical instrument that are inserted through a
laparoscopic incision in the abdomen and high
frequency electrical current that is sent to the fibroid.
The electrical current causes the blood vessels to
vaso-constrict and this basically cut off the blood flow
to the fibroids. The fibroids remain in place and are not
surgically removed. Without a blood supply, the fibroids
eventually die and shrink.
• Myolysis is only performed on subserousal fibroids
that fit a certain size range.
 • HYSTERECTOMY
Hysterectomy is a removal of the women’s uterus which is it
was a major procedure, and it was done to a healthy and non
diseased organ. It was performed for a various gyneacological
problem. There was a few indications for this surgery, such as;

 Fibroids
 Endometriosis
 Cancer of uterus, cervix or ovaries
 Pelvic inflammatory disease
 Irregular menstrual bleeding such as heavy menstrual
bleeding.
 Emergency hysterectomy such as may be necessary for
severe bleeding after delivery or during surgery.

In this case study, the indication is UTERINE FIBROID. After

a hysterectomy was performed, the patient can no longer be able
to bear children and no longer menstruate.

There are a few type of hysterectomy;

 Subtotal hysterectomy
• Involves only the removal of the uterus. The
pelvic structural ligaments are not cut and the
cervix is left in the place. Fallopian tubes and
ovaries may or may not be removed. This
procedure is always done through the abdomen.

 Total hysterectomy
• Involves removing both the body of the uterus
and the cervix, which is the lower part of the
uterus. It can sometimes be done through the
vagina ( vagina hysterectomy) ; at the other
times, a surgical incision in the abdomen is
preferable. For example, if there is large fibroids
tumors, it is difficult to safely remove the uterus
through the vagina, then abdominal hysterectomy
will be performed. In a total hysterectomy and
bilateral ( both sides) salphingo-oophorectomy,
the ovaries and fallopian tubes are removed,
along with the uterus and cervix.
  Radical hysterectomy
• It is reserved for serious disease such as cancer.
The entire uterus and usually both tubes and
ovaries as well as the pelvic lymph nodes are
removed through the abdomen.

Usually, one or both ovaries and fallopian tubes are removed

during hysterectomy. When both ovaries and fallopian tubes are
removed it is called bilateral salphingo-oopherectomy.

A hysterectomy may be life-saving in the case of cancer. It

can also relieve the symptoms of bleeding, discomfort or uterine
prolapse related to fibroids.

For Mdm Aini, Total Abdominal Hysterectomy Bilateral

Salphingo-oopherectomy is going to be performed which is the
uterus, cervix, both fallopian tubes and ovaries are removed
through abdominal incision and opening of the peritoneal cavity.
INTRODUCTION OF CASE
INTRODUCTION OF PATIENT

PATIENT PARTICULAR

Name : Mrs Aini

Age : 50 years old

RN : 546058

I/C : 560617-02-5650

Mrs Aini was stay at Alor Setar, Kedah. She is a very

pleasant lady and cooperative. She is a fulltime housewife and
stay with 3 son and 1 daughter also her husband. Her husband is
a retired ARMY and now was working as a security guard in one of
the factory in Bayan Lepas. Mrs Aini was married to her husband
30 years ago.

According to Mrs Aini, all of her children was born through

the Spontaneous Vaginal Delivery. Now her 1st son already 28
years old and married, and her youngest daughter is 15 years old.

Mrs Aini was look apparently well and healthy. There is no

symptom that she was in pain. Her 1st menses (Menarche) when
she was 14 years old with normal menstrual cycle 28-30 days,
duration was 4-5 days and heavy flow for 4 days.

Her normal flow is 2nd day every month, and her last period
is 2nd July 2006, but when she has a Sexual Intercourse with her
husband on 17th July, the next menses goes to 18th July and the
next month the date is still on 18th August with heavy flow and not
shows to be stop.

Mrs Aini went to medical check-up at private clinic in Alor

Setar. Ultra sound was done by the doctor, and she was diagnosed
as Intramural Uterine Fibroids. Then she was referred to
Gynecology Clinic Hospital Pulau Pinang on 25th August 2006.
Ultra sound was done again by Gyneacologist in Gynea Clinic and
the finding is confirm Intramural Uterine Fibroids. Then, she was
decided for Total Abdominal Hysterectomy Bilateral Salphingo-
Oopherectomy by Gynecologist on 7th September 2006.

1) Physical Examination and Assessment

Result of vital sign;
Blood pressure : 125/85mmHg
Pulse : 76bpm
Temperature : 37.2oc
On Cardovascular system, there is no any abnormality
found. No heart murmur detected and lungs also clear.

2) Medical History
No post medical history, accept the heavy flow menses. No
history of drug allergy. No history of recurrent ill and no
cough and fever.

3) Surgical history
No past surgical history.

4) Investigation
 Full Blood Count
 Blood Urea Serum Electrolite
 Random Blood Sugar
 Electrocardiogram
 4 pint Whole Blood
 PT/APTT
 Group and Cross Matched
PREPARATION OF PATIENT
PREOPERATIVE VISIT
The preoperative visit was usually done a day before
operation day. The purpose is;
 To gain rapport between patient and perioperative
nurse.
 To orientates patient about environment in operating
department.
 To orientates patient before and after operation.
 To allay fear and anxiety in patient and family
members.
 To develop a care plan for the patient who is brought
into the perioperative environment.

Before seeing the patient, the perioperative nurse usually

review the patient case notes to get a correct assessment for the
patient on the biological data, physical findings and the special
therapy ordered by Doctors give to the patient.

Mrs Aini was admitted on 6th September 2006, perioperative

visit was done on 7th September 2006 and she was scheduled for
Total Abdominal Hysterectomy Bilateral Salphingo-Oopherectomy
on 8th September 2006

The perioperstive nurse started the conversation by greeting

Mdm Aini with a pleasant smile and introduced herself to Mdm Aini.
She also explained the purpose of the visit. Mdm Aini was
understood and she looked happy. The perioperative nurse asked
the names. Age and where she lives. Mdm Aini answered the
question nicely.

When the perioperative nurse asked why Mdm Aini admitted

in the ward, she said that the doctor wanted to do the operation
and to remove the uterus because she had uterine fibroid. She
was not clear about the condition, but she hope, after the
operation, her life getting well. Mdm Aini asked a lot of question
about the operation and perioperative nurse refer to the doctor
incharge and he answer as the best as possible.

Mdm Aini was orientated about the operation theatre

environment, the member of the operation team includes the
perioperative nurse, interpret policies and routine such as
scheduled time of the surgical procedure, view on set up of OR,
reception and recovery. She also explained where the family can
wait during operation.

The perioperative nurse explained to Mdm Aini that she will

be received by the reception nurse at the reception counter and
will be transferred to operating room stretcher which is clean ,to
prevent contamination from outside to inside OR environment and
will be send to holding bay. Mdm Aini was told about the air
conditioning system which is cold and she is free to ask for the
extra blanket from any other nurses there. She also was told about
the OR staff attires were different from the ward staff which is their
are wearing the OR attires with mask and caps.

Perioperative nurse explained to Mdm Aini the perioperative

preparation such as;

 Diagnostic test
 Full Blood Count
 Blood Urea Serum Electrolite
 Random Blood Sugar
 Group and Cross Match
 Electrocardiogram
 Chest X-ray

 Remove any
 prosthesis such as contact lenses and denture, to
prevent airway obstruction.
 jewellery or hair pin for safety from diathermy burn.

 Fasting starting 12 midnight on wards must be strictly

followed to prevent possibilities of regurgitation which is
could lead to aspiration into the lung during surgery.

 Skin preparation was done preoperatively such having a

good bath especially hair shampoo and cleaning of the
operating site properly in the morning of the operation day.

 Try to have a good night sleep.

  Change the cloth to operation gown and cap when called by
operation room nurse and will be send to OR with stretcher
by ward staff.

The anesthesiologist visited Mdm Aini at the evening before

operation day. The nurse in the ward prepared the Bed Head
Ticket (BHT) together with all the investigation result. The
anesthesiologist reviewed the past and the present medical record
of Mdm Aini and tooks history by questioning allergies, adverse
reaction to drugs, past anesthetic experience, smoking
habit,genetic, metabolic problems and reaction to previous blood
transfusion.

BLOOD INVESTIGATION
• Full Blood Count
 WBC 6.4 x 10 (3) / UL
(3) / UL
 RBC 5.1 x 10 (6) / UL
/ UL
 HGB 14.5g / dL
 PLT 327 x 10 (3) / UL
Reference Range
5.2 - 12.4 x 10
4.2 - 5.4 x 10 (6)
12.0 - 16.0g / dL
130 - 400 x 10 (3) / UL

• Blood Urea Serum Electrolyte Reference

Range
 Sodium 139 mmol/L 135 - 145 mmol/L
 Potassium 3.7 mmol/L 3.5 - 5.0 mmol/L
 Urea 2.7 mmol/L 1.7 - 8.3 mmol/L
 Creatinine 70 mmol/L 57 - 130 mmol/L

• Random Blood Sugar - 4.6 mmol/L

• PT / APTT Prothrombin time Reference Range

 Prothrombin time 11.7 sec 11.5 - 13.5 sec
 INR 1.0 sec 0.8 - 1.2 sec
 APTT 29.9 sec 24.0 - 35.0 sec

Mdm Aini’s blood investigation, ECG and chest X-ray results

were within normal range.
PREPARATION AND MAINTENANCE
OF THE OR ENVIROMENT
 Certain routine and maintenance procedure must be carried
out to maintain a clean, safe OR for all our surgical patients.

 Although most post-operative wound infections are related

to endogenous bacteria, microorganisms from exogenous
sources are also capable of producing post-operative wound
infections.

 It is quite impossible to completely eliminate all exogenous

microorganisms from the operating room but directing
environmental control measures to two specific sources can
reduce their numbers :-

 Contaminated air
 Operating Room surface

CLEANING
 Operating room has many surfaces, which require dust
removal as dust harbors microorganisms. Hard surface do
not require treat with disinfectant, warm water with detergent
is usually sufficient to remove all organism contamination.

 The floor of the OR is a large, much used surface, it

accumulates setting or floor traffic bacteria. Thus, it is
important to ensure the floor be free from cracks and pits
where soil might accumulate.

 Good sanitation practices must be established in the OR to

decrease or eliminate bacteria, there by preventing the
transmission of pathogenic microorganisms to the patient.

 Principles of cleaning the OR is from inner to outer of the

room (clean to dirty) start from the OT light, sterile room,
induction room and finally the sucker machine, diathermy
machine and OT table. This was perform 1 hour before
elective list begin.
ENVIRONMENT
• Air and Dust Control
 Microorganisms are transported though the air and dust.
Preventive measure must be taken to control the dust in the
OR by eliminating its sources.
 Operating Room personnel must use event possible means
to reduce lint dissemination and air violation by reducing /
minimizing unnecessary and filters changed frequently.

• Temperature of Operating Room

 Temperature of the OR should be maintained between 18 –
22 degrees Celsius. The ideally temperature is 21 degress
Celsius. The air flow rate is 15-25per min always come from
the ceiling and exit through the wall below either positive
pressure of lamina flows.

• Humidity
 The ideally humidity of the OR between 50% - 60%, if less
than 60% dry air leading to build up the static current and
agent causing sparks to occur, if more than 60% moisture in
the air may cause fungal infection.

VENTILATION
• The operation room ventilation system must ensure a controlled
supply of filtered air. Air changes and circulation provide fresh
air and prevent accumulation of anesthetic gasses in the room.

• Concentration of gasses is dependent solely on the proportion

of pure air entering the air system to the air re-circulated though
the system.

• Air exchanges was between 20 to 30 per hour are

recommended for room with re-circulated, a gas scavenger
system is mandatory to prevent the built-up of waste anesthetic
gasses. Various types of scavengers and evacuation are used
to minimize air pollution’s that are health risk for team members.

• Ultra clean laminar airflow is installed in some operation room.

This high-flow unidirectional air-blowing system is housed in a
 wall or ceiling enclosure. The value of this system in reducing
airborne contamination is inconclusive.

• Filtration though high-efficiency particular air (HEPA) filters can

be 90% efficient in removing particles that are larger than 0.5
um. These microbial filters in ducts filter the air, practically
eliminating all dust particles. The ventilating system in the
operation rooms suite is separate from the hospital general
system.

