Preoperative preparation

(1) Preoperative visit

On the day before the operation, the visiting nurse provided psychological care to the patients in written and oral form, and explained the relevant precautions, such as operating room environment, posture coordination, fasting and water-forbidden time, accessories, watches, denture removal, female patients without makeup and nail polish, etc. To relieve patients' worries and better cooperate with anesthesia and surgery. At the same time, the general situation, allergic history and special requirements of patients were understood through interviews, so as to better cooperate with doctors to complete the operation during the operation.

(2) Preparation of articles

1. Instruments Prepare to select appropriate instruments according to the type of operation, make basic and special instruments sets, and then autoclave them for later use.

2. Dressing Prepare to fold various dressings as required and put them into abdominal bags, chest bags, thyroid bags, limb surgery bags, single bags, treatment towel bags, etc. And then used after autoclaving.

3. It is best to use disposable sterile drainage tubes, such as T-tube, thoracic drainage tube, catheter and hollow drainage tube.

(3) Instrument preparation

1. The central suction device consists of motor, vacuum pump and pneumatic bottle. Negative pressure value > > 650mmHg.

Usage: Insert the socket of the negative pressure connecting pipe into the suction socket in the center of the wall or tower, and connect the suction outlet of the negative pressure suction hood at the other end. The suction port is connected with the suction pipe on the operating table, and check the negative pressure.

2. High frequency electrotome

(1) principle

1) coagulate the tissue with high frequency current to stop bleeding.

2) Cut the tissue with high frequency voltage to stop bleeding.

(2) Method of use

1) First check whether the "output regulation" current switch is set to "0" or "off" position.

2) Turn on the power supply, turn on the main switch and adjust the output (generally about 50).

3) Connect the grounding wire.

4) Stick the negative plate on muscle-rich parts, such as thighs and buttocks.

5) After use, first set the output to "0" and then cut off the power supply.

(3) Precautions

1) It is best to choose a high-frequency electrotome with a safety device. Once the contact surface of the negative plate is insufficient or falls off, the instrument will automatically alarm and cut off the current output to ensure the safety of patients.

2) The disposable negative plate can avoid repeated use.

3) Disabled patients with pacemakers.

3. Ultrasonic scalpel

Principle (1): Mechanical vibration with ultrasonic frequency of 55.5 Hz vaporizes water in tissues, breaks protein hydrogen bonds, disintegrates cells, and cuts or coagulates tissues.

(2) Multi-purpose scissors assembly steps: 1) Tighten the conversion cap; 2) Tighten the cutter core; 3) Twist it clockwise twice with a pressure wrench and hear "click" twice; 4) Put on the coat, and pay attention to the tip of the coat and the back handle facing up.

(3) Test: the main machine is powered on, the connecting wire at the end of the handle is inserted into the main machine, and the assembled multi-purpose scissors are separated. Only after passing the test can the pedal be used.

4. Air tourniquet is mainly used for limb surgery. There are two kinds of air tourniquets: electric and manual.

(1) According to the patient's age, limb position and surgical site, choose an air tourniquet with appropriate width.

(2) It must be used under anesthesia to prevent limb pain caused by tourniquet compression.

(3) If the application site is close to the incision, the tourniquet should be disinfected before use.

(4) Check whether the pressure gauge and air tourniquet are in good condition and whether there is air leakage.

(5) Pressure: 40 kPa (300 mm Hg) for adult upper limbs and 66.7 kPa (500-600 mm Hg) for lower limbs.

Children's upper limbs are 27kPa(200mmHg) and lower limbs are 54kPa(400mmHg).

(6) The time is 1- 1.5 hours.

Intraoperative cooperation

(A) the workflow of visiting nurses

1. Visit the patients before operation, understand the general situation of the patients, prepare before operation, and do psychological care well.

2. Check the patient's name, operation name and operation site, and check whether the materials required for the operation are complete and applicable.

3. Assist anesthesia, establish venous access, and position yourself. Prepare all surgical items, such as electrotome and aspirator, and adjust the surgical lighting.

4. Assist the surgical personnel in dressing, carefully count the instruments and dressings with the instrument nurses, and make registration.

