Surgical Nursing - Lesson 1: Preoperative Considerations

Perception phase of nociception

"Knowing" that pain is present; usually results in reactions like withdrawal, vocalization, and in some cases, aggression

Explain the cleaning of the equipment located in the surgery room.

All equipment should be wiped daily before surgery with the appropriate cleaning or disinfecting solution on a damp cloth. The surgery room should never be dry dusted because this may aerosolize the dust and bacteria.

Microdrip Set

An intravenous fluid line that delivers fluids at the rate of 60 drops per milliliter; this allows for greater precision

Macrodrip set

An intravenous fluid line that delivers fluids, usually 10 or 15 drops per milliliter; this allows for a high volume to be delivered in a short time

Sterile field

Any area (person, table, or patient) that has been covered with a sterile barrier - includes gown, sterile table cover, or drape

DeBakey Thoracic Thumb Tissue Forceps

Atraumatic forceps used only on delicate tissues. The tips have no teeth but a ridge or groove design

Components of Balanced Anesthesia

Induction, Maintenance, Recovery - Pain Medication

Transmission phase of nociception

Propagation of pain impulses toward the spinal cord

Rochester-Pean Hemostatic Forceps

Similar to Crile Hemostat, just longer (8 inches with 3½ inch jaws)

Describe the difference between rebreathing and nonrebreathing circuits and the indications for their use.

The rebreathing circuit is useful because it allows the recirculation of some expired anesthetic gases and permits a lower flow of oxygen because some of the gases are rebreathed. This circuit is used with patients that have a body weight greater than 7 kg. The nonrebreathing circuit is used so that none of the gases are rebreathed. Patients weighing less than 7 kg benefit the most from the use of this circuit because of the low gas resistance. The use of this circuit requires high flows of oxygen to ensure adequate levels of anesthetic.

Point of Maximum Intensity (PMI)

The rib space where the systolic murmur is heard the loudest

Discuss the correct method of loading and passing a scalpel blade and handle.

To load a handle with a scalpel blade, the needle holder should firmly grasp the blade on the noncutting edge and slip it onto the handle. Once loaded, the handle and blade should be passed to the surgeon in a specific manner. The technician should hold the scalpel handle with the blade facing away from the hand, with the point toward the technician. The thumb and index finger should be holding the handle with the hand in a supinated position. Supination (or supinated) indicates that the palm of the hand is facing upward or outward. Pronation of the technician's hand follows as the handle is passed into the waiting hand of the surgeon. Pronation is the rotation of the hand and forearm so that the palm faces backward or downward. As the surgeon grasps the handle, the technician should maintain the forward momentum of the hand so as not to contact the cutting edge of the blade. This method of passing the instrument allows the cutting edge of the blade to face away from the assistant as well as the surgeon for optimal safety and handling.

U.S. Army Handheld Retractor

Double-ended retractor with different lengths of blades on either end, with no teeth (assisted)

Senn Handheld Retractor

Double-ended retractor with narrow, blunt blade on one end; the other end is toothed, traumatic

Understand the reasons for premedicating surgical patients.

First, the patient is more relaxed, allowing a less stressful transition to anesthesia. Second, pain management is provided at the optimum time, before surgical tissue trauma occurs. Third, appropriate premedications ("premeds") ease the transition out of anesthesia, facilitating a smooth recovery

Describe hair removal protocols for a variety of soft tissue, orthopedic, neurologic, and miscellaneous surgical cases.

For general soft tissue surgery, a good rule of thumb is to clip two (2) clipper-blade widths in every direction from the proposed incision site. Orthopedic preps use the rule of thumb of clipping the limb from the joint distal to and the joint proximal to the surgical incision. The limb needs to be clipped circumferentially to allow complete limb draping and manipulation. Neurologic surgical patients are usually quite easy to clip, especially when the surgical site is a caudal thoracic or lumbar vertebral space. Clipping two vertebral spaces cranial and two vertebral spaces caudal to the affected site is usually adequate.

List the common surgical instruments used in general, orthopedic, and ophthalmic surgery in veterinary medicine.

GENERAL 1) Scissors 2) Hemostats 3) Needle Holders 4) Scalpels 5) Thumb Tissue Forceps 6) Retractors 7) Towel Clamps 8) Others = spay hook, Dowling spay retractor, the needle rack, the groove director, & bowls 9) Intestinal Clamps ORTHOPEDIC 1) Bone Holders 2) Periosteal Elevators 3) Bone Rongeurs 4) Bone Cutters 5) Bone Curettes 6) Hand Chucks 7) Bone Chisels OPHTHALMIC 1) Beaver blade handle 2) Eyelid speculum 3) Lacrimal cannulas, both straight and curved 4) Thumb tissue forceps 5) Delicate scissors such as the baby Metzenbaum, Castroviejo, and Stevens tenotomy scissors

TS or TP - high vs low levels + importance + supplies used

Total solids or total protein Provides information on the animal's plasma protein levels. There are three major plasma proteins: albumin, globulin, and fibrinogen. These levels have a direct effect on serum oncotic pressure. The lower the TP value, the lower the serum oncotic pressure. Changes in serum oncotic pressure directly affect changes in the patient's fluid shifts between the interstitium and the vasculature. With a low serum oncotic pressure, fluid tends to accumulate in the interstitium, resulting in edema. On the other hand, with a high serum oncotic pressure, fluid shifts out of the interstitium and back into the vasculature (blood vessels) Elevated plasma protein values are associated with dehydration, malignancies (e.g., lymphosarcoma), and 48infections. Decreased plasma protein values are associated with inadequate production (albumin is made in the liver), inadequate intake (starvation), increased loss (renal disease, blood loss, parasites), and inadequate absorption from the gastrointestinal tract (pancreatic disease, inflammatory bowel disease) In addition, plasma protein levels are important because some anesthetics (e.g., some barbiturates) are highly bound to proteins. If a patient is hypoproteinemic, more free drug (not bound to plasma proteins) will be available to function as an anesthetic, effectively increasing the dose. Therefore the animal's protein levels should be noted when deciding which anesthetics to use, because the anesthetic dose may need to be adjusted accordingly. Supplies needed to check plasma proteins include a refractometer and microhematocrit tubes. After the PCV level is checked, snap the glass microhematocrit tube in the area of the plasma column. Allow the plasma to drip onto the refractometer out of the microhematocrit tube. The TS level is read on the scale seen in the refractometer.

Gelpi Self-Retaining Retractor

Traumatic instrument with single, sharp-pointed tips

Discuss factors considered for determining ET tube size.

Tube size is generally based on P's weight and should be the largest size tube possible, without being traumatic

Disadvantages of using isopropyl alcohol as a rinsing agent

Use of excessive amounts of alcohol to prepare the patient can significantly contribute to the hypothermia experienced by the anesthetized patient. Alcohol that is allowed to pool under an animal or saturate the fur can contribute to the risk of thermal burn if electrocautery is used. Therefore alcohol should not be used as a rinsing agent if electrocautery will be used intraoperatively.

Operating scissors

Used for cutting inanimate objects only, such as suture or paper drapes

Mayo scissors

Used for cutting large muscle masses, cartilage, or any other delicate tissue

Metzenbaum Scissors

Used for delicate surgical dissection

Russian Thumb Tissue Forceps

Very traumatic, bulky tip, used on skin or tissue being removed

Identify the anatomic structures of the larynx.