• Positive air pressure (0.005 inch of water pressure) in each

operation room greater than that in corridors, scrub areas and
sub sterile rooms. Positive pressure forces air from the room,
the inlet is at the ceiling. Air leaves though the outlets at floor
level. Air is drawn into the room around the doors and through
open doors. Microorganism in the air can enter the room unless
positive pressure is maintained.

• An air-conditioning system is Adele and valuable. It controls

humidity, which helps to reduce the possibility of explosion.
High relative humidity (weigh of water vapor present) should be
maintained between 50% to 60%. Moisture provides a relatively
conductive medium, allowing static charge to leak to earth as
fast as it is generated, sparks from more readily in atmospheres
of low humidity.

• Room temperature is maintained within a range of 18 degress

Celsius to 22 degress Celsius.

• Even with controls of humidity and temperature, air conditioning

units may be sources of microorganism that comes through the
filters. These must be change at regular intervals. Ducts must
be cleaned regularly.
PREPARATION OF OPERATING ROOM
1. RECEPTION ROOM
 Damp dusting
• Reception nurse must clean and damp dust all the
surface area and the horizontal area.

• They should do cleaning to created a good

environment also give therapeutic environment to the
patient before they enter the operation department.

 Check the equipment

• Check the functioning of the trolley to make sure that
trolley is safe to use as wheel can lock and both side
rail is patent. Check the oxygen cylinder to make sure
the amount of oxygen present is sufficient for use.
Prepare the oxygen tubing and face mask at the
trolley.

• The perioperative nurse also prepares clean blankets

and pillows to receive the patient and make sure there
are enough for the day.

• Check and make sure the documentation form,

message book, blood book, and specimen are at the
counter and also the call list.

• The reception nurse calls the patients according to the

operating list ½ hour before operation starts.

• Reception nurse get enough personnel to transfer

patient from ward trolley to operation room stretcher.
2. INDUCTION ROOM
 Damp dusting
• The perioperative nurse damp dust the Induction room
using warm water at all surface area and horizontal
area.
• The purpose performed damp dusting is to reduce
microorganisms are stay that area. The cleaning
suppose to do at early in the morning. Damp dusting
should be performed before starting the case.

 The anesthetist and the perioperative nurse should

prepare all equipments needed and check the anesthetic
machine and gas cylinder. The machine was assembling for
use the correct circuit was fixed up and gases supply of
nitrous oxide and oxygen was checked. Both cylinder must
always be checked before use the machine.
~ suction apparatus was connected and tested
ready for use.
~ intubation trolley prepared with :-

Figure 2

 Endotracheal Tube (ETT) various size

(depends to patients needed) and syringe
20cc for inflated the ETT cuff. Check the
functioning example the cuff is not leaking.
For female patients, size 7.0mm to 7.5mm
are required.
 2 Laryngoscopes in working order with
secure light bulb.
 2 differential size oropharyngeal airway
 various size of face mask
 McGill forceps and Endotracheal stylet
  Lignocaine jelly to lubricate Endotracheal
Tube, plasters to secure the ETT and
gauze
 Sterile water for irrigation for suction
 A selection tube connector
 Patient breathing circuit
 The head ring (donut) to stabilize the head
~ the intravenous infusion fluid and other line
required like a :-
 Warm intravenous drip solution and top up
the solution in the warmer provided for later
use
 Artery line for monitoring any bleeding intra
operation
 CVP (Central Venous Pressure) for monitor
dehydration
 Monitoring devices such as ECG machine, pulse oxymeter
and dynamicmachine.
 Anesthetic nurse must check the anesthetic machine:-

Figure 3
• The pipeline and cylinder, sources of oxygen and
compressed gases.
• The alarm system for the functioning.
• The breathing circuit system must be clean, dry and not
leaking and must be assemble correctly and use push and
twist method to secure properly.
 • Ventilator alarm operates correctly for low airway
pressure.
• The vapouriser is full and refill when necessary, such as
volatile agent – Sevoflurane and Isoflurane.
 The anesthetic drug must be ready, such as injection:-
• Fentanyl

• Norcuron

• Propofol

• Tracium

• Morphine

• Atropine

• Labutolol

• Thiopentom

 In Mdm Aini case, she will be given Epidural anesthesia

combine with General Anesthesia. A trolley for epidural
anesthesia been prepared with epidural set:-
• Spinal set

• Epidural set content :-

-Touchy needle
-Epidural catheter
-Epidural bacterial filter
-Loss of resistance syringe or 10cc syringe with
normal saline

• Local anesthetic agent – lignocaine 2%

• Epidural infusion solution – plain marcaine
• Povidone soulution / spirit
• Opsite spray
• Opsite dressing and hyperfix plaster.
OPERATION ROOM

• Beside a clean operating room and suitable environment,

there are also other things that are equally important in order
to procedure a smooth operation. During the surgery,
preparation and maintenance of the operating room
environment safely very important to perioperative nurse and
patients. This can prevent the exposure of perioperative
nurse and patient to unknown organism transmitted through
blood and body fluids.

• All the horizontal surface must be wipe from dust starting

from the overhead operating light, operation bed, mayo
stand, trolley and all surfaces equipment using moist cloth of
disinfectant solution. Disinfectant solution that been used is
Germicep 0.5gm diluted with 8 liter. Mirror of the operating
light or any mirror inside become gray. The floor also been
mopped with Germicep by house keeping staff.

• While waiting the operating room surface to dry, ventilation

system of the operating room been checked to ensure a
controlled supply of filtered air. A good air changes and
circulating provides fresh air and prevent accumulation of
anesthetic gases in the room and it has been recommended
to have 20-30 air exchanges per hour for room with
recirculated air.

• Air condition controls the humidity which helps to reduce the

possibility of the explosion. The ideal humidity level to
archive minimal static and reduce microbial growth is
between 50% - 60% and not less than 45%. It also to
consequent ignition of any flammable solution or to objects
used in the operating room. The operating room temperature
is maintained at 18-22degrees Celcius.

• All the equipment must be checked the functionql order

before the surgery performed. This is to prevent any delay
during the operation and for saving life purpose. The
equipment to be used is operating table, light, sucker
machine, diathermy machine and the GA machine should be
checked.
PREPARATION OF OPERATING ROOM
EQUIPMENT
LIGHTING.
A) Ceiling Light
Most of room light are white fluorescent but may
be incandescent. Lighting should be evenly distributed
throughout the room. The anesthesia provider must
have sufficient light, at least 200 foot candles, to
adequately evaluate the patient’s color.

To minimize eye fatique, the ratio of intensity of

general room lighting to that at the surgical site should
not exceed 1:5, preferably 1:3. This contrast should be
maintained in corridors and scrub areas, as well as in
the room itself.

Color and hue of the light also should be

consistent. All the ceiling light in the operating room
must be checked by the perioperative team nurse for
proper working prior to the operation

B) Operation Light

Figure 4 : Operating Light

The scrub nurse and circulating nurse should

damp dust the operating before operating check the
light for proper working including focusing, brightness
and any fused bulb. Bulb must be changed if found
fused.
 Illumination of the surgical site is dependent on
the quality of light from an overhead sources and the
reflection from the drapes and tissues, white glistering
tissues need less light than dull, dark tissues. Light
must be of such quality that the pathologic conditions
are recognizable.

The overhead operating light must be:-

 Make an intense light, within a range of
2500 to 12,500 foot candles into the
incision without glare on the surface. It
must give controls to the dept and
relationship of all anatomic structure. The
light may be equipped with an intensity
control.

 Be shadow less.

 Produce the blue white color of daylight.

 Be freely adjustable to any position or

angle by either a vertical or horizontal of
motion.

 Produce a minimum of heat to prevent

injury and drying exposed tissues.

 Be easy cleaned and maintained.

Suspension mounted hacks or centrically
mounted fixture must have smooth
surfaces that are easily accessible
cleaning.
OPERATING TABLE

Figure 5 : Operation Table

• Modern operating table are designed to support and

accommodate the various anatomic configurations
required in surgical position.

• They are electrically or battery operated with a manual

back up.

• Their height can be raised or lowered, tilt laterally and

trandelenburg position.

• They have roller wheels, which allow them to be easily

moved , and brakes that can lock them in place.

• The operating table are composed of a flat platform

divided into 3 sections. The section is the head, body
and foot section.

• Each section has a corresponding removable mattress,

which usually attaches to the main platform by Velcro
or straps.

• The joints of the operating table are referred to as

breaks.

• The side rails of table can accommodate multitude of

attachments including stirrups, screens, arm boards
and various retractors.
• The operating table’s width is narrow to allow ease of
access to the operative side.

• Underneath the operating table platform is tunnel that

runs under the entire body and legs sections to support
x-ray cassettes.

• The head section of the operating table can be flexed,

lowered or removed. It is connected to the bed by two
horizontal posts that fit into corresponding grooves in
front of the body section.

• The body section is attached to the base of the

operating table. Since this section supports the
heaviest part of the body, the chest, the abdomen and
pelvis. This section also has a break in the centre at
the hip level that can be flexed or lowered to allow the
head and chest areas to be elevated or lowered.

• The leg section of the operating table can be flexed or

lowered to the extend that it folds deeply beneath the
lumber section to allow leg room for sitting surgeon to
gain access to the perineal area when the patient is in
lithotomy position.

• Check the functioning order of the operation table, as

for this case, patient need to be put on trendelenburg
position, the necessary equipment needed such as arm
boards, padding, body stripes must be available.

• Check that the operating table ‘gear system’ is

functioning or the table winder is available. If the
automatic control table used, check that the remote
control was charged and ready for use. This is to
provide smooth surgery.
ELECTRO SURGERY UNIT
(DIATHERMY MACHINE)

Figure 6 : Electro Surgical Unit

To complete the electric circuit to coagulate or cut tissue

current must flow from generator via an active dispersive
electrode. Electro surgical is utilized to a greater or lesser extent in
all surgical specialities.

The scrub nurse and circulating must be familiar with

manufacturer’s detail manual of operating instruction for each type
use.

Electro surgical unit or know as diathermy is common

practice in the operating room is poses a conciderable degree of
danger to patient, surgeons and the nurses, especially if there is
lack of knowledge of the function of electro surgical unit and the
principle behind it.

Electro surgery unit is a high frequency electric current

producing machine consists of electro surgical generator. The
generator consists of following:-
 a. A cable to power source.

b. An ON / OFF switch to permit the power to flow through the

electrode.

c. A switch or dial for selecting coagulation, cutting or blend

dials to select the cutting or coagulation mood.

d. A receptacle for the dispersive electrode cable, the active

electrode cable and foot control.

The active electrodes which commonly used now are the

pregelled type dispersive pad, which can be moulded to thigh or
calf.

Type of Electro Surgical Unit :-

A) Monopolar Diathermy.

- Only one pole is active and it carries current to

operation site. It is dispersed over the dispersive
electrode ( ground pad) and returned to Electro
Surgical Unit via the dispersive electrode cable.

B) Bipolar Diathermy.

- Bipolar active electrode has a forceps configuration.

The active electrode is in the inner side and the
inactive is in outer side of the forcep. The current flows
from the unit through the active side, arcs through the
tissue to the inactive side and returns to the unit via the
same cord.
 SUCTION APPARATUS

Figure 7
: Suction Apparatus

• Suction equipment is equipment used to aspirate fluids

from body orifices or cavities with the application of
negative pressure.

• There are 2 types of suction apparatus

 portable system – run by electricity and can be
taken from place to place
 central pump unit – connected by a pipe line system
to operating suites

• Parts of suction system

 a suction tip referred to as the sucker head or
catheter. The basic configuration includes the single
hole, the ‘whistle tip’ and the multiple ends.
 the sterile tubing connected to the sucker tip to use
on the surgical procedure, suction tube connected
to the bottle. Disposable tubing and disposable
bottle recommended by universal precaution to
reduce possibility of cross infection.
 suction regulator to control the degree of vacuum
calibrated in mmHg or CmH20.
 bacterial filter to prevent cross infection from
aspirated material is avoided and should be
changed daily or when contaminated.
  usage of suction in the operating room is during
operative surgery, endoscope, anesthesia,
resuscitation, suction curettage, smoke evacuation
and suction lipectomy.