5. Observe the patient's condition changes and surgical progress at any time during the operation, cooperate with rescue and material supply, and do not leave without reason.

6. Supervise the aseptic operation of all kinds of personnel in the operating room, and keep the operating room quiet and tidy.

7. Strictly check the system, and check the number of instruments and dressings again with the hand washing nurse before and after closing the body cavity.

8. Assist in covering the wound, fill in the specimen inspection sheet, and urge the doctor to keep the specimen.

9. Fill in the bill carefully, and check the diagnosis, operation mode and operation personnel on the operation notice to make it consistent with the actual situation.

10. After the operation, clean up and supplement the items in the operating room and put them back in place.

(B) Hand-washing nurse workflow

1. Review the local anatomy and surgical procedures before operation to better cooperate with the operation.

2. Check the patient's name, operation name and operation site, and check whether the materials required for the operation are complete and applicable.

3. Prepare the sterile instrument table, wash your hands 15-20 minutes earlier than the operator, and tidy up the instrument table.

4. Carefully count instruments and dressings, and check whether all kinds of instruments and dressings are perfect and whether knives and scissors are sharp and applicable.

5. Prepare the instruments and accessories to be used, such as electrotome and suction tube.

6. Pay close attention to the progress of the operation during the operation, cooperate actively, and keep sterile articles and instruments dry and clean.

7. Carefully count instrument dressings before and after closing the cavity to prevent foreign bodies from being left in the wound.

8. Assist in dressing wounds and handling specimens.

9. Clean the instruments after operation, and dry them, oil them and pack them. Special instruments should be handed over to the instrument group, and the instrument truck should be wiped and repaired.

(3) Surgical position

1. supine position is suitable for neck, maxillofacial region, abdomen, hands and other operations. The patient lay on his back with a soft pillow on his head; The arms are fixed on one side of the body with pads; Put a soft pillow under the knee and fix the knee with a lower limb fixing belt.

(1) The patient undergoing breast surgery is supine, with the operating side close to the operating table, and the shoulder pad folded with the abduction of the upper arm and placed on the armrest; The rest is the same as above

(2) For neck surgery, such as thyroidectomy and tracheotomy, a soft pillow should be placed horizontally on the shoulder, and a circle should be placed under the head to make the head lean back. The rest is the same as above

(3) During hepatobiliary surgery, pay attention to the alignment between the patient and the lower lumbar bridge under the costal margin. Pelvic surgery requires placing a soft pillow in the sacrococcygeal region to expose the surgical area.

(4) the head surgery is fixed with a head frame.

2. Lateral position is suitable for chest, kidney and back surgery.

(1) Patients undergoing thoracic surgery lie 90 degrees on their side, with a soft pillow under their armpits, and the soft pillow is pressed under the mattress with a gasket. The thigh flexes, the calf straightens, a soft pillow is placed between the legs, and the hip and knee are fixed with a basin frame and a fixing belt respectively. Straighten both upper limbs and fix them on the armrest.

(2) Patients undergoing kidney surgery lie on their side at 90 degrees, with their kidneys aligned with the lumbar bridge of the operating table, their thighs straight and their calves bent. The rest is the same as above

3. Prone position is suitable for spine and back surgery. Adjust the prone position pad according to the patient's body length, so that the patient is prone on it, and the head is placed on the head frame or fixed with head nails. Half-bent arm, put it on the armrest. Put a circle under the knee and a soft pillow on the calf. The pelvis and popliteal fossa are fixed with a fixing belt.

4. The lithotomy position is suitable for perineum, urethra and anus surgery. The patient lies on his back, moves his hips to the swinging position at the tail of the operating table, puts on leg covers, puts his legs on the leg frames respectively, puts a cotton pad on the popliteal fossa, and fixes them with a fixing belt.

5. Semi-sitting and lying position is suitable for nasal tonsil surgery. Shake the head end of the operating table up to 75 degrees, the end of the operating table down to 45 degrees, and the legs are half bent. The head and trunk cling to the swinging operating table, and the whole operating table leans back 15 degrees, and both hands are fixed on both sides with fixing belts.