Vocal folds, epiglottis, and glottis + esophagus

Transduction phase of nociception

When a tissue is traumatized, that event is converted to a signal to be sent to the central nervous system (CNS).

Crile Hemostatic Forceps

Wide horizontal serration extending the entire length of the jaw

Kelly Hemostatic Forceps

Wider horizontal serration (as compared to Halstead) and extends to half the length of the jaws

BG (blood glucose) levels indicate; what raises & lowers them? Whose levels should be checked? Supplies used?

carbohydrate metabolism and measure the endocrine function of the pancreas. Eating raises BG levels, and fasting lowers them. Stress will elevate BG levels in cats. In juvenile patients and diabetic patients, BG values may need to be checked preoperatively, intraoperatively, and postoperatively if the procedure is especially long. Glucometers are used - only a drop of fresh whole blood required

Surgical conscience

is the commitment of the surgical personnel to adhere strictly to aseptic technique, because anything less could increase the potential risk of infection, resulting in harm to the patient.

Box Lock

the joint or hinge of the instrument with ring handles

Identify the components of an endotracheal (ET) tube.

- The hose connector is found at one end of the ET tube. It connects the tube to the Y piece, nonrebreathing system, or Ambu bag. - The body is the major portion of the ET tube. Several numbers may be found on the tube body. The length measurements are in 2-mm increments and identify the length of the tube. The manufacturer's name may also be seen on the body. The large bold number is the size of the internal diameter in millimeters. The most common tubes are available in sizes ranging from 3.0 to 12.0 mm in 0.5-mm increments. - The cuff indicator is used to determine the pressure of the cuff on the trachea once air has been infused into the cuff. - The cuff is present to permit the creation of a leak-proof system. Air is infused into the cuff, via the cuff indicator, to ensure a seal between the ET tube and the lumen of the trachea. The cuff prevents the patient from inhaling room air, which would dilute the gas delivered to the patient during anesthesia. The cuff also prevents the patient from exhaling anesthetic gas into the operating room and from aspirating any vomitus while intubated. - The Murphy eye is found at the tip of the ET tube. It allows airflow in the event that the end of the tube becomes occluded with respiratory secretions (mucous plugs)

Discuss the indications for placement of an intravenous (IV) catheter.

1) Provides easy access for vet tech to administer induction agents (reduces stress for P) 2) Allows for IV fluid therapy 3) Allows for immediate access of emergency drugs

List the supplies required for IV catheter placement.

1) Catheter - either OTN or TTN + appropriately sized 2) Injection caps, T-ports, & Fluid administration sets 3) Extension sets 4) Tape 5) "Prep" Materials: blade for hair removal, cotton balls or gauze soaked in diluted povidone-iodine scrub or chlorine iodine scrub for cleansing + 70% isopropyl alcohol or saline for rinsing 6) Fluids or heparinized saline (for flushing) 6) Bandage materials (help catheter remain in place)

List supplies required for endotracheal intubation.

1) ET tube 2) Gauze or piece of IV line/plastic tie to secure ET tube to P 3) Lubricant to permit easier passage of tube through larynx 4) Cuff syringe - needed to inflate cuff of ET tube 5) Laryngoscope or light source - allows visualization of larynx 6) Mouth speculum - not necessary but can open the mouth wider to allow better visualization, prevents P from biting the ET tube, and helps restrained keep mouth open

List the individual components of an anesthesia machine.

1) Oxygen Source (E tanks & H tanks) 2) Yoke 3) Tank Pressure Gauge 4) Pressure-Reducing Valve 5) Flowmeter 6) Fast Flush Valve 7) Vaporizer (precision vs nonprecision) 8) Unidirectional Inspiratory Valve 9) Negative-Pressure Relief Valve 10) Corrugated Breathing Tube & Y Piece 11) Unidirectional Expiratory Valve 12) Adjustable Pressure Relief Valve ("Pop-Off" Valve) 13) Manometer 14) Rebreathing Bag (Reservoir Bag) 15) CO2 Absorber 16) Scavenging System

List examples of equipment used perioperatively in veterinary surgery.

1) Patient warming devices 2) Surgical lights 3) Surgery table 4) Electrosurgery 5) Suction

Discuss the technique for IV catheterization of peripheral vessels.

1. Before beginning the placement of the catheter, be sure all supplies are available and readily accessible. 2. Clip an ample amount from the area where the catheter is to be placed. Bear in mind that no component of the catheter and no accessories (e.g., injection cap, end of fluid line) should be resting in hair once the catheter has been placed. When in doubt, clip more than would seem necessary. 3. After clipping, remove all loose hair from the tabletop and dispose of it in the waste can. 4. To begin, the restrainer should occlude the vessel to be catheterized. Proper restraint must be used to prevent contamination of the prepped catheter site (Fig. 3.7). 5. Cleanse the area using a surgical scrub product and rinsing agent combination, either povidone-iodine/70% isopropyl alcohol or chlorhexidine/70% isopropyl alcohol (Fig. 3.8). Cotton balls are best used to help prevent depositing excessive amounts of fluid on the area. The target pattern should be used when preparing the area. Begin at the proposed puncture site and move in a circle progressively toward the hair margins. Cotton balls that have left the center of the area must never return to the center. A rinsing agent should be used in the same manner to remove the scrub from the skin. A minimum of three "cycles" of scrub/rinse should be performed. If, however, after the third rinse the skin is still dirty, continue cleansing until the skin is clean. No final prep solution is necessary unless the catheter will be left in place after the surgery is completed. In this case apply the solution using the target pattern as previously described. 6. Open the catheter using aseptic technique. Remove both the injection plug at the end of the catheter and the cover on the catheter. If the cap at the end of the catheter has a paper filter, the cap may be left in place as the catheter is placed. The filter will allow the blood to "flash back" while preventing excessive bleeding. Take care to avoid touching the exposed catheter. 7. Place the thumb of the nondominant hand parallel to, but not touching, the prepared vessel. The same hand should be holding the leg in extension as well. 8. Hold the catheter at the junction of the catheter and stylet with the thumb and index finger of the dominant hand (Fig. 3.9). 9. Ensure that the bevel of the stylet is facing up. 10. Using a 10- to 20-degree angle, quickly penetrate the skin with the catheter and then insert it into the vessel. 11. Check the stylet for blood flow (Fig. 3.10). If flow is present, advance both the catheter and the stylet 1 to 2 mm, and check the stylet again. If blood flow is still present, grasp the stylet with the hand that is holding the leg. Using the other hand, advance only the catheter into the vessel (Fig. 3.11). (It is possible to use one hand to hold the stylet and advance the catheter; grasp the stylet with the middle and ring fingers while using the index finger to advance the catheter.) Be sure to advance the catheter all the way to the hub. If blood flow is not present, redirect the catheter until blood flow is established. 12. Using the other hand, quickly remove the stylet and connect either an injection cap, a T-port, or a fluid administration set to the catheter hub (Figs. 3.12 and 3.13). 13. If using a fluid administration set, be sure to turn on the fluids to maintain a patent line. If using an injection cap or a T-port, flush the catheter with 2 mL of heparinized saline. (It may be easier to insert an injection cap, secure the catheter with the first piece of tape, and then hook up the fluid line. The weight of the fluid line may otherwise pull the catheter out.) 14. Use a dry gauze sponge to remove any blood on the clipped area or hair near the catheter. 15. Begin securing the catheter by using a ½-inch-wide piece of tape long enough to encircle the limb at least once. Place the tape, sticky side up (Fig. 3.14), under the hub of the catheter all the way up to the puncture site. Bring the long side of the tape over the hub (Fig. 3.15) and tape all the way around the leg, leaving a tab of tape folded over (Fig. 3.16) to aid in removal of the tape when the catheter is removed later. This piece should be snug, but not occlusive, because it is the "anchor" for keeping the catheter in place. 16. Place a 1-inch-wide piece of tape, sticky side down, under the catheter all the way up to the first piece of tape (Fig. 3.17). Bring the long side of the tape over the catheter hub and around the leg, securing the hub of the catheter. Be sure the connection of the fluid line and the catheter is not covered. 17. The final step in securing the catheter is to use the piece of tape to secure the fluid line with a stress loop (Fig. 3.18). When making the stress loop, be sure not to kink the line to impair or obstruct the flow of fluid. Tape the loop to one of the other pieces of tape to ensure that it is secure. 18. Ensure that the catheter is still patent by checking the limb for any swelling or "blebs." Generally the fluid will not run if the catheter is not in the vessel. The drip chamber of the fluid administration set can also be observed to see that the fluid is flowing. Another trick to check catheter placement is to place the bag of fluid lower than the patient's heart and see whether blood flows back into the catheter.