• Two units suction apparatus should be available in

operating room. One for anesthesiologist, to evaluate
gastric content or secretion in the respiratory so that
can maintains patient airways. Another one is to be
used by surgeon in order to minimize the accumulation
of blood, body fluids and indignation fluids in surgical
wound

• Routine maintains and inspection of suction apparatus

are important duties of nurse to check good
performance of suction.

• Connect suction tubing to patient suction tube

connection or inlet and the outlet is for the vacuum.
• The suction tubing is approximately 2 ½ to 3 yards
long.

• Clear tubing is recommended as it allows easy viewing

of materials passing through it during suctioning.

• Tubing must be good condition, without punctures and

with a clean lumen.

• The degree of suction required initially by compressing

the tubing after switching on machine whilst setting the
adjustable valve at the necessary position.

• After used, suck water to rinse through to aid in

cleaning the nozzle and tubing.

• The collection bottle and tubing always be thoroughly

cleaned and sterilized after used. The applies only to
reuseable bottle and tubing.

• Checked the functional order of the machine. Check

the washer if there is leakage there will be no vacuum
created. Check wall outlet for proper connected.
• Avoid kinking or being compress the sucker tubing
from wall to machine because they will increase
pressure and this will weaken the power and later spoil.

• Show the anesthetist the nature and amount of

content.
 SCRUB ROOM

Figure 8 : Scrub Room

Adequate scrubbing and hand washing facilities should be

provided for all operating members.

The scrub room is adjacent to the OR for safety and

convenience. Individually enclosed scrub sinks with automatic
sensor control, foot, knee or elbow operated faucets were used
to eliminate the hazards of contaminating the hands after use.
The sink was deep and wide enough to prevent splashing.
Scrub sinks should be used only for scrubbing or hand washing.
They should not be used to clean or rinse contaminated
instrument or equipment.

Sterile dispenser with reuseable sterile brushes was hung

up. Each must be removed without contaminating the others.
The brush must be soft enough not cause abrasion.

Various antimicrobial ( antiseptic ) detergents are used

for surgical scrub. Scrub lotion such as hibiscrub or povidone
iodine was used as the antimicrobial/ antiseptic agent due to its;
 Effectiveness and broad spectrum property
 Fast and prolonged action
 Non – irritating and non – sensitizing
 Independent of cumulative action
 A sterile gown cannot be donned over damp scrub attire
without resultant contamination. Reuseable woven gowns may
be particularly vulnerable to strike-through of moisture after
repeated washing. The scrub room was prepared by the scrub
and circulating nurse by starting with damp dusting the scrub
room.
 RECOVERY ROOM

Figure 9 : Recovery Room

• Recovery nurse do the cleanliness the counter, the

patient trolley, cabinets and equipment such as ECG
machine, suction apparatus and pulse oxymeter.

• The perioperative nurse washes the circuit tubings

which are already used, change the water in oxygen
humidifier bottle, oxygen tubing, suction tubing and
suction bottle.

• Recovery nurse also prepare the suction catheter and

mask are various sizes each every section, checked
the emergency trolley and make sure all the drugs and
item are available for emergency.

• Also indenting the lotion, anesthesia drug and DDA

( Dangerous Drug Acts).
PREPARATION OF OPERATION ROOM
ATTIRE
Introduction of Operation Room Attire
• All operating room personnel were requires to changed
the street clothes to proper operating room attire when
entering the operative suite.

• The purpose of wearing the operating room attire is to

provide the effectives barrier that prevent
dissemination of these microorganism to patients and
protects personnel from blood and body substances of
patients. before perfomed the procedure are ready with
clean and neat OR attire.

• OR attire consist of body covers such as two piece

pantsuits, cap, mask and shoes including the shoes
cover. Personal Protective Equipment such as
eyewear, gloves and aprons and also a part of OR
attire. this is to prevent sources of external
contamination to the patient. Proper attire is a part of
aseptic environmental control that also protect
personnel against exposure to communicable disease
and hazardous materials.

• OR attire should not be worn outside the OR

department or outdoors. Before leaving the OR
department, everyone should change the street
clothes.

• OR personnel should remove all jewellery including

rings, watches and chain before entering the Operation
Theatre. Microorganism may harbored under the rings
thus preventing effective hand washing. The necklace
or chain can grate on the skin increasing tesquanation
it can fall into wound or contaminate a sterile field.
 COMPONENTS OF APPROPRIATE
OPERATING ROOM ATTIRE

Figure 10

~ each of attire is means for contaiment of on protection

against
and potential sources of environment contamination
including skin, hair and nasopharyngeal flora and
microorganism in air, blood and body fluids.

• HEAD COVER / CAP

Figure 11

 Hair is a gross contaminant, so that a cap is put on before

changing the cloth to the OR attire in the semirestricted area
(changing room). The caps meets same safety requirement
as the scrub suit and should donned before scrub to prevent
the shedding the bacteria from the hair to the OR attire.
 All hair surfaces must be covered including sideburns. The
cap should be clean, lint free and completely covers all head.
Head cover should be freshly laundered daily. Persons with
scalp infection should not entering the operating room.

BODY COVER

Figure 12

 Everyone dons attire intended for use within a semirestricted

or restricted area such as two piece pantsuits. All should fit
the body snugly for comfort and appearance. Pantsuits
confine organisms shed from the perineal region and legs
effectively.
 Shirt and waistline drawstrings are tuck inside pants to avoid
their touching sterile areas. The scrub suit should be
changed as soon as possible whenever becomes wet or
visibly soiled.
 OR personnel must worn a clean freshly laundered pantsuit
everyday. The sleeves should be short enough to perform a
proper hand scrub and also prevent the sleeves from
becoming wet during the scrub. When pants are donned,
they should not allowed to touch the floor, since dust and
bacteria can contaminate team.
 SHOES
 Shoes should be cover the toes and soles. A good pair of
shoes should provide support and protection for feet, easy to
clean, well padded and not slippery. Shoes should be
comfortable, supportive and closed in all sides to minimize
fatigue and for personnel safety. Sandal or clog type shoes
are hazardous in the operating room because they may slip
off or cause a fall if a person most move quickly, shoes must
be wash and dry regularly when dirties and also it must be
put on before enter semirestricted area.
PERSONAL PROTECTIVE EQUIPMENT
 Personnel should be protected from hazardous condition in
the semirestricted and restricted areas.protective attire does
not allow blood or other potentially injurious materials to
reach the inner clothing, skin or eyes.

1. Aprons
 A decontamination apron worn over the scrub
suit to protect against liquids and cleaning agent
during cleaning procedure. It should be full front
barrier. Fluid proof aprons worn by sterile gown
when extensive blood cores or irrigation is
anticipated.

 Leads aprons worn under sterile gowns protect

against radiation exposure during procedures
performed under fluoroscopy or image
intensification or when personnel are exposed to
radioactive implants.

2. Eyewear
 Eyewear or face shield is worn whenever a risk
exists of bleeding or body substances from the
patient splashing into the eyes of sterile team
members. A combination surgical mask with a
visor eye shield or a chin-length face shield is
another option. Care is taken that the lower edge
of the face shield does not touch the front of the
gown.

3. Gloves
 Nonsterile latex or vinyl gloves are worn to
handle any material or items contaminated by
blood and body substances. Gloves are never
washed between patients contact, they are
discarded. Clean or sterile item should not be
handled with contaminated gloves.

 Sterile gloves are worn by sterile team members

for all invasive procedures. Sterile gloves are
packaged impairs with an averted cuff on each to
 protect the outside of the sterile glove during
donning.

4. Mask
 Mask is worn in the restricted area to contain and
filter droplets containing microorganisms expelled
from the mouth and nasopharynx during
breathing, talking, sneezing and coughing.

 Mask filter about 99% of particulate matter larger

than 5mm in diameter but only about 45% to 60%
of particles 0.3mm in diameter.

 The mask should be cover the nose and mouth

completely and it must be tie securely at the back
of the head for upper string and behind the neck
for lower string and pinched to confirm the nose
to provide a secure proper fix.

 Mask never left hanging around the neck, place it

top of the cap or put it in the pocket for future
use. It must be removed and discard when wet
and for every patient and handle it to the ties
only. After discard the mask, the personnel must
wash and dry the hands thoroughly.
 RECEIVEING PATIENT ~
RESPONSIBILITIES
BEFORE
 Called ward staff for send patient to the Operation Room by
charting the name of the ward staff and time of calling. In this
case, Mdm Aini was numbered as number 3 in the operating
list. So that, reception nurse was called patient at 10am.
 While waiting patient arrive to OR, the perioperative nurse
check the stretcher whether it is functioning good such as it
can be locked or unlocked. To prevent patient from fall from
the trolley which is can be a hazardous to the patient.
 The perioperative nurse prepared the pillow and the blanket
for covering patient from cold.

DURING
 When the patient arrives, the perioperative nurse greeted
and welcomed patient with the pleasant smile.
 The perioperative nurse introduced herself and also give the
gently touch to Mdm Aini to creat a good rapport and allay
her fear and anxiety.
 She asked the full name Mdm Aini, age and identity card
number and compared the information with the consent form
and operating list to make sure that the correct patient.
 The perioperative nurse checked the consent for the
signature, the date for validity, the type of the operation and
site clearly written on the consent. The patient giving consent
must be legal age and mentally competent and signed
consent is legally regarded as valid not more than 14 days. It
is to protect the patient from ungratified and unwanted
procedure and to protect the surgeon and hospital or facility
from claims of an unauthorized operation or other invasive
procedure.
 The perioperative nurse asked Mdm Aini when she takes the
last meal and drink. The patient should ingest nothing by
mouth 6 to 8 hours before the operation to prevent
regurgitation or emesis and aspiration of gastric contents
during or after intubation.
 The perioperative nurse asked the patient about the
jewelleries and prosthesis or implant to prevent possible burn
because of electro surgical unit will be used and the denture
to prevent obstructed airway.
  The perioperative nurse also confirming the investigation
result, ECG chart, X-ray film and availability of blood, with
the ward staff.
 The perioperative nurse makes sure the patient was
completely wearing OT attire, which is clean OT gown and
cap.
 The patient was transferred to a clean trolley and change to
a clean pillow and blanket to avoid contamination from
outside to inside OR. During transfer the patient,
perioperative nurse make sure the intravenous infusion not
dislodge. Place patient’s arms, legs and head in canvas.
 One personnel must be at the other side of the trolley to
receive patient and transfer patient slowly, gently, smoothly
and simultaneously to provide safety.

AFTER
 Perioperative nurse securely the side rails in place to prevent
patient from fall and injured.
 Check the intravenous infusion and it was functioning well
and no redness or swollen at the puncture site and put the
intravenous infusion on drip stand.
 The vital sign was checked by perioperative nurse such as
blood pressure, pulse rate and temperature before sending
Mdm Aini to OR for database during anesthetized.
 The perioperative nurse sent the patient to the waiting bay.
 Patient was observed the anxiety level by perioperative
nurse and make sure patient is in comfortable and provide a
safe and quiet environment at the waiting bay.
Figure 13 : Reception Area
 INDUCTION OF PATIENT
After Mdm Aini wheeled to the induction room, the anesthetist
nurse applied the blood pressure cuff at the right arm to monitor
the blood pressure for database before, during and post
anesthesia for the patient undergoing anesthetized. Intravenous
line with Hartman’s solutionwas set up at the left arm.

The anesthetist performs scrubbing, gowning and gloving. Then

anesthetist nurse and the circulating nurse put the patient in the
sitting position. The spine is flexed with chin lowered to sternum,
arms crossed and hold the pillow.

After positioning the patient, the anesthetist nurse help the

anesthetist give the Epidural with:-
 Opened the outer layer of the spinal set.
 Pour the 10% povidone iodine to the patient skin for
antiseptics purpose.
 Opened the:-
- Epidural set.
- syringe 5cc & 10cc
- Lignocaine 2% for local anesthesia

Figure 14
 EPIDURAL ANESTHESIA
• The Epidural space is a part of the human spine inside the
spinal canal separated from the spinal cord and its
surrounding cerebrospinal fluids by the dura mater.

Figure 15

• Epidural is often short for Epidural anesthesia, a form of

regional anesthesia involving injection of drugs through a
catheter placed into the epidural spaced. The injection can
cause loss of feeling and loss of pain (analgesia).