6. The folding knife position is suitable for anal surgery. Move the hips to the swinging position at the rear of the operating table, put on leg covers, adjust the prone position pad according to the patient's body length, make the patient prone on it, put the legs on the leg plates respectively, and fix the separated leg plates with fixing belts.

7. Preventive measures

(1) Ensure the comfort and safety of patients and good exposure to the maximum extent.

(2) The effect on respiration and circulation is minimal.

(3) Don't press or overstretch any nerve to prevent paralysis.

(4) Don't overstretch the muscles to prevent injury or postoperative pain.

(5) Don't overstretch your limbs to prevent joint dislocation.

(6) The limbs shall not be suspended, and must be padded.

(7) Sponge pads should be used to protect easily compressible parts.

(4) Preparation of aseptic workbench

1. Hand-washing nurses should prepare clean, dry and suitable instrument tables and sets before washing their hands.

2. Put the set on the instrument table, and after passing the inspection, open the outer cloth by hand.

3. Take sterile forceps and open the inner cloth and sterile sheet.

4. Put the items needed for the operation on the sterile table, and cover them with sterile sheets after all the items are ready.

5. Nurses should put on surgical gowns and gloves after washing their hands, tidy up the instrument table and put it in order and category.

6. When preparing aseptic workbench, you should pay attention to

(1) 4-6 layers should be laid on the sterile table mat sheet, with the edge hanging 30cm.

(2) The prepared aseptic table shall not exceed 4-6 hours.

(3) After the sheets are wetted by water or blood, they must be covered with sterile sheets.

(5) the principle of surgical aseptic operation

1. A sterile area must be established before the operation. Only sterile items can be used in sterile areas.

2. After the operator puts on the surgical gown, the forearm should not droop and should be kept above the waist. Don't put your hands near your face or cross them under your arms, and your elbows should be retracted and close to your body.

3. When exchanging positions with another operator, it should be back to back.

4. Items taken from sterile containers or sterile areas shall not be used, but it is forbidden to put them back.

5. Anything below the edge of the operating table or the edge plane of the sterile table should be regarded as bacteria, and any dropped hoses, wires, stitches, etc. should be regarded as bacteria. Should not be pulled out or reused.

6. If the gloves are broken, they should be replaced.

7. Before cutting the skin, cover both sides of the incision with sterile gauze, or stick the surgical membrane on the skin, and cut the skin through the membrane to protect the incision from pollution. Wipe with disinfectant before lengthening the incision or suturing the skin.

8. Protect the surrounding tissues with gauze pads before handling the hollow organs, and absorb the discharged secretions at any time. Contaminated instruments and other items should be placed in an arc-shaped tray and isolated.

Polizel's therapy

(1) Conventional surgical treatment

1. Brush all surfaces of the instrument with running water, and the shaft joint should be opened. If there is a lumen, brush it with a straight rod or a special brush. You can also use an ultrasonic cleaning machine or an automatic cleaning sterilizer. Then, the instrument is dried, oiled, packaged and repaired.

2. Dirty dressing should be placed in the designated place and handled by the laundry room.

3. The operating room floor, surface with disinfectant to wipe, and then air disinfection.

4. Organize the operating room, restore and supplement materials.

5. Bagging and burning medical wastes.

(2) Surgical treatment of infection

1. Isolation signs should be set up in polluted operating rooms or outdoors, and all required items should be transported by outdoor visiting nurses.

2. Indoor visiting nurses and anesthesiologists should wear isolation gown, gloves and shoe covers. Operators should wear shoe covers before washing their hands and must not leave the operation room during operation.

3. After the operation, the contaminated surgical gown, shoes and flat car taken off by surgical personnel and surgical cloth should be disinfected with air.

4. Use disposable dressing and burn after operation.

5. All indoor articles and floors should be scrubbed with disinfectant.

6. These instruments can only be cleaned after disinfection.

7. Indoor air should be disinfected.

8. The treatment of special infections such as tetanus and gas gangrene should pay attention to:

(1) air-sealed, disinfected with high concentration disinfectant for 24 hours. After air and body surface culture were negative, routine treatment was carried out.

