Enhance your learning with Evolve Student Resources.
These online study tools and exercises can help deepen your understanding of textbook content so you can be more prepared for class, perform better on exams, and succeed in your course.
Activate the complete learning experience that comes with each NEW textbook purchase by registering with your scratch-off access code at http://evolve.elsevier.com/Phillips/BerryKohn/
If your school uses its own Learning Management System, your resources may be delivered on that platform. Consult with your instructor.
If you rented or purchased a used book and the scratch-off code at right has already been revealed, the code may have been used and cannot be re-used for registration. To purchase a new code to access these valuable study resources, simply follow the link above.
Contents in Brief
Section 1: Fundamentals of Theory and Practice
1 Perioperative Education, 1
2 Foundations of Perioperative Patient Care Standards, 15
3 Legal, Regulatory, and Ethical Issues, 35
Section 2: The Perioperative Patient Care Team
4 The Perioperative Patient Care Team and Professional Credentialing, 52
5 The Surgical First Assistant, 60
6 Administration of Perioperative Patient Care Services, 74
Section 3: The Patient as a Unique Individual
7 The Patient: The Reason for Your Existence, 93
8 Perioperative Pediatrics, 118
9 Perioperative Geriatrics, 153
Section 4: The Perioperative Environment
10 Physical Facilities, 169
11 Ambulatory Surgery Centers and Alternative Surgical Locations, 189
12 Care of the Perioperative Environment, 203
13 Potential Sources of Injury to the Caregiver and the Patient, 210
Section 5: Surgical Asepsis and Sterile Technique
14 Surgical Microbiology and Antimicrobial Therapy, 230
15 Principles of Aseptic and Sterile Techniques, 251
16 Appropriate Attire, Surgical Hand Hygiene, and Gowning and Gloving, 266
17 Decontamination and Disinfection, 286
18 Sterilization, 303
Section 6: Surgical Instrumentation and Equipment
19 Surgical Instrumentation, 328
20 Specialized Surgical Equipment, 350
Section 7: Preoperative Patient Care
21 Preoperative Preparation of the Patient, 368
22 Diagnostics, Specimens, and Oncologic Considerations, 384
Section 8: Pharmacology and Anesthesia
23 Surgical Pharmacology, 409
24 Anesthesia: Techniques and Agents, 421
Section 9: Intraoperative Patient Care
25 Coordinated Roles of the Scrub Person and the Circulating Nurse, 455
26 Positioning, Prepping, and Draping the Patient, 487
27 Physiologic Maintenance and Monitoring of the Perioperative Patient, 523
Section 10: Surgical Site Management
28 Surgical Incisions, Implants, and Wound Closure, 538
29 Wound Healing and Hemostasis, 569
Section 11: Perianesthesia and Postprocedural Patient Care
30 Postoperative Patient Care, 596
31 Potential Perioperative Complications, 602
Section 12: Surgical Specialties
32 Endoscopy and Robotic-Assisted Surgery, 632
33 General Surgery, 648
34 Gynecologic and Obstetric Surgery, 680
35 Urologic Surgery, 712
36 Orthopedic Surgery, 742
37 Neurosurgery of the Brain and Peripheral Nerves, 770
38 Spinal Surgery, 788
39 Ophthalmic Surgery, 806
40 Plastic and Reconstructive Surgery, 826
41 Otorhinolaryngologic and Head and Neck Surgery, 851
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Senior Content Development Specialist: Danielle Frazier
Publishing Services Manager: Julie Eddy
Project Manager: Grace Onderlinde
Design Direction: Renee Duenow
An inspiration to all perioperative nurses and caregivers of the past, present, and future.
Mary Lou Kohn
This page intentionally left blank
Preface to the Fourteenth Edition
This time-honored text has its roots in the operating room (OR) orientation manual created by Mary Louise Kohn in the late 1940s while working as an OR educator at University Hospitals of Cleveland, Ohio. Her impeccable notes were a source of interest to many OR supervisors and educators who wanted to standardize their teaching techniques in accordance with Mary Louise’s orientation tool. Many observers requested copies of her writings, and eventually the cost of providing copies became prohibitive.
In 1951, at the request of her publisher and with the encouragement of her superiors, Mary Louise assembled her orientation material into a manuscript suitable for publication. She spent countless hours writing and revising material until the birth of her daughter. Her dedication to her family led her to seek assistance for this project from Edna Cornelia Berry, who became her willing partner and coauthor through the first four editions.
The first edition of Introduction to Operating Room Technique by Edna Cornelia Berry and Mary Louise Kohn was published in 1955. I was fortunate to have obtained a copy for my collection. The first edition was dedicated to “those nurses who accept the tension and challenge of coordinated teamwork as they minister to the patient in the operating room.” The main emphasis was on intraoperative care of the patient.
Berry and Kohn’s Operating Room Technique has been the perioperative text of choice for 60 years because it emphasizes the importance of the patient and presents the material in concise, understandable language. The name remains “Operating Room Technique” because that is how it has been commonly known and identified, although the text has a comprehensive perioperative focus. It would be a disservice to our patients to merely describe the intraoperative phase and not include preoperative and postoperative care.