• Common local anesthetics include lidocaine, bupivicaine,

ropivicaine and chloroprocaine. Common apoids are fentanyl
and pethidine. These are then injected in relatively small
doses.

• Using a strict aseptic technique a small volume of local

anesthetic, such as 1% lignocaine, is injected into the skin
and interspinous ligament. A 16, 17 or 18 gauge touhy
needle is then inserted into the interspinous ligament and a
“loss of resistance” technique is used to identify the epidural
space.

• Traditionally anesthetists have used either air or saline for

identifying the epidural space. After placement of the tip of
the touhy needle into the epidural space the catheter is
threaded through the needle.
• The needle is then removed. Generally the catheter is then
withdrawn slightly so that 4-6 cm remains in the epidural
space.

• The anesthetist performed scrubbing, gowning and gloving

then arrange the spinal. The anesthetist nurse assist the
Doctor with open the epidural set.

Figure 16

• The Anesthetist painted the Mdm Aini’s back at the area

where the Epidural will be given with povidone iodine 10% to
reduce the number of microorganisms and remove the dirt,
residue at the skin.

• Then the Anesthetic drape the area with a fenestrated drape

which only expose the lumbar puncture site.

• The Anesthetist palpate the iliac crest to felt the level of the
L4 vetebra and mark it. He give the intradermal local
anesthesia lignicaine 1% about 3mls exactly the chosen
interspace to reduce the pain while touhy needles inserted.
 Figure 16

• The anesthetist inserts the 18 gauge touhy needles about 1-

1.5cm into the epidural space between L3-L4. the anesthetist
push in the air via the needle using the loss of resistance
syringe and no resistance seen.

Figure 17

• The Anesthetist confirm that the correct space, he push the

percutaneous indwelling catheter until 5cm mark and
connect the catheter to the bacterial filter.
 Figure 18

• The anesthetist nurse spray with opsite spray at the puncture

site and secure with a small opsite dressing. Then the
catheter was secure with a plaster.

Figure 19

• The anesthetist clears the things and removed all the drapes.
Then the anesthetist nurse ask Mdm Aini to lay down and
wheeled Mdm Aini into the operating room.
GENERAL ANESTHESIA
• Mdm Aini was transferred to the operating table. The
anesthetist nurse and the circulating nurse put Mdm Aini in
the supine position and was make sure that Mdm Aini are
comfortable.

• The anesthetist nurse applied the ECG lead and the pulse
oxymeter to monitor the heart rate and oxygen level in blood
circulation. She was also put the doughnut for support the
patient head.

• The Anesthetist was request ETT tube size 7 for intubation.

The anesthetist nurse lubricates the tip till the cuff part of the
Ett with K-Y jelly for easy to intubate.

• Mdm Aini was preoxgenated with 100% of 10 liters oxygen

via face mask. The patient was instructed to breath deeply.
This is to provide a margin safety in event of airway
obstruction of apnea during intubations.

• The anesthetist was induced analgesic injection Fentanyl

50mg via intravenous administration, followed by an
induction agent as Sodium Thiopentone 200mg to put patient
to sleep.

• Then, the muscle relaxant agent short acting,

Suxamethonium 50mg was given which act about 5-10
minutes. The Anesthetist hold the face mask and bagging the
reservoir bag to give patient 100% oxygen because patient
cannot breath herself.

• When fasculation had occurred, the anesthetist was

intubated Mdm Aini with ETT size 7. The Anesthetist nurse
was inflated the cuff with a 10cc of air.

• The anesthetist auscultated the patient to make sure the ETT

was properly placed by listening the air entry both lung. The
anesthetist nurse was anchored the ETT at the 19cm marked
by a plaster and the anesthetist connect to the GA machine.
• The anesthesia was maintained with used the Nitrous Oxide
2 liter per minutes, oxygen 1.5 liter per minutes. Long acting
muscle relaxant injection Atracurium 10mg every 30-45
minutes was given via intravenous administration.

• The anesthetist and the nurse had a close observation of the

monitor screen and record the observation every 5 minutes.
They also checked the intravenous infusion was flowing well
and top up as required.
 PREPARATION OF STERILE TEAM
MEMBERS
SCRUBBING, GOWNING AND
GLOVING
1) Scrubbing
 The purpose of scrubbing is to reduce the bacterial to
an absolute minimum to prevent from multiplying
during the operation.

 Before scrubbing, the scrub nurse must be completely

attired – wearing the operating room attire with hair
covered by cap and mask covering the nose and
mouth.

Figure 20

 The recommended method is the counted brush stroke

method following the anatomical pattern of hand and
arms

 The hands and arms are divided anatomically into

sections and equal number of strokes. This method is
to ensure that each area are covered during the
procedure.
 Hand washing step;-
1) Initial scrub

R
emo
ve
any

jewelry or watch on hands and wrists.

Wet hands and forearms. Dispense surgical

foam

Wet both hands and forearms up to 2 inches

above the elbow.
 Rinse the hands
and arms
thoroughly under
running water with
hand upwards
allowing water to
drip from the flexed
elbow.

2) Surgical Scrub

Pick a sterile brush from the dispenser.

Dispense the small
amount of chemical
agent on the brush.

Brush a nail of both

hands applying 10
brush strokes.
Rinse nails of both
hands and brush.

Dispense a small
amount of chemical
agent on brush and
brush all sides of
each finger, the
web of the fingers
10 strokes.
The palm of the
hand – 10 strokes
 The back of the
hands – 10strokes

The four planes of the applying 10 brush strokes to each plane up

to 2 inches above elbow.

Scrub the elbow 2 inches about 10 strokes

60
 Rinse the brush, the hands and the arms up to
2 inches above the elbow thoroughly from
under running water to drip from the flexed
elbow. Discard brush. Repeat for other hands
and arms.

3) Hygienic hand washing

Dispense an
antiseptic agent on
the palm

61
Apply the antiseptic agent using friction palm to
palm.

62
 Right palm over
the left dorsum and
left palm over the
right dorsum

Backs of fingers to
opposing palms
with fingers
interlocked.

Rotational rubbing
of right thumb
clasped in left
palm and vice
versa.

63
64
 Rotational rubbing,
backwards and
forwards with
clasped fingers of
right hand in left
palm and vice
versa.

Rotational rubbing
of right wrist and
vice versa. Rinse
and dry thoroughly.

Rinse the hands

and arms
thoroughly under
running water with
hand upwards
allowing water to
drip from the flexed
elbow.

65
 After scrubbing, the hands must
be kept higher then the elbow to
allow water to flow from clean
area.

It is important that splashing be

avoided because wet scrub attire
will contaminate the sterile gown
when it is donned and can be a
strike through.

2) Gowning
PURPOSE
The sterile gown are worn to
 Exclude the skin as a possible contaminant.
 Create the barrier between the sterile and non-sterile area.
 Prevent microorganisms from the hands and clothing of the
surgical team being transferred to the wound.

• The package of the sterile gown was opened by circulator

nurse without touching any sterile area of the sterile
package.

66
• Then, the scrub nurse will open the second layer of the
package which is sterile.

• The scrub nurse reach down to pick up the towel without

contaminate the gown.

• After scrubbing, the scrub nurse’s hands and arms must be

thoroughly dried before wearing the sterile gown. This is to
prevent contamination of sterile by organism from the skin
and the scrub attire.

67
• Open towel full length, holding one end away non-sterile
scrub attire. Bend slightly forward to avoid towel touching
attire.
• To dry the arm – hold the towel in the opposite hand and
using an oscillating motion or the arm, draw the towel up to
elbow. Then, repeat the same motion to the other hand using
the unused end of the towel.

• All gown are folded and packaged for sterilization with the
inside exposed so that the scrub nurse and the surgeon may
handle the gown without contaminating the outside of the
gown.

• Grasp the inside of the gown and lift the gown away from the
table.

68
• Unfold the gown by placing the hands at the neck edge.

• Locate the arms holes. Slips the arm carefully with the eyes
follow when the hands slip into the sleeve to avoid touching
the unsterile area. Do not thrust hands through the cuffs.

69
• Circulator pulls the back of the gown and ties the gown
strings from the back.

• The circulator passed the sterile glove to the scrub nurse

without touching inner layer of the sterile glove.

70
• Place the right glove on the right palm. Thumb of the glove
over the thumb and the finger of the glove facing towards
wearer.

• Grasp a bit the glove cuff with the thumb, stretch over the
end of sleeves with hand within the sleeve. Work fingers into
the glove.

• Cover the cuff of the sleeve with the cuff of the glove.

71
• Repeat the same technique to the left hand.

Gown are
considered sterile
2” from neck line to
waist line and 2”
above the elbow

• Sterile person always keeps hands in sight, above waist level

to prevent contamination to sterile gown and gloves.

• The perioperative nurse ready for laying out the instrument

and assisting the operation.

72
PREPARERATION OF INSTRUMENT
TROLLEY AND MAYO’S STAND.
 The circulating nurse open the outer layer of the sterile pack
instrument pack. She lifts the wrapper back while keeping
hands on the outside. Hands is in folded cuff to avoid
contaminating the inner layer of the pack.

 Then, the scrub nurse open the inner layer of the pack.
Touch the inner layer and drapes the trolley as necessary
according to standard procedure.

 In this procedure, the nurse use 3 trolleys including the Mayo

stand for layout the General set and Total Abdominal
Hysterectomy Extra.

 The scrub nurse drape the Mayo stand. Both the frame and
the tray are draped.

Figure 21

73
 The Mayo stand cover is like a pillowcase. It is transfolded
with a wide cuff to protect gloved hands. With hands in cuff,
fold the drape are supported on the arms, in bend of the
elbows to prevent its falling below wrist level.

Figure 22

 While sliding cover on, place foot on base of stand to

stabilize it.

 The scrub nurse count sponges, sharps items and

instruments with circulating nurse according to the list.

74
GENERAL SET

Figure 23 : General Set

BIL ITEM QUANTITY

1. Instrument Tray 1
2. Kidney Dish 3
3. Gallipot 4
4. Backhaus towel clip 8
5. Sponge holder 4
6. Scssor’s:-
• Mayo’s straight 14cm and 17cm 2
• Mayo’s curved 15cm 1
• Metzenbaum curved 1
7. B/P Handle - size 4 2
- size 5 1
st
8. 1 Mayo’ pin:-
• Halstead Delicate Artery Forceps 8
• Crile Artery Forceps 8
nd
9. 2 Mayo’ pin:-
• Babcock tissue forceps 2
• Allis tissue forceps 2
• Littlewood tissue forceps 2
2
• Duvals tissue forceps
2
• Spencer well artery forceps,straight 3
• Needle holder 1
• Yaunker sucker 1
• Pool sucker 1

75
 • Sucker tubing – long
10. Dissecting forceps:-
• Mc Indoe 1
• Gillies 1
• Medium toothed 1
1
• Medium non toothed
1
• Waugh toothed 1
• Waugh non toothed
11. Retractor:-
• Small Langenback 1 Pair
• Medium Langenback 1 Pair
• Morris 1Pair
12. Mc Donald Dissector 1
13. Dennis Brown 1
14. Raytex gauze – 10 pieces per bundle 2 bundles

76
TOTAL ABDOMINAL HYSTERECTOMY
EXTRAS SET

Figure 24 : TAH extra

BIL ITEMS QUANTITY

1. Instruments tray 1
2. Deavers retractor 2
3. Scissors :-
• Mayo uterine 1
• Straight 9” 1
4. Dissecting forceps:-
• Toothed 1
• Non toothed 1
5. Mayo’ pin :-
• Kocher curved tissue forceps 6
• Kocher straight tissue 6
• Littlewood tissue forceps 6
2
• Teale vulsellum forceps
6. Balfour Abdominal Retractor with 1
centre blade
7. Gynae pad 1

77
LAYOUT OF THE INTRUMENT
 The scrub nurse arrange the instruments and accessory
items on mayo stand and instrument trolley. The circulating
nurse open the packages of sterile supplies such as
diathermy flex with pin, light handle, sutures and blade.

 She flip the blade packet from over wrap into the kidney dish,
then she opened the light handle packages and diathermy
pin. Scrub nurse take contents from wrapped open and avoid
touch the unsterile outer wrapper.