(2) Use disposable clothes and burn them after operation.

(3) Before cleaning, soak the instrument in double disinfectant for 60 minutes, and then perform autoclaving and routine treatment.

Second, minimally invasive surgery cooperation

Preoperative preparation

(1) Preoperative visit: same as before.

(2) Preparation of equipment and instruments

1. TV camera system: It consists of operating endoscope, miniature camera, monitor and video converter.

2. Cold light source.

3.CO2 pneumoperitoneum system: It consists of CO2 gas cylinder, high-pressure conduit, gas injector and pneumoperitoneum conduit.

4. Blood stasis cutting system: composed of high-frequency electrotome and ultrasonic scalpel.

5. Washing and suction device.

6. Endoscopic instruments.

Laparoscopic instruments: pneumoperitoneum needle, 5mm and 10mm puncture, 0 and 30 laparoscopy, grasping forceps, separating forceps, tissue forceps, separating hook, separating spoon, scissors, titanium forceps, puncture needle, washing suction tube, lithotomy forceps, needle holder, knotter, snare core and various connecting wires, such as camera and optical fiber. In particular, check whether the insulation of the instrument is damaged or perforated to avoid electrical damage. (For thyroid surgery, prepare 0 and 30 5mm endoscopes, several sets of 3mm or 5mm plastic sleeves, 2mm surgical scissors, separation forceps and 5mm titanium forceps. )

Thoracoscopic instruments: cannula (5.5 mm, 10.5 mm, 1 1.5 mm), thoracoscope, lung grasping forceps, separating forceps, biopsy forceps, scissors, claw retractor, titanium clip, direct cutting suture device, stump closer, irrigation suction tube, specimen bag, etc.

Spinal endoscopic instruments: guide needle and dilation tube, nerve stripper, curette, gun rongeur, nerve retractor, micro knife scissors, fiber circular saw, channel, free arm, nucleus pulposus forceps, bipolar electrocoagulation, lens and its optical fiber, etc.

Knee arthroscope equipment: knee arthroscope, foreign body forceps, blue forceps (scissors), puncture needle, olecranon forceps, hook knife, fork knife, flat stand, bent stand, probe, planer head, lens and its optical fiber, etc.

Bladder electrosurgical instruments: 100 electrosurgical mirror, 300 observation mirror, electrosurgical sheath, obturator, plasma electrosurgical ring, electrosurgical column, operating handle and Ellik irrigator.

Surgical instruments for laser treatment of varicose veins of lower limbs: optical fiber, indwelling needle 1 root (18, 20, 22,) vascular dilator, angiography tube core and cannula.

7. Traditional surgical instruments.

(3) Disinfection of instruments

1. High temperature resistant instruments shall be sterilized by high pressure steam.

2. Instruments that are not resistant to high temperature should be sterilized with ethylene oxide or soaked in 2% alkaline dialdehyde 10 hour.

Intraoperative nursing

(1) Minimally invasive surgical position

Abdominal surgery usually adopts supine position, and thoracic surgery adopts lateral position. In some operations, surgeons like to stand between the abduction legs of patients. Tilting the operating table is a very effective method, which is beneficial to expose the operating field. Upper abdominal surgery, head high and feet low, omentum and small intestine moving down. During pelvic surgery, the head is low and the feet are high, and the small intestine and sigmoid colon move to the abdomen. Tilt left or right. Conducive to the separation of the two colon.

(2) Physiological monitoring closely observe blood pressure, pulse, blood oxygen saturation and body temperature to prevent hypothermia and surgical emphysema. In order to keep the patient's body temperature, the room temperature should be controlled at 22-25℃, and the washing liquid should be kept at 38℃.

(3) Keep the surgical area sterile. Because the endoscope is relatively long, we should pay attention to avoid being contaminated.

(4) Technical supervision

1. Be familiar with the performance and operation steps of each instrument, put the instrument cart opposite the operator, turn on the power supply, preheat 15min, carefully check and remove obstacles in time, and operate in strict accordance with the operation procedures.