Describe the different types of surgical hand prep solutions.

1. Chlorhexidine Gluconate 2. Iodophors 7.5% 3. Alcohol 4. Parachlorometaxylenol (PCMX)

Different types of gloving techniques include:

1. Closed gloving. The hand never comes in contact with the outside of the gown. In this gloving procedure, the glove palm is laid down over the cuff of the gown and the fingers enter the glove through the gown. Your bare hand should never contact the gown sleeve or the sterile glove on the opposite hand 2. Open gloving. Only the hands must be covered. Open gloving is commonly used during urinary catheterization and biopsy procedures. It's also used when one glove becomes damaged or contaminated during surgery and needs to be replaced. When this happens, you must first carefully remove the damaged glove and then place a new sterile glove on the hand. To do this, a surgical assistant must open the glove wrapper. The assistant grasps the glove's inner cuff. The surgeon moves his or her thumb into the glove's thumb and then places the rest of the fingers inside. 3. Assisted gloving. An assistant wearing a sterile gown and gloves helps another person glove. The assistant's hands should never touch unsterile surfaces. The assistant holds the glove open for the hand to be inserted. The assistant keeps his or her thumbs under the cuffs while the hand is thrust inside.

Describe the method for performing a leak check of an anesthesia machine.

1. Connect oxygen hose to oxygen source or turn on local oxygen source. 2. Attach circuit to be used. 3. Check vaporizer for adequate level of liquid anesthetic. 4. Securely occlude patient end of circuit with thumb, palm of hand. 5. Completely close pop-off valve. 6. Depress fast flush valve until a pressure reading of 40 cm H2O registers on the manometer. 7. Observe needle of manometer for declining movement, which would indicate a leak. 8. If there is no leak, proceed to step 12. 9. If there is a leak, turn on oxygen flow to 200 mL/min. 10. If leak is corrected—indicated by a stable needle on the manometer—no further action is needed. Proceed to step 12. 11. If leak is not corrected, perform machine maintenance to determine location of leak (see text for possible locations of leak). Correct leak. 12. Without removing the occlusion from the patient end of the circuit, open the pop-off valve. The rebreathing bag should deflate. 13. Remove hand, thumb from circuit end. 14. Check scavenging system to ensure that connections are intact. 15. Completely open pop-off valve.

Explain the steps to perform a sterile preparation of the surgical site.

1. Open the sterilized surgical bowl containing gauze sponges. 2. Pour off a small amount of surgical scrub solution into a trash can to cleanse the lip of the container, then pour the soap on the gauze sponges. 3. Open the container of sterile water and pour off a small amount into trash can to cleanse the lip of the container, then dilute the scrub soap in the bowl with sterile water. 4. Open a second sterile bowl containing sterile gauze. 5. After pouring a small amount of "rinse" (70% rubbing alcohol or sterile water) into the trash can, carefully pour the rinse on the sterile sponges until they appear soaked. 6. Aseptically perform the open-gloving technique. 7. Once you have put on surgical gloves, grasp a gauze sponge filled with scrub using your designated "clean hand," then squeeze out the excess liquid. 8. Transfer this sponge to your other hand, designated your "dirty hand," and start scrubbing. Use the same (clean) hand to retrieve each new sponge, and then transfer it to the other (dirty) hand to do the scrubbing; thus the phrase clean hand, dirty hand technique. Only the clean hand goes into the sterile bowl, and only the dirty hand touches the patient. (Rather than clean and dirty, both hands are actually sterile because they are covered with sterile gloves.) 9. The surgical site is scrubbed for the appropriate length of time recommended by the manufacturer of the scrub product, usually about 5 minutes. Scrubbing is done in a target pattern starting from the intended incision site and working outward to the edge of the shaved area. The time can be adjusted according to the duration of the initial surgical scrub performed in the surgery prep area. 10. Begin at the center of the clipped area over the proposed surgical incision. 11. Without touching the hairline, scrub the length of the incision with long, straight strokes. Scrub outward toward the periphery while slightly overlapping the previously scrubbed line in a circular fashion. 12. Never go back to the center of the area with the same gauze sponge. 13. After scrubbing the skin at the margin of the clipped area, discard the used gauze sponges and start again. 14. The skin should be cleansed thoroughly but gently. Excessive friction can result in hyperemia and bleeding of the skin and subcutaneous tissues. 15. The surgical scrub must have an overall contact time as recommended by the manufacturer. After the appropriate duration has elapsed, wipe the scrub away by using the "rinse"-soaked gauze.

List antiseptic products available for use to prepare patients for surgery.

1. Povidone-iodine - is bactericidal (kills bacteria), viricidal (kills viruses), fungistatic (inhibits growth), and fungicidal (kills fungus); does stain clothes/white fur 2. Chlorhexidine gluconate - has bactericidal, viricidal & fungicidal properties; does not stain and has the best residual effect of any available product

Discuss different patterns used in applying materials for the surgical preparation (scrubbing)