Figure 25 : Layout instrument on the instrument trolley

 The scrub nurse put the blades on the bard parker handle
using spencer well never use finger alone. Holding the
cutting edge down and away from eyes or anybody. Grasp
the blade at its widest, strongest part, and slip the blade into
groove on the knife handle.

78
Figure 26 : Layout the instrument on the Mayo stand

 A click indicates the blade is in the place. To prevent damage

the blade, the instrument must not touch the cutting edge.
The scrub nurse fix the diathermy pin.

 The circulating nurse pour the povidone iodine 10% into the
gallipot for skin preparation. The scrub nurse put 3 pieces of
the gauze into the gallipot without touching the solution
because the solution is not sterile and the glove can be
contaminate.the scrub nurse ready for arrival of the surgeon.

 The surgeon request for a catheter to insert the CBD to Mdm

Aini. The circulating nurse prepare the set for the
catheterization.

 The circulating nurse open the outer layer of the

catheterization set, then the scrub nurse open the inner layer
of the set.

 Circulating nurse pour the Hibitine in Aques, water and K-Y

jelley. She also gives the catheter size 18FR and syringe
10cc for syringe out the water. Then, she assist in any way
possible.

79
 After catheterization is over, Mdm Aini was put back on
supine position.

 The scrub nurse put the inactive plate at the Right thigh
muscle. It should be as closed as possible to site of incision
to minimize current through the body.

 The plate should cover as large of patient’s skin as possible

in an area free of hair, scar tissue, which tend to act as
insulation.

80
 Figure 27

RESPONSIBILITIES AND THE SAFE OPERATION

OF ELECTRO SURGICAL UNIT ( ESU )

Responsibilities Before.

a. The perioparative nurse must have knowledge to use and

maintain the Electro Surgical Unit.

b. Must know which Electro Surgical Unit is to be used and

how to use it. Read and follow instruction manual.

c. Only used equipment that is designed and approved for unit.

d. Check the functioning order of the ESU for any damage or

with missing parts e.g. broken plugs, missing part, dials,
frayed cracked cable and the power point is working.

e. Check the generator , on generator and check to ensure the

alarm systems are working. This is to prevent diathermy
burns

f. The dial, turn to ‘ 0 ‘ before switch on the unit.

g. Used the correct dispersive pad according to patient’s

weight and size, make sure there is enough gel to ensure
good contact. Do not cut, dispersive pad to ensure safety.

81
 h. Check the area applying the dispersive pad is dry, avoid
bony protuberance, skin folds, scar tissues, excessively fatty
or hairy areas, to be x-ray or skin lesion. All this to ensure
good skin contact.

i. Avoid place dispersive pad at the sites where fluids might

pool.

j. Apply the dispersive pad after positioning patient to prevent

dislodges and get the dispersive pad is dry.

k. Check and ensure no skin surface is touching any metal

parts of the table and its accessories to prevent diathermy
burn.

l. Fixed up the active electrode and turn the unit on and set
the dials, start at very low setting and slowly increase.

m. Inform surgeon of the dial setting.

n. Do not learn the generator and place heavy objects or

solution on top to ensure safety.

Responsibilities During.

a. Position all cable or wires so that they do not present a

tripping hazard. Do not wheel equipment over the cords.

b. Check and ensure the active electrode tip is firmly secured.

c. Keep the active electrode clean at all times during surgery.

Escher build-up increases resistance, reduce performance
and require higher settings.

d. Keep the electrode separate from all conductors on the

sterile field.

e. An unused active electrode should be place in a protective

sheath or pocket because the electrode can be activated
accidentally and so burns the patient or medical personnel.

Responsibilities After.

82
a. Disconnect the unit, turn the dial to ‘0’ and turn the power
switch OFF.

b. Disconnect the cable from the active electrode by grasping

the plug not the cable to prevent damage to the cable.

c. Remove the dispersive pad gently, support the skin and peel
the dispersive pad slowly to remove it.

d. Check the site of dispersive pad for any redness or burn.

Clean the skin to remove all gel.

e. Document in the swab count form the site dispersive pad

applied and condition of the skin.

f. Coil the cable or wire loosely to prevent kink.

Wipe all the equipment with damp cloth to maintain cleanliness.

83
POSITIONING OF THE PATIENT FOR
SURGERY
After obtaining permission from the anesthetist, Mdm Aini
was positioned to supine. In this position Mdm Aini lay flat on the
back with the head and spine in a horizontal line, do not cross
touching each other legs.

The head supported by a medium donut to prevent stretching

of neck muscles that supported the head. Arm were placed on the
padded arm board and positioned less than 90 degree angle to
prevent injury to brachial nerve. The arms were placed supine
(palm up) to prevent ulnar nerve compression.

Proper body alignment was carefully giving attention to

prevent muscles strengthening. The patient was not disturbed by
being moved or touched until the permission was granted by the
anesthetist.

The anesthetic (L) screen was attached at the head end of

the table so that during draping the head ring of the patient was
not covered and this allowed the anesthetist to check and observe
the patient throughout the surgery.

Anesthetist nurse applied warming blanket at the upper chest

area to keep patient warm and to prevent hypothermia and
temperature also generally cool in operation room to reduce
mortifications of microorganisms. To reduce the potential of
compression or electric burn, no part of patient’s naked body
allowed contacting with metal surfaces.

The door of the operating room were kept in close at all time
except as needed for passage of personnel. Traffic in and out of
the operating room was kept to a minimum.

Activity increase air turbulence which carries bacteria to

wound. Therefore, movement in operating room was reduced to
minimum.

Personnel with acute infection such as upper respiratory

infection or skin lesion were excluded from the operating room.

84
PAINTING PROCEDURE
 Povidone iodine 10% was used for painting because its act
as an antiseptic agent, which leave a residue on the skin to
inhibit the growth of microorganisms.

 After the scrub nurse passes the sponges and povidone

iodine 10% to the surgeon, the circulating nurse fold back
the blanket and patient’s gown 2inches beyond limits of prep
area.

 The surgeon wet the sponge with antiseptic agent and

squeeze out excess solution and start the painting.

 The painting starting at side of incision, with a circular motion

to periphery, with uses enough pressure and friction to
remove dirt and microorganisms from skin pores. The
surgeon discard sponge after reaching the periphery and
repeat painting with a separate sponge for each round.

 Painting was commenced at the incision site and is extended

away from the centre. One swab used for each cleansing
round. Painting is done from breast line to upper third pf
thigh including pubic area. The objective is to remove
microorganisms, dirty and oil from the skin and create an
antiseptic field for the incision to prevent infection intra
operatively and post operatively. After painting sponge holder
and gallipot would be discarded.

Figure 28

85
 DRAPING PROCEDURE

 After the surgeon painting the patient, the scrub nurse ready
to assist in draping and the circulating nurse ready to wacth
for breaks in technique.

 If the drape contaminated or expose of a non sterile area

might be source of an infection for the patient. For this
operation, square drape are used.

 Draping technique was performed by two sterile persons.

The drape was place around the operative site to expose
only the operation site.

 The scrub nurse hand, one end of fan folded sterile towel
across table to surgeon, and one hand to the assistant and
they holding it tent until it is opened, then lay it down on the
below site incision.

 The scrub nurse never touch the surgeon hand glove

because it may be contaminated to povidone during painting.

 Drapes were held high enough to avoid touching non sterile

area below and the operating light above.

 Gloved hands were protected from any contamination by

cuffing end of sterile folded towel over them and the hand
was stretched out to hand the drape to the surgeon on the
opposite side.

 Below incision site must covered with 2 layer and follow to

drape the upper incision site.

 After that, the scrub nurse give the towel, one for the
surgeon, one for the assistant to drape the side of the
incision by fold ¾ and secure it with towel clips.

 Repeat the same to cover the below and upper site of

incision. After draping, the scrub nurse put the extra towel
below incision site to practice SEPTIC TOWEL TECHNIQUE
to maintain the sterile field by avoid the spillage from vagina

86
 vault and attach the suction tubing and diathermy cord along
with the flex pin to drape and secure with towel clip.

 Ample length was allowed to reach both incision area and

the machine. One sterile towel cover the coil of tables and
diathermy pin pointed away from the incision site to ensure
safety to the scrub nurse.

 The scrub nurse bring the Mayo stand into position over
patient and makes sure that it does not rest on the patient
and position the instrument trolley at a right angle to
operating table.

 The circulating nurse in moving Mayo stand and instrument

trolley into position, being carefully not to touch drapes.

 The circulating nurse connect the suction and diathermy

cable and the scrub nurse checked the functioning order of
the equipments.

87
POSITIONING OF OPERATING TEAM
1. GA MACHINE 1
2. WARMING MACHINE
3. GA DOCTOR
4. OPERATING TABLE
5. DRAPE PATEINT 2 3
6. 1ST ASSISTANT
7. SURGEON
8. 2ND ASSISTANT 4
9. MAYO’S TABLE
10. 1ST SCRUB NURSE
11. INSTRUMENT TROLLEY 5
12. 2ND SCRUB NURSE
13. DIATHERMY MACHINE
7 6
14. SUCTION APPARATUS
15. KICK BUCKET-CLINICAL
WASTE
16. KICK BUCKET-GENERAL
WASTE
8

9
10

11
14
13

12

16 15 15

Figure 29

88
89
 ANATOMY AND PHYSIOLOGY OF THE
FEMALE REPRODUCTIVE SYSTEM.

Figure 30 ; Location of the uterus

THE UTERUS
The uterus is a hollow, flattened, muscular, pear-
shaped organ which lies in the true pelvis above the vagina,
receiving the insertions of the two fallopian tubes into its upper and
outer angles. It lies in the pelvic cavity between the urinary bladder
and the rectum in an anteverted anteflexed position.
• Anteverted – means that the uterus leans
forward
• Anteflexion – means that it is bent forward
almost at right angles to the vagina with its
anterior surface resting on the urinary bladder. As
the bladder fills the degree of anteflexion is
reduced slightly. When the body is in the upright
position the uterus lies in an almost horizontal
position.

90
 It measures 3 inches (7.6cm) in length, 2 inches (5.1cm) in
width at its widest part and 1 inch (2.5cm) in depth, whilst its walls
are ½ inch (1.3cm) in thickness. The uterine cavity is therefore 2 ½
inches (6.4cm) long. The uterus weight about two ounces (56g). It
consist of the following parts:

• The body ~ is the main part which comprises the

upper two-thirds of the uterus. It is narrowest inferiorly
at the internal os where it is continuous with the cervix.
• The fundus ~ is the dome-shaped part of the uterus
above the opening of the uterine tubes, which is the
portion of the body of the uterus lying between the
insertions of two fallopian tubes.
• The cervix ~ protrudes through the anterior wall of the
vagina, opening into it at the external os.

The walls of the uterus are composed of three layers of tissue;

• Endometrium
• Myometrium
• Perimetrium

91
 Figure 29

THE ENDOMETRIUM
This is the mucous membrane which lines the interior of the
uterus. The mucosa of the uterine body differs markedly from that
of the cervical canal. It is composed of columnar epithelium and
contains many straight tubular glands. The thickness of this layer
varies during the monthly menstrual cycle. The upper two-third of
the cervical canal is lined with mucous membrane. The lower third
is lined with squamous epithelium, continuous with that of the
vagina.

THE PERIMETRIUM
The perimetrium consists of peritoneum. It covers the fundus
and the anterior sutface to the internal os, and is then reflected on
to the bladder forming a small pouch between the uterus and the
bladder, termed as uterovesical pouch. The posterior surface is
covered to where the cervix protrudes into the vagina and is then
reflected on to the rectum forming the rectouterine pouch. Laterally
the perimetrium extends over the uterine tubes forming a double
fold, the broad ligament leaving the lateral border of the body
uncovered.

92
THE MYOMETRIUM
The myometrium is a thick muscle layer composed of
bundles of smooth muscle fibres arrange in 3 interlacing layers.
• The inner layer of fibres runs in a circular fashion.
• The middle layer of fibres runs obliquely.
• The outer layer of fibres runs in a longitudinal fashion.

Figure 31

THE FALLOPIAN TUBES

These are two small tubes, each about 4 inches (10.1cm)
long and one –quarter of an inch (6mm) in diameter, which are
attached to the cornua of the uterus. They pass laterally from the
uterus across the pelvis almost to reach its side walls, where they
turn backwards and downwards towards the ovaries.