2. Adjust the surgical position, connect wires and adjust the white balance and contrast according to the operation needs.

3. When operating the gas injector, adjust and strictly control the gas flow at any time. At the beginning of inflation, the flow rate is easy to slow down to prevent gas embolism caused by improper needle tip position, or sudden increase of intra-abdominal pressure caused by too fast inflation speed and too high flow rate. On the one hand, the diaphragm is obviously increased, which can reduce the ventilation, hinder the discharge of CO2, produce CO2 accumulation and complicate hypercapnia. On the other hand, it stimulates peritoneal stretch receptors, excites vagus nerve and reflexively causes cardiac arrest.

4. Ensure that CO2 must be used to make pneumoperitoneum, and the pressure should be maintained at 12- 14mmHg. When the inflation flow reaches 15mmHg, inflation monitoring will be turned off, and intra-abdominal pressure will cause surgical emphysema.

5. Upper limbs should be selected for intravenous infusion, because pneumoperitoneum or high head and low feet will affect the venous blood flow of lower limbs, and the incidence of thrombosis will gradually increase with the extension of blood stasis time.

6. Use electrotome and ultrasonic scalpel correctly, and regularly check the insulation and connection of the instrument to prevent the electrotome from being damaged.

7. Monitor the working state of the equipment to prevent the interruption of operation caused by the failure of the film and television system.

8. Carefully control the endoscope and instruments, remove the tissue fragments in the pipeline, the front end of the instrument and the moving parts at any time, and do not disconnect the endoscope from the optical fiber. Unless the light source is turned off first, it will prevent accidental burns.

(5) Keep the quantity of articles and instruments correct.

(6) At the end of the operation, when the last puncture device is pulled out, remind the doctor to release the residual CO2 in abdominal cavity, so as to reduce the discomfort caused by excessive intra-abdominal pressure after operation.

(seven) correctly record the patient's situation, and maintain effective communication between nurses and doctors during the operation to ensure the safety of patients.

Maintenance of minimally invasive surgical instruments

(1) Equipment maintenance

1. When cleaning the instrument, first disassemble the attachment to wash away the blood, then soak it in a suitable enzyme solution for 5 minutes, and then rinse it with tap water, taking care to avoid losing the attachment. It can also be cleaned by ultrasonic cleaning machine or automatic cleaning and disinfection machine.

2. Instrument inspection: check the function according to the purpose. Instruments with joints should check the joints; For mobility, occlusal function and occlusal condition, sharps and scissors should be tested for sharpness. Instruments with insulation package or metal coating should be checked for cracks or defects, and instruments with screws should be checked for completeness and looseness.

3. The equipment should be prevented from being hit, dropped or squeezed by heavy objects. Handle it carefully and don't throw it about. Sharp or pointed parts should be protected by protective sleeves to avoid immersion in salt water. If it is necessary to soak, it is best to use distilled water to keep the equipment clean. Articulating equipment can be treated with water-soluble lubricant.

(2) Maintenance of instruments

Strictly implement the operating procedures. When starting up, turn on the main power supply first, and then turn on the switches of various instruments. When shutting down, first turn off the switches of all instruments, then turn off the main power supply, unplug all wires and conduits, and clean the spiral coil to avoid breaking the optical fiber. Make a good registration, keep it clean, cover it with cloth and put it in a fixed position.

Third, the use and management of clean operating room

(A) the principle of purifying the operating room

Clean air passes through a high-efficiency filter and a static pressure box (clean ceiling), and then is sent vertically into the operating room. From the air supply outlet to the air return outlets on both sides of the wall, the cross-sectional velocity of air flow is uniform, especially in the working area, the streamline is unidirectional and parallel, and there is no suspended flow. Clean air pushes indoor polluted air out of the air return port like an air piston, which keeps the operating room clean all the time.

(B) the purpose of cleaning the operating room environment

The control of surgical environment is not equal to the whole process from the beginning of surgical incision to the end of incision suture. Air purification measures are an important means to eliminate hidden dangers and establish good environmental control, which is completely different from the previous aseptic control relying on disinfection.

project

Modern control concept

Previous control concept

Control concept

The concept of whole process control is not only the result of "patients are not infected"

Relying on drug control to achieve the result of "patients are not infected"

Control requirements

Control the whole operation process, cut off all pollution channels (including air) and prevent bacteria from contacting the wound.