1. Target: most common; resembles target or bull's-eye; primarily used to prepare surgical sites for abdominal, thoracic, and neurologic procedures - Clip hair & vacuum - Wipe around the periphery of the clipped margin using rinsing sponge (this flatters the hair down, helping to keep hair from flying onto clipped area once prep begins) - To begin preparation of the surgical site, pick up one scrub sponge and fold it in half and then in half again, or bring all four corners to the center and hold the sponge by the corners (Either method produces a smaller contact surface that will be easier to control) *Always start at the proposed incision site and then move the sponge progressively outward in a circle until the hair is reached *Once the hair or any other dirty or contaminated area has been touched with the sponge, the sponge must never return to the incision site. - The surgical site should be rinsed with 70% isopropyl alcohol. The same target pattern should be used with the alcohol rinsing sponges as with the scrub sponges - Process of scrubbing then rinsing should be repeated 3 times; if dirt is still present during 3rd rinse, repeat until last rinse gauze is clean 2. Orthopedic - Remove hair from sx site - Any remaining hair on the foot must be covered - an inverted exam glove is placed over the foot & secured with tape - Make a stirrup to allow suspension of the limb for preparing & draping - Once the limb is suspended, clipping can be completed, and the scrub prep can begin. - With a scrub sponge in hand, begin the prep at the tape edge of the suspended limb. Scrub the limb from distal to proximal, moving circumferentially around the limb - As the sponge dries out, discard it and continue with a new sponge - As with the target pattern, the wrist must be kept moving to provide the scrubbing action - Repeat the scrub a minimum of 3x before rinsing to achieve the best antimicrobial efficacy - The rinsing agent is applied in the same pattern, starting at the taped foot and moving proximally to the dorsal midline - After the final rinse, place a clean towel over the medial surface of the down limb *This provides a clean surface on which the prepped limb can lie - The final prep is performed in the surgery room, so the towel only needs to be clean, not sterile 3. Perineal: it is important that a purse-string suture be placed in the anus before the preparation is begun (prevents the evacuation of fecal material onto the surgical site during the procedure). It needs to be placed carefully to avoid puncturing the anal glands. It is the technician's responsibility to ensure that the suture is removed after the procedure. The perineal pattern is basically three separate target patterns performed in a particular sequence. - The first step is to do a target pattern on the clipped area to the right of the anus - The second step is to perform another to the left of the anus - The third pattern is done on the anus itself *The "dirty" area should always be prepared last to minimize contamination - As with other patterns, the scrub is followed by a rinsing agent.

Describe how to calculate the size of rebreathing bag to be used.

5 × Tidal volume = Bag size in milliliters (mL) Tidal volume calculated as 10 mL/kg of body weight. or Body weight in pounds × 30 = Bag size in milliliters (mL)

Over-the-Needle Catheter

A catheter that's mounted over the needle

Central Venous Pressure (CVP)

A measure of blood volume and venous return used to monitor fluid volume status

Asepsis vs sterile

A: the absence of pathogenic organisms that cause infections, or w/o infection Sterile: no life forms exist on an object or in an environment (difficult to achieve & short-lived)

Explain the process to aseptically dry hands and arms after performing a surgical hand scrub or rub.

After completing the surgical hand scrub, or rub, the hands and arms need to be thoroughly dried with a sterile towel. From the sterile gown and towel pack, pick up the towel by the corner. Be careful not to drip water on the gown pack. Step back from the sterile table, always being aware of the sterile items in the environment to prevent contamination. Open the towel full length, using one end of the towel to gently rub the fingers, hand, and arms (in that order) of the first hand and arm. Do not rub back and forth; instead, rub circumferentially beginning at the wrist and moving to the elbow. Bend at the waist slightly so that the towel does not brush against the scrub suit. When ready to dry the second hand and arm, bring the first, dry hand to the opposite end of the towel and repeat. When drying is completed, drop the towel onto the floor with the hand that is currently holding it, without allowing either hand to fall below waist level.

Describe how to open items & fluids for use in the sterile field

Before opening any sterile items for use in the sterile field, make sure the packages are inspected for sterility. Confirm that (1) there are no tears or holes in the outer package and (2) the items have gone through the proper sterilization by checking the sterile indicators. Indicators are located on the outside of the package, or there may be indicator tape on the front of the package. Check the seal of the package to ensure it is secure and not broken at any point. Check the package itself, and if it looks worn from being handled too much, it should be considered contaminated. All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity. Edges of all sterile wrappers and packages are considered nonsterile. Therefore, when opening an item, be sure all edges are secured so that they do not contaminate the field or the sterile packaged item. The surgical nurse may lift the item straight out of the package, without touching any of the edges of the package. Heavy, sharp, or large items may be opened on a separate table near the sterile field for retrieval by the surgical nurse. Sterile supplies are opened by unwrapping the flap farthest away first, the sides next, and the nearest flap last. Never reach across or over a sterile area to open the final flap Irrigation fluids should be poured carefully to prevent any spills onto the sterile field and to avoid splash-back. Therefore 101it is best to have the scrubbed-in person hold the basin away from the field or to place it at the edge of the sterile table. Once the fluids have been opened, the cap is considered contaminated and cannot be replaced onto the bottle, so the remaining fluids must be discarded

BUN - how do levels increase? Supplies needed? Importance of checking it?

Blood urea nitrogen Urea is a nitrogenous compound that is a product of amino acid breakdown in the liver. BUN levels are used to evaluate the kidney's ability to remove nitrogenous wastes (urea) from the blood. If the kidneys are not working properly, an insufficient amount of urea is removed from the plasma, resulting in increased BUN levels. An estimate of the patient's BUN value can be assessed quickly using a reagent strip Supplies needed to check BUN on a reagent strip include the reagent strip, a fresh blood sample, a watch with a second hand, and a strong stream of water to rinse the strip. The color change on the reagent strip is compared with the color scale on the bottle for the strips. The corresponding color match between the reagent strip and the bottle indicates the estimated BUN (Fig. 2.13). The patient's BUN level can also be assessed using a commercial chemistry analyzer. Some anesthetics are primarily metabolized by the kidneys, and if there is any question regarding the patient's renal function, choosing a drug that is not primarily metabolized by the kidneys ought to be considered. Further diagnostic tests assessing kidney function (e.g., urinalysis, blood creatinine level) should be considered as well.

Discuss potential patient reactions from clipper or chemical irritation

Clipper irritation: Irritation of the skin can inhibit wound healing if the irritation is over the proposed incision site. Irritation can also promote bacterial growth, which could cause an infection. Clipper burns on the peri-incisional skin can be an irritation to the patient, promoting excessive licking, which can also compromise the healing process. Chemical irritation: Reactions to prepping products generally manifest as plaques or wheals. Certain breeds (Labrador, Shar Pei) seem more prone to these reactions, although any breed may be affected. Povidone-iodine tends to cause more reactions than chlorhexidine. If a patient has a chemical-related reaction, a notation should be made in the medical record so that an alternative product can be used the next time.

Discuss methods of assessing proper ET tube placement.

Cough: Many animals cough as the tube is passed into the trachea. Although fairly accurate, this method can be deceiving because as the animal coughs, the ET tube may move off the glottis and into the esophagus as it is advanced. Fogging in the tube: When an ET tube has been properly placed in the trachea, there should be fogging of the lumen of the tube with each expiration. This method can be employed only if a clear tube is used. Blowing of gauze or hair: A few strands of gauze or hair placed at the connector end of the ET tube blow away with each expiration if the tube is correctly placed. A disadvantage is that the hair may move from the tube because of excessive movement of room air rather than expiration. Air movement: If the ET tube is in the trachea, forced air should be felt at the connector end of the tube with each expiration. Bilateral chest compressions can be used with this method to ensure placement. Care must be taken to avoid compressing the abdomen, because an incorrectly placed tube may provide a false-positive assessment. Palpation: Palpation of the ventral neck should result in the identification of one "tube." If the ET tube is in the trachea, only one firm, tubelike structure should be felt. If the ET tube is in the esophagus, however, two firm, tubelike structures are palpated.