The tubes posses a lumen which communicates with the

cavity of the uterus medially and which opens into the peritoneal
cavity laterally.

The female genital tract is thus an open pathway which leads

from the exterior to the peritoneal cavity via the vulva, vagina,
uterus and fallopian tubes.

The tubes are attached medially to the uterus, and as they

pass transversely across the pelvis they carry with them the

93
peritoneum. This is draped across them forming a fold which
passes down to the pelvic floor below, so constituting the broad
ligaments.

Where the lateral extremities of the tubes bend backwards,

the peritoneum is continued as folds to the side walls of the pelvis,
producing what are known as the infundibulo-pelvic ligaments.

It can thus be appreciated that these are peritoneal

structures and not true ligaments, although they do accord some
means of support both to the Fallopian tubes and ovaries. They
also transmit the ovarian vessels, lymphatics and nerves.

THE OVARIES
The ovary is an organ whose structure and function vary at
different ages of the individual. The ovaries are two small almond-
shaped bodies, dull white in colour and corrugated on the surface,
measuring 3cm in length, 2cm in breadth and 1cm in thickness and
weighing about 6 grammes. They are attached to the posterior
layer of the broad ligament, and lies inside the peritoneal cavity.
They sometimes rest in a small depression in the parietal
peritoneum on the lateral wall of the pelvis below the bifurcation of
the common iliac artery, which is known as the ovarian fossa of
Waldeyer. The lateral portion of the Fallopian tube arches over the
ovary and end in close proximity to it, being connected to it by the
fimbria ovarica. When the uterus is retroverted the ovaries may lie
in Pouch of Douglas.

The place of attachment of the ovary to the posterior layer of

the broad ligament is known as the mesovarium, and the part of
the broad ligament extending above this point to the Fallopian tube
is called the mesosalpinx.

This attachment however is too weak to support the ovary,

which is suspended from the uterine cornu by the ovarian
ligament. As described above this is a strong structure, containing
smooth muscle, through the medial margin of the mesovarium.

Similarly the lateral pole of the ovary is suppoted by the

infundibulo-pelvic ligament, which has already been described as a
fold of peritoneum running to the side wall of the pelvis and
transmitting the ovarian vessels, lymphatics and nerves.

94
THE CERVIX
The cervix of the uterus tapers below the body and its lower
end is clasped tapers of the vagina into which it protrudes. Its thus
has vaginal (lower) and supravaginal (upper) parts.

The latter like the body of the uterus having intestinal and
vesical surfaces. The intestinal surface is covered by peritoneum
that contenoues from the body on the upper part of the fornix,
forming the anterior wall of the recto uterine Pouch of Douglas.

The body of the uterus is rarely exactly in the midline, when

deviated to one side the cervix becomes deflected to the opposite
side, so one ureter may be closer to the cervix than the other.

The canal of the cervix is continuous with the cavity of the

body at what is commonly called the internal os. The lower
opening into vagina is the external os.

THE VAGINA
The vagina is thin-walled, 8cm fibromuscular tube extending
from the vestibule obliquely backward and upward to the uterus,
where the cervix project into the top of the anterior wall.

The vagina is elastic and capable of distention during

intercourse and parturition. The bladder lies anteriorly to it. The
rectum lies posteriorly to it. It is lined with mucous membrane and
contains glands that procedure a cleansing acid secretion.

The anterior vaginal wall is shorter than the posterior wall.

The upper third of the posterior wall is covered by peritoneum
reflected onto the rectum. Normally the anterior and posterior walls
relax and are in contact.

The vault (dome, or upper part of the vagina) is divided into

four fornices. The anterior fornix, in front of the cervix, is adjacent
to the base of the bladder and distal ends of the ureters.

The pouch of Douglas directly behind the larger posterior

fornix lies behind the cervix.

95
 This pouch separates the back of the uterus from the rectum,
anteriorly by the uterine peritoneal covering, which continues down
to cap the posterior vaginal fornix and posteriorly by the anterior
wall of the rectum. Lateral uterosacral ligaments embrace the
lower third of the rectum.

The lateral fornices lie on either side of the cervix, in contact

with anterior and posterior sheets of the broad ligaments
surrounding the uterus.

Proximal structures are the uterine artery, ureters, fallopian

tubes, ovaries and sigmoid colon.

96
SUPPORT OF THE UTERUS

Figure 32

The uterus is supported in the pelvic cavity by the

surrounding organs muscles of the pelvic floor and ligaments that
suspend it from the walls of the pelvis. The supporting structures
is;
 THE TWO BROAD LIGAMENTS
Although these are mentioned here for the sake of
completeness, it must be clearly understood that they
are not consederations of pelvis fascia, but are, intead,
folds of peritoneum passing laterally from the uterus to
the side walls of the pelvis. They are not true ligaments
in any way, and are more fully described later.

The uterus and pelvic cellular tissue lie in the pelvis

above the levator ani muscles, which form a platform to
support them in their normal positions. When these
muscles relax, as during defaecation, the ligaments act

97
 as direct supports of the uterus, the most important in
this way being the cardinal ligaments.

 THE TWO ROUND LIGAMENTS

Begin at the cornua of the uterus, pass downwards,
forwards and outwards within the broad ligaments, and
then cross the lateral parts of the pelvic floor to reach
the internal inguinal ligaments in the anterior abdominal
wall. They then turn medially around the deep
epigastric vessels and enter the inguinal canals in the
groins. They traverse the canals, emerge through the
external rings in the oblique muscles, and end in the
fatty tissue of the labia majora.

These ligaments are of embryological interest, for they

mark the route along which the testes descend in the
male, in whom the scrotum corresponds to the fused
labia majora.

 THE TWO CARDINAL LIGAMENTS

Also known as the transverse cervical ligaments and
Mackenrodt’s ligament, run in a radiating of the manner
from the lateral aspect of the cervix below the level of
the internal os and the lateral fornices of the vagina to
the side walls of the pelvis, where they are attached to
the fascia overlying the obturator internus muscles.
The ureters on their way to the bladder pass through
these ligaments, lying in what are known as the
ureteric canals.

 THE TWO UTERO-SACRAL LIGAMENTS

Pass from the cervix in an upward and backward
direction, and encircle the rectum to become attached
to the periosteum of the sacrum.

98
  BLOOD SUPPLY

Figure 33

The main blood supply to the uterus is from the uterine

arteries which are branches of the internal iliac arteries.
They run up the lateral borders of the uterus and
anastomose with the ovarian arteries just below the level
of the uterine tube.

The blood vessls run a tortuous course twisting in and out

through the muscle fibres. There is a plexus of veins
which lies between the layers of the broad ligament and
which drains blood from the uterus into the uterine and
ovarian veins.

 LYMPHATICS DRAINAGE
The main lymphatic drainage is through the deep and
superficial iliac glands.

 NERVE SUPPLY
The nerve supply is through the sympathetic and
parasympathetic nerves. The sympathetic nerves are
derived from the hypogastric plexus and the
parasympathetic from the first, second and third sacral
nerves.

99
OPERATION PROCEDURE

Figure 34

• When the scrub nurse ready for assisting the surgery, the
scrub nurse give the surgeon one gauze to wipe off the
povidone iodine from incision site and surgeon will discard
the gauze into the clinical waste receptacle.

• The scrub nurse passed the blade size 23 in the kidney dish
to surgeon to make skin incision to avoid accidentally cut.
The blade were put at the edge of the trolley because the
skin is not sterile and the blade consider contaminated. Then
the scrub nurse give two gauze one for the surgeon, one for
the assistant.

100
• The surgeon made a Pfeannenstiel skin incision. The first
cut should extent well into the subcutaneous layer, these
were then separated with the knife down to the rectus
sheath.

Figure 35

• At the same time, the circulator documented the operating

time start into the Swab Count Form.

Figure 36

• Small vessel in the subcutaneous layer bleed and surgeon

diathermized using dissecting forcep.

101
 Figure 37

• The full depth of the fat was incised down to rectus sheath
but only in about the central 3 or 4 cm of the skin wound this
is done with one stroke of the scaple with the left hand
steadying in the wound area so that there is no sideways
slip.

Figure 38

• The rectus sheath is cut transversely, exposing the rectus

and the paramidalis muscle.

102
Figure 39

• Freeing anterior rectus sheath from underlying muscles. The

sheath is release in an upwards direction with mayo scissor
cuts as shown and the recti muscles fall back from the raise
sheath.

Figure 40

• The rectus muscles are cut transversely. The deep

epigastric vessels are ligated and cut. Transversalis fascia is
exposed. The assistant use the 1/2 “ langenback to exposed
it.

• The transversalis and peritoneum are cut transversely. Care

was taken at the lower end of the wound to be sure that the
gut or bladder was not injuired.

103
• The taut fold was palpated between forefinger and thumb
before incision to exclude the presence of underlying
structures.

Figure 41

• When the peritoneal cavity was opened, scrub nurse take all
the loose gauze away and removed from the operation site.
Swab on stick and abdominal pack was used instead.

• Once the uterus was identified, the Balfour Retractor was

used to ensure adequate exposure and scrub nurse gave 2
warm saline abdominal pack to surgeon to pack of the guts
thus gave better exposure to work on the uterus. The
abdominal pack were marked with crile artery forceps that
clamped at the tape attached. This is to ensure the correct
count.

• Then the surgeon ask the anesthetist and inform the

circulator to put the patient in trendelenburg position to
provide better visualization of the pelvic cavity. At the same
time circulating nurse and scrub nurse make sure that Mayo
tray not touch patient’s leg and patient in good body
alignment.

• The scrub nurse watch operation field and try to anticipate

the surgeon’s needs. She must be one step a head of the
surgeon in passing the instrument, sutures and sponges.
The scrub nurse passes the instrument in a decisive and

104
 positive manner. The tip is visible, hands is free. Handle was
placed directly into surgeon palm.

Figure 42

Figure 43 Kocher Curved and Straight

• The surgeon elevate the uterus, then the scrub nurse gave 2
curved kocker artery forceps one by one with handle placed
firmly and directly into surgeon hand. The kocker forcep is to
clamp the round ligament near uterine cornu and followed by
the mayo curved scissor to cut . The scrub nurse passed the
safil 1 Taper Cut Needle to ligate a short distal lateral to the
clamp. Assistant ready to cut suture with suture cutting
scissors. One end of the suture was held with the crile artery

105
 forceps while the other strand was cut. This was done one
side at a time. Curved kocker artery forceps was then
handed to assistant, thus opening up the anterior leaf of the
broad ligament. While passing the instrument scrub nurse
hold the instrument by hinge.

Figure 44

• The forcep on the uterine remnant of the ligament were left there
which allow a means of traction to exposure. The posterior leaf of
the broad ligament was pushed forward through the opening of the
anterior leaf with the surgeon. It was then incised with
metzenbaum scissors to create opening.

• To removed the tube and ovary the infundibulo pelvic ligament

was clamp with curved kocker artery forcep on the ovarian side
and lateral side with one more curve kocker artery forcep. Then the
scrub nurse give curved mayo scissor to cut the ligament. The same
was done to the other side. The ligament were transfixed with Safil
1 suture.

106
 Figure 45

• While assisting, the scrub nurse still do the same thing such
as give the instrument to the surgeon with the handle was
placed into surgeon palm firmly, maintain the aseptic
technique and keep talking to a minimum to avoid
contamination.

Figure 46

• The anterior utero vesical fold was incised using the

metzenbaum scissor aided by waught non toothed dissecting
forceps. Holding the peritoneum covering the bladder with
the dissecting forceps the curved scissor are used to
separate the bladder off the front of the lower uterus and
cervix in direction of the arrow. Surgeon do not favour the

107
 method of using a gauze on finger or swab on the stick to
push the bladder down, because it is liable to result in tearing
of weak bladder wall.

• The uterine arteries running close to the uterus along its

lateral wall was clamp with curved kocker forceps, then cut
with Mayo scissor and transfixed with Safil 1 suture.

• The circulating nurse give the suture and the scrub nurse
take the suture pocket opened and held by circulating nurse.
The scrub nurse clips the neelde – needle holder and gives
to surgeon. The surgeon suturing the stump using suture and
tie technique.