Depending on the drug disinfection environment, patients take a lot of antibiotics.

Control thinking

"Preventive" measures

"Remedial" measures

affect

"Full control" to prevent bacteria from entering the human body. Drugs are only the "result" of various safety measures to ensure the minimum harm to patients.

Bacteria enter and destroy the human body, and then relying on a large number of drugs to control infection is only a "result", and the control process has failed.

(3) Classification

Grade standard of clean room in clean operating department

Equal grade

Maximum average concentration of settling (planktonic) bacteria

Air cleanliness level

Ⅰ

operating room

0.2 blocks in the operation area/30min φ 90 blocks (5 blocks /m3).

The surrounding area is φ90( 10/m3)0.4/30min.

The operating area is 100,

Surrounding area 1000.

Cleaning assistant

Auxiliary room

0.2/30min φ 90 dishes (5 dishes /m3) in local 100-level areas.

The surrounding area is φ90( 10/m3)0.4/30min.

1000 level

(Local level 1000)

Ⅱ

operating room

Operation area1/30min φ 90 dishes (25 /m3)

2/30min Φ 90 dishes in the surrounding area (50 /m3)

Operation area 1000 slope

Surrounding area 10000.

Cleaning assistant

Auxiliary room

2/30 min φ 90 dish (50 dish /m3)

10000 level

Ⅲ

operating room

Operating area: 2 discs/30min φ 90 (75 discs /m3).

4 dishes in the surrounding area /30 min φ 90 dishes (150 dishes /m3)

Operation area 10000 elevation

Surrounding area 100000.

Cleaning assistant

Auxiliary room

Φ 90 discs for 4/30min (150 discs /m3)

100000 level

Ⅳ

operating room

5/30 min φ 90 dish (175 dish /m3)

Class 300,000

Cleaning assistant

Auxiliary room

Scope of application of clean operating room

Clean hand surgery operating room

area of application

First-class special clean operating room

Joint replacement, organ transplantation, brain surgery, cardiac surgery, ophthalmology

Secondary standard Zheng Jie operating room

A sterile operation in thoracic surgery, plastic surgery, urology, hepatobiliary and pancreatic surgery, bone surgery, egg retrieval and general surgery;

Three-level general clean operating room

General surgery (except one kind of surgery), obstetrics and gynecology.

Class Ⅳ quasi-clean operating room

Anorectal surgery, pollution surgery.

(D) clean operating room management

1. Strict partition management

Clean operating room is the application of air purification technology. By establishing scientific personnel flow and strict zoning management, the purpose of controlling particulate pollution and ensuring the safety of surgical patients is finally achieved. Therefore, in addition to air purification technology, staff, patients, sterile items and dirt should be strictly separated, and there should be no one passage.

2. Control pollution sources and reduce pollution.

1) The personnel entering the operating room need to change their shoes and clothes according to regulations. It is recommended to wear a full-body inhalation suit to prevent the spread of bacteria.

2) Strictly control the number of visitors and reduce the flow of people. It is best to use the TV teaching system to watch the operation.

3) The items in the operating room should be concise and applicable. Prevent the air return opening from being blocked by articles, so as not to affect the air circulation, and clean the filter once every 1-2 weeks.

4) When picking up patients, exchange cars should be used and marked, so as to separate the inside and outside, reduce the pollution sources in the ward and bring them into the clean operating room. The patient put on his hat and went in.

5) Before the equipment, instruments and articles enter the clean operating room, the outer packaging should be removed first, and then moved in after being wiped clean.

3. Maintain the positive pressure distribution in the operating room and keep the airflow direction from the high cleanliness area to the low cleanliness area. The operating room door should be closed at any time to maintain the positive pressure of the operating room.

4. Set full-time personnel to regularly maintain the purification system, determine the main technical indicators, and replace the filter according to the monitoring results.