Pure Agonists

Drugs that bind and stimulate all types of opioid receptors, causing maximum analgesia

Agonists

Drugs that bind to an opioid receptor and cause expression of activity

Endogenous contamination vs exogenous contamination

Endo: comes from the patient itself (can occur from P's skin or if P has an underlying, asymptomatic infection) Exo: occurs from the sx team & environment (can occur from not using proper hygiene/attire)

Describe the procedure for donning a surgical gown.

Gowns are folded inside out in the packs. Grasp the whole gown, and lift the folded gown out of the package. Step away from the table, making sure there is adequate space to gown without contaminating anything. After locating the neckline and armholes, hold the gown by the neckline and allow it to unfold (do not shake it). Keep the inside toward the body and the hands in the armholes. Slide both arms into the sleeves of the gown by reaching and extending both arms at the same time. The circulating nurse (nonsterile assistant) will continue to pull the gown onto the scrubbed-in person, carefully bringing the gown over the shoulders, fastening the neck of the gown, and tying the waistline, all while standing behind the person gowning and touching only the hem of the collar and back of the gown. If the gown is not fitting comfortably, the circulating nurse may grasp the gown by the hem at the bottom of the gown and pull downward. This may help the gown fit more comfortably. After the scrubbed person has gloved, the neck fastening may need to be adjusted to remove excess slack in the sleeve area of the gown. The scrubbed person's hands remain inside the cuffs and must not be exposed outside the gown to perform the closed-gloving technique. If the surgical gowns used are the wraparound style, the front tie should not be touched until sterile gloves have been donned by the surgical nurse. On reusable gowns the wraparound ties are tied in the front of the gown by a single bow-tie knot. On disposable gowns, a disposable paper tag covers the end of the ties. This gown can be properly donned with the help of a nonsterile circulator. Both these gowns cover the back of the body, thereby reducing the chance of contamination because most of the body is covered. The back of the gown or the body is never considered sterile. If either tie drops on the reusable gown or the disposable gown, the circulating nurse retrieves both ties and fastens them behind the scrubbed person's back.

Ferguson Angiotribe

Has a crushing jaw design with one jaw raised and the other recessed

Adson Thumb Tissue Forceps

Has a narrow tip that broadens to a ½-inch wide shaft. The tips can be of various designs.

Tissue Thumb Forceps

Has a straight shaft with length ranging from 5 to 12 inches. Tips can have 1 × 2 or 3 × 4 teeth

Rochester-Carmalt Hemostatic Forceps

Has both vertical and horizontal serrations on the jaw near the tip

Halstead Mosquito Hemostatic Forceps

Has small jaws, with fine horizontal serration extending the entire length of the tip

Balfour Self-Retaining Retractor

Has two blades to keep the abdominal walls in lateral retraction and a third blade for cranial retraction

List examples of suture material and their main properties.

Monofilament sutures are made of a single strand of material. Multifilament sutures consist of several strands of material and are more pliable and flexible than monofilament. Absorbable sutures are normally used internally to tie off blood vessels and close incisions in muscle layers and subcutaneous tissues. After a certain amount of time, the body breaks down absorbable sutures. This characteristic is important for the type of surgery for which the sutures are used. One of the first absorbable suture materials was catgut, or surgical gut. This suture material is composed of the submucosa of sheep intestines or the serosa layer of bovine intestines. Catgut is 90 percent collagen and is inexpensive, but it can cause inflammatory reactions and promote infections. Plain gut—untreated catgut—dissolves within 10 days. Chromic gut—catgut that's treated with chrome or aldehyde— will dissolve in three to six weeks. Synthetic absorbable sutures are usually more expensive than catgut, but cause fewer problems. These are generally broken down by hydrolysis. These materials are less likely to cause skin irritation and are more resistant to degradation by infection. Nonabsorbable sutures can be made from metal, synthetic fibers, or natural fibers, such as cotton and silk. Metal sutures are typically stainless steel and usually come in the form of clips and staples. Synthetic nonabsorbable sutures are more expensive, but they usually cause less tissue reaction. Like catgut, natural-fiber sutures are inexpensive but prone to capillary action and infection. Outer skin wounds are usually closed with nonabsorbable sutures. Since the patient's body won't absorb the sutures, the veterinarian must remove them when the incision site has healed, which typically takes between 10 and 14 days.

Describe how to move around the sterile field

Movement creates air currents, which can be a source of contamination in the surgical room. Movement in the room should be kept to a minimum, and traffic in or out of the room should only occur as necessary. Scrubbed personnel should not walk away from the sterile field by wandering around the room or leaving it. When scrubbed-in personnel must change positions around the sterile field, they should be a safe distance apart so as not to touch. When they pass each other, they should pass face to face (sterile to sterile) or back to back (unsterile to unsterile). Unscrubbed (non-scrubbed-in) personnel should always face the surgical field. Unscrubbed persons should not walk between two sterile fields. The surgical scrub team should not change levels of position—from sitting to standing, and vice versa—during a procedure. The lower portion of the gown is considered contaminated, and when the scrubbed person sits, this portion of the gown is closer to the hands, arms, and the sterile field and therefore could cause contamination. There should be minimal talking in the surgery room, and the surgery room doors should remain closed as much as possible. All non-scrubbed-in persons should be a safe distance from the sterile field. A limited number of non-scrubbed-in observers should be allowed in the surgery room at one time.

Circulating nurses are + responsibilities

No sterile assistants who help place needed supplies & equipment, usually before the surgical procedure begins Must wear cpas & masks before placing items on Mayo stand Also responsible for opening surgery packs & arranging materials for surgery

Explain the mechanisms of action of the different types of analgesics.

Opioids: bind to opioid receptors in the spinal cord. The mu (μ) and kappa (κ) opioid receptors are primarily responsible for producing analgesia, with the μ receptor producing the most profound analgesia. The κ receptors produce much milder analgesia. Both receptor types are also responsible for producing respiratory depression, euphoria, sedation, and miosis. NSAID's: exert their antiinflammatory effects by inhibiting activity of COX-1, COX-2, or both α2-Agonists inhibit release of the excitatory neurotransmitter norepinephrine to produce analgesia and sedation. These agents interrupt the pain pathway by inhibiting nerve impulse transmission, modulating nociceptive signals in the spinal cord, and inhibiting perception within the brain Local Anesthetics: act by inhibiting transduction and transmission of nerve impulses and by modifying the signals at the spinal cord. Local anesthetics inhibit generation and transmission of nerve impulses by blocking sodium channels in the neuron's cell membrane. This effect slows the rate of depolarization of the neuron cell membrane and prevents the threshold potential from being reached.

Describe the drug options available for preemptive analgesia.