Figure 47

• The cardinal ligaments or the transverse cervical ligament

was now clamped, cut and sutured with Safil suture. This
was done by placing the straight kocker artery forceps
parallel to the cervix, squeezing the paracervical tissue off
the cervix to give the most lateral room and protection to the
uterus. Since the blood supply had been controlled a single
clamp suffices and the incision was made. The same was
done for the other side.

• Once the opening of the vaginal vault was made, Septic

Towel Technique was practiced. This was to prevent

108
 contamination of spillage to other surrounding tissue and
organs in the peritoneal cavity and also soiling of sterile
drapes and other instruments.

• After the surgeon had identify the vagina and make sure the
bladder was mobilized from the cervix and vagina, a knife
was plunged into the anterior fornix. The vaginal vault was
incised and
•

Figure 48 Uterine scissors

cut with uterine scissor. Littlewood tissue forceps were applied

on the edges of the vaginal vault one at a time while the
surgeon continued to cut the vaginal vault until the uterus was
removed.

109
 Figure 49

Figure 50 : Littlewood

• Scrub nurse get ready to receive the specimen together

with the forceps attached and put on top of sterile towel
placed earlier. This is to avoid contamination to the sterile
area.

• The circulating nurse put on the glove and get ready to

receive the specimen. The scrub nurse confirmed with the
surgeon type of specimen gives it to the circulating nurse,
avoiding from touching the circulating nurse’s glove hand.

110
 Figure 51

• Prior to the closure of the vaginal vault, blades, sutures and

swab were counted by the scrub nurse with the circulating
nurse to confirm the correct number.

Figure 52

• The vaginal vault was sutured with Vicryl 1 suture. The

corner of the vaginal vault were tied off with the cardinals
and round ligaments to give support.

111
 Figure 53

• The instrument used on the vaginal vault were considered

contaminated. They were littlewoods forcep, toothed dissecting
forcep, uterine scissors, knife, needle holder, suture scissor,
yaunker sucker and sutures.

• They were all receive in the kidney dish and when the vaginal
vault was closed, scrub nurse wrap the kidney dish with the
towel that put earlier and gave to the circulating nurse who were
ready to receive the things. The circulating nurse lay out the
instrument on the floor for counting purpose.

• The surgeon checked for bleeding points and diathermized

using dissecting forcep. Before close the peritoneum, patient
was put back in supine position.

• Two abdominal pack put earlier in the peritoneum cavity was

taken out. Balfour self retaining retractor also removed.

• Then, the scrub nurse start to counting the sponges,

atraumatics needles and instrument with the circulating nurse.
All the sponges, needles and instrument count were found
correct and the surgeon was noted and he acknowledged the
scrub nurse.

112
• The circulating nurse bring the swab count form during the
counting and documented immediately.

• The surgeon request for the drainage tube. The scrub nurse put
the blade size 23 in the kidney dish and pass it to the surgeon
to make the incision at the right abdomen to insert size D portex
drain with 3 holes and put back the blade into the kidney dish to
prevent injury during passing the blade either to the surgeon or
scrub nurse. The surgeon used Fraser Kelly Artery Forcep to
pull the drainage tube outside the abdomen. The drainage tube
was anchored with Silk 2/0 Cutting Needle by assistant.

• 4 crile artery forcep were used to hold the rectus sheath during
closing the peritoneum. The surgeon used Safil 1 Taper Cutting
Needle to close the peritoneum and assistant wait with suture
cutting scissor in the hand for cutting. Then, surgeon used the
Safil 1 for closing the rectus sheath.

Figure 54

• The scrub nurse start to count gauze, abdominal pack,

needles, sharp instrument and all instruments that uses
during operation side to mayo tray, instrument trolley and
finally on the floor with the circulating nurse. The count must
be tally with the Swab Count Form. It to avoid any of them
left inside patient and injured her.

• Before closed the skin, the scrub nurse perform the final
count with the circulating nurse and documented in the Swab
Count Form assure that swabs , needles and instrument
used were correct.

113
• The surgeon used the Monosyn 3/0 to closed the skin.
During skin closure, key hole opsite dressing was prepared
to put on the drain site. At the same time, scrub nurse
dissemble blade from B/P handle. Discard the blade into
adhesive pack, then put sharp instrument in the kidney dish.

• After skin closure had finished, the scrub nurse get ready 2
pieces of gauze, 1 gauze soaked with normal saline and 1
gauze dry. The scrub nurse put the soaked gauze into the
incision, roll it up from one side to a side. Then scrub nurse
protect the wound with the dry gauze. The soaked gauze
was used to clean the surrouding area around the incision
and followed by dry gauze.

• The scrub nurse applied the dressing at the wound and key
hole at the drain site and plastered with hyperfix dressing.
The portex drain was connected to a urine bag. After
applying the dressing, the scrub nurse took the towel clips
from the drapes. The nurse removed the drapes with roll it to
prevent sparking and air borne contamination and put into
the linen bag.

• The circulating nurse switch off the operating light, suction

apparatus and diathermy machine. She disconnected the
sucker tubing and removed the inactive dispersive plate. The
nurse checked the sign and symptom of burn at the skin
where the inactive dispersive plate was placed and the skin
looked normal.

• The scrub nurse push away the Mayo stand and the
instrument trolley from the operating table. The scrub nurse
wet the extra gauze for removing the excess povidone iodine
10% from skin patient. The circulating nurse cover the
patient with warmed blanket to provide hypothermia and
avoid unnecessary expose the patient.

114
PRINCIPLE OF COLLECTING AND FIXING
SPECIMEN

 Collecting and fixing specimen is responsibilities by the

circulating nurse.

 Before the case was start, the circulating nurse get ready the
correct size of specimen container to fix the specimen. The
correct size is must be able to contain the specimen with the
fixative agent 10-20 times volume of specimen.

Figure 55

 Get ready the fixative agent to used – 10% formaline in

saline, to make sure the specimen was fresh and light can
penetrate through.

 Get ready the correct specimen form and label. Label the
patient’s full name, R/N, I/C No, ward follow the admission
form.

 During the procedure, while the specimen was out, the

circulating nurse get ready to receive the specimen with
wearing the Personnel Protective Equipment such as mask,

115
 gloves and goggles to prevent spillage to the eyes and
contamination.

Figure 56

 Then the circulating nurse confirmed the nature of the

specimen with the scrub nurse and as the surgeon whether
the surgeon want to cut or not or get the permission from the
surgeon to fix the specimen immediately to prevent autolysis,
decomposition and putrefaction. This is to obtain correct
pathology result.

 After that the circulating nurse put the specimen into the
container and pour the formaldehyde until the specimen
immerse or the volume is 10 – 20 times of the specimen.

 After fix the specimen, disinfect the surrounding container

along with the cover with swab spirit 70% for safety handling
and to prevent contamination.

 The label must applied at the side of the container not on the
cover, this is to prevent mistake.

 Put the container in biohazard plastic bag to prevent cross

infection.

 After operation finished, circulating nurse along with the

scrub nurse checked the HPE form filled correctly and tally
with the label at the container and make sure Doctor has
sign.

116
  Lastly circulating nurse documented the specimen in swab
count form and recorded in the specimen dispatch book
before sent to Pathology Department.

CONCEPT OF CONFINE AND CONTAIN

 Confine and contain princip was originally introduced to
perioperative nurse in earlier 1970. this principles
recommended that personnel restricted all patient micros to
an area of 3 feet around the patient and that when the
patient leave that limited area they should be either confined
to all impervious container to be destroyed. Establishment of
procedure to implement this principle prevent the transfer of
micros and protects patients and personnel.

 After operation was over, the circulating nurse put all soiled
sponges bloodied waste and disposable items in the
appropriate impervious bag and tie it. Then she put it into an
impervious receptacle to prevent contamination.

Figure 57

 Kick bucket is normally design to practice confine and

contain with for easy movement in the theatre. It is consist of
a wheel frame and a basin in it. The basins is line with a
biohazard impervious plastic bag with a cuff turned over the
edge and create a drain to receive the soiled sponges during
surgery and it should be thoroughly tie up before discarded
after every case to prevent contamination.

117
 Effective sanitation technique is should be established to
control and reduce the possibility of cross infection of patient
in the OR. Blood and tissue fluids from any patient may
contain microorganism. That is pathogenic to other persons.
OR structure should be developed to provide complete
isolation from each patient. This isolation is accomplished by
considering surgical wound to be potentially contaminated.

 The scrub nurse put the blades, atraumatic needles that

were used into an appropriate rigid, puncture proof container
to prevent injury and contamination.

Figure 58

 All the clinical waste was put in the sluice room and hospital
support service worker will removed it for destroyed.

118
REVERSAL OF PATIENT
• The anesthetist was turned off the Isoflorane and
Nitrous Oxide at the last skin stiches. He was off the
ventilator and disconnected the circuit and do manual
bagging until gag reflux seen. Then the reversal was
given injection Neostigmine 2-5mgm and proceeds by
injection Atropine 1mgm. The Neostigmine can cause
bradycardia and increase the secretion. The atropine
was given to minimize side effect of the Neostigmine.

• The anesthetist nurse carried out the suction and the

anesthetist called the patient’s name. When the patient
opened her eyes and breathe spontaneously, the
anesthetist nurse deflated the cuff and the anesthetist
removed the tube. The patient was given 100% oxygen
via face mask and oral airway was put in her mouth to
prevent airway obstruction.

• Before transfer the patient GA nurse check and make

sure the oxygen cylinder under the OR stretcher is full
with oxygen. When her vital were stable, oxygen
saturation was good, the monitoring attachments were
removed. The patient was transferred to the OT
stretcher. Before transferring, the stretcher was locked.
Head, both hands and both legs of patient were within
the canvas to prevent injury. GA nurse, scrub nurse
and circulating nurse will help to assist in transfer the
Mdm Aini to OT stretcher. They transfer Mdm Aini
gently, smoothly and simultaneously.

• Check again patient’s both hands and legs is tug under

the blanket before wheeled the patient to the recovery
to prevent crush injury to pateint’s hands or legs. GA
nurse passed over the patient to the recovery nurse
and inform patient’s name, type of surgery done and
type of anesthesia. Inform any problem that had been
occurred in the OR eg difficulties during intubation.

119
 CLEANING AND CHECKING OF
INSTRUMENT
 After sent Mdm Aini to the recovery room, the scrub nurse
come back in the operating room. She must clean all the
instrument was used and circulating nurse was helping her.

 The scrub nurse collect the instruments from mayo stand

and instrument trolley. She separates the sharp instrument to
avoid injury during cleaning. She also opens the all hinged
instruments to expose box locks and secretion.

 The instrument was brought into the sluice room for cleaning.
The scrub nurse rinse the instruments with warm water to
removed the dried blood and debris.

 After rinsing, the scrub nurse count and arrange the

instruments as they placed in the tray, together with
circulating nurse. The instruments count must tally with the
instrument list.

 The scrub nurse wrap the tray and put it outside the sluice
room and attendant from TSSU will take the sets for cleaning
before sterilization.

120
 REMOVAL OF GOWN AND GLOVES
• At the end of the procedure, used gown are untied and
removed. The gown is always removed inside out to protect the
arms and scrub suit from the contaminated outside of the gown.
The gown is removed as followed:-

Figure 59

 Grasp the left shoulder with the right hand and pull the
gown downward from the shoulder and off the left arm,
turning the sleeve inside out.

Figure 60

121
 Turn the outside of the gown away from the body with
flexed elbows.

Figure 61

 Grasp the right shoulder with the left hands and remove
gown entirely. Fold the gown inside out.

Figure 62
 Pulling it off inside out. And put it directly in the linen
receptacle.
 The gloves are also removed inside out, using technique
of dirty to dirty and clean to clean.

122
• The cuff of the gloves usually turn sown as the gown is pulled
off the arms. A glove to glove, then technique is used to protect
the clean hands from the contaminated outside of the glove.
The glove is removed as followed:-
 Grasp the cuff of the left glove with the glove fingers of the
right hand and pull it inside out.

Figure 63

 Slip the ungloved fingers of the left hand under the cuff of
the right glove and slip it off inside out.

Figure64

 Discard the gloves in the trash receptacle and wash hands.