Opioids: provide analgesia; help reduce anxiety & nonpainful distress; produce minimal side effects; ex: Morphine NSAIDs: treat inflammation & mild to moderate pain associated with surgery; can be safely combined with opioids; ex: Rimadyl Alpha2-Adrenergic Agonists (Alpha 2-agonists): short-duration sedative-analgesic-muscle relaxants that can be rapidly reversed with α2-antagonists, which makes these drugs suitable for procedures requiring short-term restraint and analgesia as well as premedication for longer surgical procedures; ex: Dexmedetomidine & Xylazine Local Anesthetics: offer 3 benefits - (1) produce true analgesia, (2) nonscheduled agents (require no paperwork), & (3) techniques to administer them are relatively easy to perform; can and should be used in any surgical patient with an identifiable site for nerve blockade; local anesthetics are most often the drugs of choice for epidural anesthesia and analgesi

Describe what is considered a minimum database for particular patients.

Packed cell volume (PCV) or hematocrit (HCT), total solids (TS) or TP (total protein), blood glucose (BG), blood urea nitrogen (BUN), and alanine aminotransferase (ALT)

PCV or HCT - low vs high levels + supplies

Packed cell volume or hematocrit The percentage of whole blood that is made up of RBC's Low PCVs are found in cases of decreased RBC production (as in chronic renal failure), decreased RBC life span (as with some autoimmune diseases and parasite infections), and blood loss (secondary to trauma, blood-clotting disorders, or gastric ulcers). Increased PCV may indicate dehydration (common) or absolute polycythemia (rare). Checking a PCV requires microhematocrit tubes, a tube sealant (e.g., Critoseal), a centrifuge, and a hematocrit card reader

Describe how to open peel-away pouches, wrapped packs, & gowns and gloves

Peel-away pouches have a side sealed with an arrow indicating which end to open - Holding the packet at the end with the arrow allows easy opening of this type of seal; with both hands, grasp the package with the thumbs and slowly peel the package open by adducting the thumbs - While peeling the package open, hold the item firmly so that the item is stabilized and does not slide across the nonsterile edges of the package. Wrapped sterile packs are opened on a clean, flat, dry surface in the surgery room. Place the sterile pack on a flat surface so that the wrapped edges are uppermost. Remove or tear the indicator tape and open the distant flap first, taking care not to reach over the sterile contents of the pack. Open the side flaps one at a time, taking care to touch only the exposed tabbed corners and no other part of the wrap. Open the nearest flap last. For especially large packs, the circulating nurse may need to walk around the table to avoid reaching over the sterile field. If the package is double wrapped, the scrubbed-in team member can open the inner wrap. Gowns are opened much like packs. There needs to be a clean, flat, dry surface for both gown and gloves. Remove the gown from the package (if a disposable, sterile gown) and place the gown on a flat surface so that the wrapped edges are uppermost. If a resterilized cloth gown is used, remove the tape from the outer wrap. Open the distant flap first, taking care not to reach over the sterile contents of the pack. Open the side flaps one at a time, taking care to touch only the exposed tabbed corners and no other part of the wrap. Open the nearest flap last. If the gown is double wrapped, the scrubbed-in team member can open the inner wrap. Sterile gloves are removed from the outer package and placed on the table. At the top and bottom of the package are folds. Unfold these ends, taking care to overfold slightly to decrease the memory of the paper. Place hands under the flaps of the side and pull toward the outside. Take care that the top and bottom folds do not come back in and contaminate the gloves. If possible, fold the cuff end of the paper wrap over the edge of the counter.

Identify appropriate sites for placement of IV catheters.

Peripheral catheters (a catheter placed in a peripheral vessel such as the saphenous or cephalic vein) are completely adequate for short-term use (1-3 days), anesthesia induction, and medication administration. However, for long-term use (>3 days), extended fluid therapy, or systemic monitoring, a jugular catheter (central line) should be placed.

Differentiate between nonmovable (permanent) and movable equipment in a surgery room.

Permanent items are pieces of equipment that are attached to the floor, wall, or ceiling in the surgery room. Nonmovable pieces of equipment include: surgery lights, surgery table, & radiographic view box Movable pieces of equipment can be transported to other areas of the hospital. Although movable items should not leave the surgery room, they are required to serve a dual purpose in many veterinary facilities and are moved to other areas of the hospital. If these items must be moved, they must be cleaned and disinfected thoroughly before being returned to the surgery room. Movable equipment items include the following: Anesthesia machine, Monitoring equipment, ECG machine, BP cuffs and monitors, Airway tubes and monitors, Heating pads, IV drip stand (or IV pole), Instrument table, Mayo stand, Suction unit, Cautery unit, Kick bucket

Describe the use of different oxygen flow rates and the indications for their use.

Rebreathing circuits generally use a high O2 flow rate for induction and recovery, with large-volume delivery of gas. This creates a speedy induction and assists in a quick recovery. Maintenance flows for rebreathing circuits are significantly less than the induction and recovery flow rates. Only enough oxygen to match the patient's tidal volume is needed because, in addition to the fresh gas being supplied, the patient is rebreathing some of the gases already in the system. Usually a buffer is added in calculating the flow to allow for large breaths that may be given to or taken by the patient. Nonrebreathing systems also use high O2 flow rates, but the flows remain at a constant high flow whether the patient is undergoing induction, maintaining the desired depth of anesthesia, or recovering. Continuous high flow rates are necessary to provide adequate gases to the patient. Smaller patients cannot rebreathe any of the gases because of the difficulty in moving that much air with each respiration. Fresh gases need to be provided to these patients at all times.

Allis Tissue Forceps

Ring-handled instrument with teeth configured in a 3 × 4 or 4 × 5 style, used to grasp tough tissue or tissue being removed from the animal

Discuss the differences between the one-person technique and the two-person technique for performing ET intubation.

Single-Person Endotracheal Intubation 1. Place the animal in sternal recumbency. 2. Place the mouth speculum in the mouth. 3. Position a floor lamp or overhead light if being used. 4. Holding the mandible with the nondominant hand, fully extend the tongue and hold it in place with the thumb. The thumb should be caudal to the canine tooth, and the rest of the hand should be on the ventral surface of the mandible. 5. Visualize the glottis. If the epiglottis is lying dorsally, it will need to be pulled down with the ET tube to ensure visualization of the glottis. 6. Pass the lubricated tube through the glottis to the predetermined length, as indicated by the gauze tie placed on the tube. 7. Secure the tube to the patient. a. For dogs, tie the gauze tie in a bow on the muzzle, just caudal to the canine teeth. b. For cats or brachycephalic dogs, tie the gauze in a bow behind the ears at the base of the skull. 8. Leave the mouth speculum in place until the patient has reached a surgical plane of anesthesia, to avoid accidental biting of the tube. Alternatively, a blind technique can be used, as follows: 1. Place patient in lateral or dorsal recumbency. 2. Place the mouth speculum in the mouth. 3. Insert the nondominant hand into the mouth and feel for the epiglottis with the index finger. 4. With the dominant hand, pass the lubricated ET tube through the glottis using the index finger of the nondominant hand as a guide. 5. Follow steps 7 and 8 from above. Two-Person Endotracheal Intubation 1. The restrainer holds the patient in sternal recumbency. 2. The restrainer opens the mouth by holding the maxilla in one hand and the mandible in the other hand. a. In a dog, the maxilla should be held caudal to the canine teeth. b. In a cat, the maxilla should be held just caudal to the ear pinna so that the skull is in the palm of the restrainer's hand. 3. The hand holding the mandible grasps the tongue and fully extends it over the mandibular incisors (Fig. 3.23). 4. The restrainer lifts the head and extends the neck to aid the intubator's visualization. 5. Using the laryngoscope, the intubator illuminates the larynx for proper visualization (Fig. 3.24). 6. The intubator visualizes the glottis and passes the tube between the vocal folds into the glottis (Fig. 3.25). 7. The intubator advances the tube to the predetermined depth as indicated by the preplaced gauze tie. 8. The intubator secures the tube to the patient: a. For a dog, tie the gauze in a bow on the muzzle (Fig. 3.26). The gauze should be snug but should not constrict circulation. b. For a cat or brachycephalic dog, tie the gauze in a bow caudal to the ears at the base of the skull.