123
 PREPARATION OF OPERATION ROOM
FOR THE NEXT PATIENT
The cleaning procedures described provided adequatede
decontamination and terminal sterilization after any surgical
procedure. With a well coordinated team, minimal turnover time
between surgical procedures can be accomplished; in an
average time of 15 to 20 minutes, the room will be ready for
next patient. The turnover time includes cleaning up after one
procedure and setting up for the next procedure.

Additional equipment brought into the room and should be

damp-dusted before sterile supplies are opened for the next
case. After the patient leaves, the circulating nurse is free to
assist with clean up of the room. Environmental service
personnel may also be available to assist with cleaning.

Clean but not sterile gloves are worn to complete the room
clean up. The scrub nurse changed gloves after the sterile field
is dismantled. Decontamination of the environment includes the
following:-

FURNITURE
Wash horizontal surfaces of all tables and equipment, including
the anesthesia machine, with a disinfectant solution or warm
water according to hospital policy.

OVERHEAD OPERATING LIGHT

Wipe overhead light reflectors with a clean cloth that has been
damp with warm water or disinfectant solution. Commercial
reflector cleaner prevent clouding of the surface than can cause
dullness and glare.

ANESTHESIA EQUIPMENT
All reusable anesthesia masks and tubing are cleaned and
sterilized before reusing. Some of this equipment can be steam
sterilized; if not, it may be sterilized by EO gas and aerated
before reuse. If the method is not available, items should be
chemically sterilized according to the sterilant manufacturer’s
recommendations.

124
LAUNDRY
After all cleaning procedures have been completed, discard
cleaning clots or put in a laundry bag if they are not disposable.
To help protect laundry personnel, an alginate bag that
dissolves in hot water may be used as the primary laundry bag
or as a liner within a cloth bag. Transport reusable woven
fabrics soiled with blood or body fluids in leak-proof bags.

TRASH OR WASTE
Collect all trash in a plastic or impervious bag, including
disposable drapes and kick bucket and wastebasket liners.
Trash can be separated into infections waste, noninfectious
trash and recyclable items. Separate receptacles should be
available.

WALLS
If wall are splashed with blood or organic debris during the
surgical procedure, wash those areas. Otherwise, walls are not
be washed between surgical procedures.

FLOOR
Clean a perimeter of several feet in circumference of the

125
 POST OPERATIVE CARE IN RECOVERY
• Recovery room is the place provide maximal care of patients
immediately following their operations. It is evolved to meet a
need for constant observation of patients within facilities
equipped for specialized care until recover from anesthesia.

• When Mdm Aini arrived in the recovery room, the anesthetist

nurse passed over the case to the recovery nurse. The
anesthetist nurse informed that Mdm Aini was given General
Anesthesia combined Epidural Anesthesia and was undergo the
Total Abdominal Hysterectomy Bilateral Salphingo-
Oophorectomy.

• The recovery nurse give oxygen 6 liter/perminute via facemask

and apply the monitor devices such as ECG lead, blood
pressure cuff and pulse oxymeter. After that cover Mdm Aini
with warming blanket to prevent from hypothermia.

• The recovery nurse observes the monitoring and charts the vital
sign at the GA form every 10 minutes. Assure that intravenous
infusion in functioning well, the infusion pump was connected by
the anesthetist to the Epidural line, observe dressing site for
bleeding, make sure that drainage tube not kinking and flowing
well and monitor urine output. She also observe for level of
consciousness by calling MdmAini’s name, listen for any
bubling or gagling sound, if got recovery nurse will do the
suction to clear the airwayand observe the color of the patient
for pale, cyanosed or dusky.

• After Mdm Aini’s vital sign and general condition are stable and
orientated, the anesthesiologist score the patient according to
the GA form. Mdm Aini was discharge from recovery room after
45 minutes.

• The recovery nurse call the ward staff C20 to take Mdm Aini
back to the ward. After 15 minutes, the ward staff came and the
recovery nurse passesover the patient. The nurse make sure
Mdm Aini is safe during transferring to ward stretcher. At the
same time ward staff check the dressing, drainage tube, CBD,
intravenous infusion and the vital sign chart. After satisfied with
patient condition, ward staff wheeled the patient to the ward.

126
POST OPERATIVE VISIT
 In the ward, Mdm aini was put in the acute cubicle for closed
observation. She was on Epidural infusion ( Bupivacaine 0.1% +
Fentanyl 2mg/min) 5mls perhour. When the perioperative nurse
visits her after 5 hour post operation, she was alert but slightly
dizziness and weak. She was able to move both lower limb and
no any other complaint except slightly pain at the operative
site.

 Mdm Aini ‘s post operative care was carried out by the ward
staff as it was ordered by the surgeon in the operation notes as
followed:-
 Keep nil by mouth until review.
 Intravenous drip 5 pint for 24 hours (2 pint Dextrose 5%
and 3 pint Normal Saline)
 Epidural as planned by anesthetist
 SC heparin 5000ǜ BD till ambulating well
 Strict I/O , pad and drain chart.
 Vital sign monitoring every 5 minutes for 2 hours, then ½
hours for 2 hours then hourly monitoring the blood
pressure and pulse rate.
 Wound inspection Day 3
 Hb Day 2

 Post Op Day 1
• Mdm Aini was looked well.
• Her vital sign was stable. Blood pressure 100/60mmHg,
Pulse 60/min
• Patient complaint of nausea/ vomiting – I/V Maxolone 10mg
TDS was given ordered by Doctor.
• She complaint of slightly pain at the operative site. APS still
continue at 5mls / hour. Drain bag - 100cc( Haemoserous
fluids)
• She was allowed to take nourishing fluids. IVDrip was off but
the branula was kept insitu.
• CBD still insitu
Perioperative nurse advise MdmAini to encourage early
ambulation for better and fast recovery.

 Post Op Day 2

127
 • Mdm Aini was looked comfortable and starting to walk to the
toilet. Her vital sign was stable and she was allowed to take
high protein diet.
• Her APS was still kept as she still complaint pain over the
operative site. Doctor was ordered C. Tramadol 50mg TDS
for the pain.
• Drain tube and CBD was off.
• FBC was taken according the order from the Doctor.
Perioperative nurse advised Mdm Aini to do deep breathing
exercise .

 Post Op Day 3
• Wound inspection was done and no sign of inflammation
seen. Patient was tell to inspect her wound herself and
observe for sign and symptom of infection such as redness
and purity and avoid to lift heavy thing or ruff cough to
prevent wound gaping.
• APS was off as she can tolerate with the pain.

 Post Op Day 4
• Mdm aini was discharge and was given the follow up gynae
appointment on 9/10/2006 in Gynae Clinic Hospital Pulau
Pinang at 8am.
• Medication was supllied by the Doctor as required.
• Perioperative nurse give health education to Mdm aini such
as:-
~ avoid stair climbing for at least 1 month
~ avoid lifting heavy thing more than 4.5kg to 9kg
~ encourage walking
~ consume food that aid healing tissue such as high in
protein, iron and vitamin C
~ try to calm down when the sign and symptom of
menopause such as mood swinging, night sweat and hot
flashes.

 Follow Up Day
• Mdm Aini was looked confident and the wound was found
healthy. The HPE result shown that no sign of malignancy.
• She was given Hormone Replacement Therapy by Doctor
and also the next appointment on the next 6/52.

128
 NURSING PROCESS
1
NURSING OBJECTIVES INTERVENTION EVALUATION
DIAGNOSIS
Fear and Anxiety To make 1.Encourage patient The patient looks
related to the patient discus to talk and ask more confident
surgery and fears and question and give
prognosis anxiety time to listen during Family and patient
preoperative visit able to recognize
To make 2.Involved family in their fears
patient talk discussion where
realistically of appropriate but
future allows patients
privacy when
needed.
3. Give explanations
of all procedure
doing for patient
such as Branula
insertion, CBD
insertion, transfer
and transporting and
General Anesthesia
and Epidural
Anesthesia.
4. Provide
information related to
post surgical
treatment regimen.
5. Allow patient and
family to ask
question
6. Encourage family
to give emotional
support to patient
7. Explian to patient
the operation team
will be around to help
her
8. Carry out the
preoperative visit.

129
 2
NURSING OBJECTIVES INTERVENTION EVALUATION
DIAGNOSIS
Potential for Infection will 1.Assess for allergies No sign of infection
infection due to not occur before skin prep
surgical Body 2.Notice the Wound heal without
interuption of temperature presence of any skin complication
skin intergrity maintain at 37 rashes, bruises,
degress laceration, Body temperature
celcius. acchymoses and maintain 36.5 –
record them 37.4 degress
3.Knowledgeable celcius
and conscientious
observence of
aseptic technique
should be shown by
all theatre personnel.
4. Entry of personnel
into the operating
theatre is restricted
5. Regulation
regarding the
clothing to be worn in
the operating room to
avoid possible
transmission of
organism by steert
cloth.
6. Bedding from the
ward is not brought
into the theatre

130
 3
NURSING OBJECTIVES INTERVENTION EVALUATION
DIAGNOSIS
Pain related to Patient will 1.Monitor the patient Patient states that
surgical experience for the presence of the pain is reduce
procedure. less pain and pain assessment and she was
more aids in proper comfortable
comfortable. management

2.Encourage relaxion
and slow breathing
technique to
minimize pain.

3.Use non
pharmacological
method of relieving
discomfort such as
back rubs, or push
up the head bed or
change the position it
is because this
technique can
reduce the pain

131
 4
NURSING OBJECTIVES INTERVENTION EVALUATION
DIAGNOSIS
Mobility is The patient will 1. Assist patient to Early ambulation
impaired as a demonstrate perform deep promotes
result of surgery, intact skin with breathing exercise respiratory and
decreased no areas of and encourage circulatory function
energy and redness or compliance with and helps prevent
presence of oedema. programmed initiated complications
drainage tube by the
Ability to move physiotherapist Movement reduces
about freely stasis and vascular
2.Change the patient pooling in leg.
Ambulation position every 2-4
progressively hours while she
increases over cannot move. Assess
the first few condition of skin
days post regularly to prevent
operatively wound break down.

3.Encourage early
mobilization gently
increase activities
from sitting on side of
the bed to walking
and sitting in a chair.

4. Observe incision
and drainage tube
sites for signs of
redness, tenderness,
swelling and
drainage during each
dressing changed.

132
 5
NURSING OBJECTIVES INTERVENTION EVALUATION
DIAGNOSIS
Hypothermia The patient’s 1. Provide the patient Patient will be free
related to room temperature with a blanket prior to from hypothermia
temperature, will maintain induction of and injury related to
skin exposure between 36.8- anesthesia to avoid heat loss.
and an open 37 degrees the patient from cool
wound. Celcius
2. Put the warming
mattress under the
patient during
operation.

3. Ensure that
normal saline for
irrigation iswarm to
provide the
vasodilatations

4. Cover patient with

warm blanket after
operation finish till to
the recovery to avoid
from cool and
shivering

5. Put the patient

under radiant heater
in the recovery room
to warm the patient

133
BIBLIOGRAPHY
1. Atkinson L.J.(2000), Berry And Kohn’s Operating Room
Technique
(9th ed.)St.Louis:Mosby Year Book Incorpotion.

2. David H.L & Albert S (1978) Abdominal Operations For Benign

Conditions (2nd ed.) London: Wolfe Medical Publications Ltd

3. Huth, M., & Meecker. (1999). Care of Patient in Surgery. (7th ed)
U.S:Mosby Year Book.

4. John A.R&Howard W.J (2003) Te’ Linde’s Operative

Gynaecology (9th ed.) Philadelphia: Lippincott William &
Wilkins.

5. Jordan K (1994)Atlas of Regional Anesthesia (2nd ed.) USA:

Appleton&Lange

6. Phillips Fortunato N.(2004) Berry & Kohn’s Operating Room

Technique (10th ed.) Mosby INC.

7. Ross J.S & Wilson K.L.W. (1973) Faundations of Anatomy &

Phisiology (4th ed.) Edinburg: Churchill Livingstone.

8. Smeltzer, S.C., &Bare, G.B. (2000). Textbook Of Medical

Surgical Nursing. (9th ed).New York:Lippincott Williams and
Wilkins Com.

9. Susan S. Fairchild (1999), Peri Operative Nursing Principles

And Practice (2nd ed). London:Little,Brown And Company.

10. Wilson K.J.W. (1992), Anatomy And Physiology In Health And

Illness (7th ed). Edinburg:Churchill Livingstone.

134