Modulation phase of nociception

Some pain signals are handled locally by the release of endogenous opioids, whereas others are sent to the brain for further processing.

Explain the ideal layout of a surgery suite and adjacent areas.

The American Animal Hospital Association (AAHA) recommends three distinct and separate areas for a surgical facility: the preparation area, the scrub area, and the surgery room. Preparation Area: should be adjacent to the surgery room. This prep room can be used for patient preparation (e.g., clipping and initial scrub) and the storage of surgical supplies. AAHA recommends placement of storage and cabinets in the prep area, not the surgery room. Scrub Area: may be a small area with the scrub sink, autoclave, and room to put on gown and gloves. This is a transitional area where the veterinarian and technician can prepare to move into the surgery room. Surgery Room: a separate room that should be used only for surgery. AAHA recommends that the surgery room be easy to clean and be closed off from the rest of the hospital. Closing the door minimizes traffic, maximizes cleanliness, and helps ensure that the surgery room is used only for aseptic procedures. This room should be a dedicated room reserved for aseptic surgical procedures; it should not be used for other types of procedures that may introduce bacteria into the room.

Absorbability of the Suture Material

The ability of the suture to be broken down by the body through different processes like phagocytosis or hydrolysis

Describe the function of an anesthesia machine.

The anesthesia machine delivers inhalant anesthesia and removes unneeded gases from the patient and the surgery suite. Generally this is accomplished with the use of a corrugated tubing system. The inhalation anesthetic gas is delivered to the patient through oxygen molecules; oxygen (O2) is the carrier gas for the anesthetic gas. Another purpose of an anesthesia machine is to deliver oxygen as the sole gas, as in cardiopulmonary resuscitation (CPR). For the machine to perform properly, it must do the following: 1. Deliver O2 at a controlled rate. 2. Vaporize (turn a liquid into a gas) a designated concentration of liquid anesthetic, mix the anesthetic with oxygen, and deliver the mixture to the patient. 3. Remove exhaled gases from the patient, then dispose of the gases through a scavenging system or recirculate them (after removing the carbon dioxide) to the patient. These steps can occur only if the machine is properly maintained and repaired.

Describe the final preparation before surgery.

The final step in the surgical site preparation is the application of the solution product, or paint. Povidone-iodine solution is in the same chemical family as the scrub, but the paint does not contain a detergent. The solution also has a stronger concentration of iodine, therefore increasing its potential for staining. It is corrosive when it contacts metal. The full-strength solution is applied to the patient and remains on the surgical site. It has much better efficacy when allowed to dry on the patient's skin before the drapes are applied or the incision is made. *A 2nd current option for a final solution is chlorhexidine gluconate. As with povidone-iodine, chlorhexidine as a solution contains no detergent. Chlorhexidine also has better efficacy when allowed to dry on the patient's skin before the incision is made. ***It is important to remember that only povidone-iodine scrub should be followed by povidone-iodine solution. Likewise, only chlorhexidine scrub should be followed by chlorhexidine solution. Using a povidone-iodine scrub with a chlorhexidine solution, or vice versa, is counterproductive and strongly discouraged.

Describe the steps used to manufacture surgical instruments.

The following five steps are involved in the production of surgical instruments: 1. Forging: forming or shaping of an instrument by heating and hammering. 2. Milling: cutting a forged piece to produce a final product. 3. Tempering: hardening the instrument by slowly heating in a salt bath and then immersing in oil, or "quenching." 4. Passivation: using a chemical bath to remove the particles created from grinding and other foreign materials, strengthen the steel, and aid in rust protection. 5. Polishing: refining the surface to produce a shiny or matte finish.

Describe the characteristics of suture material.

The ideal suture material has the following characteristics: High tensile strength (not easily broken) Good memory to return to its original package form for ease of handling Complete absorbability (breaks down completely) or inactivity (inert and ignored by the body) depending on the purpose in the body Absence of wicking (capillary action that draws up fluids and microbes, and may lead to infection) Causes no tissue reaction Ability to hold knots adequately (no unraveling) Relatively inexpensive

Prophylaxis

The measure taken in the prevention of disease

Urine Scald

The moist, irritating effect of urine in contact with the skin

Surgical Hand Scrub

The process of removing as many microorganisms as possible from nails, hands, and arms by mechanical washing and chemical antisepsis before a person participates in a surgical procedure

Explain a surgical hand rub.

The rub should always start with the fingers, proceed to the hands, and continue up the arms to the elbow. The rub process will follow the same procedure as the traditional scrub. This means to apply the rub to all sides of the hand, fingers, and arm. Wash hands and forearms with soap and running water immediately before beginning the surgical hand antisepsis procedure. Clean the subungual areas of both hands under running water using a nail-cleaning pick. Rinse the hands and forearms under running water. Dry the hands and forearms thoroughly with a paper towel. Dispense the manufacturer-recommended amount of surgical hand rub product. Apply the product to the hands and forearms, following the manufacturer's written directions. Some manufacturers may require the use of water as part of the process. Rub thoroughly until dry. Repeat the product application process as indicated in the manufacturer's written directions.

Describe a surgical hand scrub.

The surgical hand scrub is defined as the process of removing as many microorganisms as possible from nails, hands, and arms by mechanical washing and chemical antisepsis before a person participates in a surgical procedure. The surgical hand scrub is also designed to maintain the lowest possible microbial counts throughout the surgical procedure. The scrub procedure consists of a mechanical part and a chemical part. The mechanical part is the removal of bacteria and debris by producing friction when rubbing or brushing. This removes dirt, oil, and transient organisms that are loosely attached to the skin. During the chemical part of the scrub, the antiseptic, antimicrobial skin-cleansing agents are used. These agents inactivate or inhibit the growth of microorganisms found on the surface of the skin and in hair follicles, sebaceous glands, and sweat glands. Wash hands and forearms to the elbows with antimicrobial scrub and running water immediately before beginning the surgical scrub. Make sure to thoroughly cover all areas with the scrub because contact time is important for most agents to work properly. Clean the subungual areas of both hands under running water using a disposable nail-cleaning pick. Rinse hands and forearms under running water. Keep the hands above the elbows, and allow water to run off at the elbows. Remember to always hold the hands higher than the elbows and away from surgical attire. Dispense the approved antimicrobial scrub agent according to the manufacturer's written directions. Do not touch anything with your hands. Apply the antimicrobial agent to wet hands and forearms. Some manufacturers may recommend using a soft, nonabrasive sponge. Visualize the surfaces of the fingers, hand, and arm as having four sides with the additional tip of the fingers. Begin by brushing the fingertips of the first hand 10 times, making sure the brush also goes under the fingernails. Move to the lateral side of the index finger and scrub from the tip to the base of the finger 10 times. Repeat the 10-time scrubbing process on the other 3 sides of the index finger. Make sure that the brush and antimicrobial scrub also contact the webbing between fingers. Move to the other four fingers and repeat the process on all sides of each finger. When scrubbing the lateral side of the last finger, make sure to scrub the lateral side of the hand in the same motion. Move the brush to the palm of the hand and scrub 10 times. Move to the thumb side of the hand and scrub the outside of the thumb and the side of the hand in 110one motion. Complete the three remaining sides of the thumb. Move to the back of the hand and scrub from the base of the fingers to the wrist using 10 strokes. Scrub the arm from the wrist to the elbow in the same manner, using 10 strokes on each of the four sides of the arm. Leaving the antimicrobial scrub on the first arm, proceed to the second arm and follow the same process. When the scrub on both arms is complete, rinse the first arm, beginning at the fingertips. Make sure to keep the hands above the elbows and allow water to run off the elbow. Do not allow the any part of the hands or arms to touch anything (sink, scrub top, etc.). Rinse the brush and rescrub the first arm. Rinse the second arm in the aforementioned fashion. Repeat this process on each hand and arm to make sure that manufacturer contact time requirements are met. It is important to avoid splashing surgical attire. *** All jewelry, name tags, and pens need to be removed before the surgical hand scrub or hand rub is begun. *** The purpose of the surgical hand scrub or hand rub is to remove as many microorganisms as possible from the nails, hands, and arms. *** When an antimicrobial detergent is used, it is important to follow the manufacturer's directions regarding the scrub time and whether or not a scrub brush should be used.

Explain the process to secure the patient to the surgery table in a safe, accessible manner.

The techniques used are dictated by the surgical procedure. The animal's limbs may be tied to the table. The body may be braced in position by a V-trough or sandbags. The head, neck, or abdomen may need to be elevated through the use of a foam rubber tube or rolled towels. The patient's legs should not be forced to bend or extend beyond their natural anatomic limitations. Bony prominences should be cushioned to protect against excessive compression. The use of a sturdy, flexible cord is common practice for securing the animal's limbs in position to the table. Most surgery tables are fitted with four stays (supports) located near the corners of the table. Some tables have adjustable stays that are capable of sliding and thus accommodating patients of various sizes. The end of the cord can be wrapped in a figure-eight fashion around the stay with a half-hitch loop to secure the cord in place. It is important to tie the cord to the table with a quick-release method because the patient may need to be untied quickly. The cord should be wrapped around the stays only two or three times, and then locked with a half-hitch loop at the end. If the surgery table does not have stays to secure the cords, they can be tied to each other under the tabletop. The knot used should be a quick-release knot such as a bow tie. It is best to spread out the distribution of pressure around the limb by placing two half-hitch loops, one proximal to and the other distal to the elbow, carpus, or hock. If the animal has a catheter in its leg, both loops should be placed distal to the catheter. For abdominal procedures the patient is placed in dorsal recumbency and secured by all four limbs to the table. Patients with deep-chested conformation can be challenging when it comes to keeping them in perfect dorsal recumbency. Deep-chested dogs need to be placed in a V-trough or braced by sandbags. For canine castration, the veterinary surgeon may prefer dorsal recumbency or a modified version of this position. For modified dorsal recumbency, the hind limbs are secured to the table. The forelimbs are not tied, and the cranial half of the dog rolls toward the side on which the surgeon stands. For feline castration, the cat is placed in dorsal recumbency with the hind legs pulled toward the head. The legs may be taped into position, held by the assistant, or tied to the surgery table For procedures involving the extremities, the patient is placed in lateral recumbency. If the left limb is the focus, the patient is positioned in right lateral recumbency. If the right 80limb is the surgical site, the patient is placed in left lateral recumbency. The paw may be wrapped in gauze and tape. The limb is suspended from above by tying the tape around the paw and tying the tape to an IV pole. The limb is clipped and scrubbed in this position. All sides of the limb are prepared. For procedures involving the tail or perianal area, the patient is placed in ventral recumbency. The forelegs are secured to the table, with the hind limbs hanging over the edge at the end of the table. A rolled towel is placed under the caudal abdomen for extra padding. A piece of adhesive tape is placed in a spiral on the tail, with a long extension of the tape attached above to an IV pole or other object. The patient having back surgery is placed in ventral recumbency. Positioning in a V-trough or placing sandbags on both sides helps brace the patient and prevents listing to one side. The forelimbs are extended cranially. The hind limbs are bent in a natural sitting or squatting position. A strip of adhesive tape may provide additional stabilization across the shoulders. The patient undergoing thoracic surgery is placed in lateral or dorsal recumbency, depending on the surgeon's intended approach. The forelimbs are extended cranially as much as possible and secured to the table.

Describe the different styles of suture needles.

The two most common needle points are taper-cut needles and cutting-edge needles. Taper-cut needles are used for internal structures as they minimize tissue damage. Cutting-edge needles are usually used for tough skin that's difficult to penetrate with a taper-cut needle. Needles can be straight (limited application in veterinary medicine), curved (full curve, half curve, or double curve), or circular.

ALT

alanine aminotransferase An enzyme found in high concentration in the liver cells of dogs, cats, and primates. Damage to hepatocytes can elevate blood ALT levels. Certain drugs, such as anticonvulsants and corticosteroids, can also raise blood levels. ALT, although not indicative of specific liver disease, can be used as a general hepatic screen.

Describe appropriate techniques to conserve body heat.

• A pad with circulating warm water is placed under the patient as soon as the animal is under anesthesia. Electric heating pads can become too hot and can burn the patient's skin and therefore should not be used. The circulating warm-water pad avoids the risk inherent with electric heating pads because the water is constantly circulating between the pad under the patient and the warming unit. Water bottles do not provide a constantly renewable source of heat and also carry the risk of leaking. A wet patient can quickly become a cold patient. • Warm-air convection blankets consist of an electrical unit that warms air and pumps it through a tube to a pad. The pad has a series of holes that allow the warm air to escape slowly. The pad is laid on top of the patient, or the patient rests on top of the pad; this creates a warm microenvironment. When used for the surgical patient, the unit is not activated until the surgeon has completed draping the patient. • Some stainless steel surgery tables are fitted with heating coils that warm the entire surface of the table to approximate body temperature. The need for warm-water blankets and bottles is eliminated while the patient is on the heated surgery table. • The SnuggleSafe Microwave Heat Pad (SnuggleSafe, Lenric C21 Ltd., Littlehampton, West Sussex, UK) is a flat 83plastic disc that is placed in a microwave oven for a set number of minutes. This disc retains heat much longer than warm water bottles. • A plastic bottle (e.g., soda bottle) can be filled with dry, uncooked rice and heated in a microwave oven. The bottle with rice holds heat longer than a water bottle and eliminates the risk of leaking water on the patient. • The bag of IV fluids can be warmed in a microwave oven to approximately the same temperature as body temperature. The line for the IV administration set can run through a bowl of warm water to make the fluid warmer before going into the patient. • Plastic bubble wrap can be wrapped around the patient's extremities, including the head. The plastic wrap is light but provides warmth by retaining the body heat that would be lost through the extremities.