Every new edition of this classic perioperative text has addressed changing roles, needs, and evolving technologies while maintaining the fundamental focus that still remains valid—the care of the surgical patient. This edition of the text identifies the knowledge and skill needs of the caregiver and strives to incorporate components of patient care from preoperative, intraoperative, and postoperative practice areas. A systems approach is used to help organize patient care to minimize the risk for human error.
Berry and Kohn’s Operating Room Technique is designed to meet the needs of educators, learners, caregivers in diverse disciplines, and managerial personnel who care for surgical or interventional patients in many types of environments. Knowing the “why” of patient care is as important as knowing the “how.” Additionally, it is important to stress that outcomes must be evaluated to support evidence-based practice. This text is the book of choice for certification preparation in diverse disciplines and incorporates all elements of the core curricula specified by several accrediting and certifying bodies.
Features of the Fourteenth Edition
• A user-friendly 12-section arrangement.
• A logical and sequential order of the subject matter.
• Incorporation of the AORN Guidelines for Perioperative Practice (2019) and AST’s Core Curriculum for Surgical Technology, 6th edition, to reflect modern perioperative practice.
• A focus on the physiologic and psychologic considerations of perioperative patients to provide guidelines and standards for planning and implementing safe individualized care.
• Use of the systems approach as a foundation to support solid evidence-based practice to establish patient care procedures in such a way that all team members can identify their roles in a cooperative spirit of safety and efficiency.
• In-depth discussion of patients with special needs related to age or health status considerations.
• Discussion of perioperative patient care in inpatient, ambulatory, and alternative sites/locations to highlight considerations based on the setting, as well as the surgical procedure.
• Encouragement of the patient care team to identify and examine personal and professional development issues that influence the manner in which care is rendered.
• Detailed information about the fundamentals of perioperative nursing and surgical technology roles.
• Building of knowledge in a logical sequence—from fundamental concepts to implementation during surgical intervention—to enable readers to apply theory to practice.
• Comprehensive coverage of a broad range of essential topics to provide a thorough understanding of fundamental principles and techniques and an understanding of their applications in various surgical procedures.
• Descriptions of specific surgical procedures in each specialty chapter to assist the learner and caregiver in planning and delivering patient care in the perioperative environment.
• An Evolve website that has learning and teaching aids to enhance the classroom experience and support assimilation of knowledge. For the student, this includes tips for the scrub person and circulating nurse, historical perspectives, body spectrum software, student interactive questions, and an audio glossary. For the instructor, this includes a TEACH manual with a lesson plan, lecture outline, case studies, and PowerPoint slides for each chapter; test bank; and collection of all the images in the book.
New to the Fourteenth Edition
• New and revised art is provided throughout the book.
• Insightful Pros & Cons boxes throughout the text examine the two sides of a patient care topic and provide references for further reading.
• Updated references highlight the evidence-based practice approach used in the book.
• Terminology and key words have been updated to reflect modern practice.
• Each chapter has been revised to emulate current practice and knowledge.
Organization
Section 1 describes education, learning, and professional issues. The correlation of theory and practice is integral to the success of patient care in the perioperative environment. Fundamental professional and personal attributes of the caregiver are examined, with an emphasis on objectivity in the development of the plan of care. Legal and ethical issues are discussed.
Section 2 delineates the roles of the members of the health care team as both direct and indirect caregivers. Nonphysician first assistant roles and credentials are discussed in a separate chapter. Management of the perioperative patient care areas is described, including Magnet Status.
Section 3 provides in-depth information on patient assessment and the development of an individualized plan of care, with the patient viewed as a unique individual. Special needs are identified by health condition and age. Geriatric and pediatric chapters are included.
Section 4 examines the physical plant of the perioperative environment—both hospital-based, freestanding ambulatory facilities and alternative locations. Diagrams of conventional and nonconventional perioperative suite designs are included with airflow designs. Care of the perioperative environment, occupational hazards, and safety issues are examined in depth.
Section 5 explains microbiology and the importance of microbiologic control in the perioperative environment, with an
emphasis on standard precautions. It delineates aseptic and sterile techniques as fundamental to intermediate aspects, such as attire, scrubbing, gowning, and gloving. Separate chapters are provided regarding the sterilization and disinfection of surgical instrumentation and patient care supplies.
Section 6 details the primary surgical instrumentation and equipment used during surgical procedures. The safe use of specialized surgical equipment is presented. Electricity is explained.
Section 7 discusses preoperative patient care and includes the family/significant other in the plan of care. Diagnostic procedures and specimen handling are described.
Section 8 covers methods of anesthetic administration and the role of caregivers during this process. Physiologic patient responses and related potential perioperative complications are discussed in detail. Surgical pharmacology is included.
Section 9 describes intraoperative patient care, including positioning, prepping, and draping. The interactive roles of the circulator and the scrub person are specified in Chapter 25. Economy of motion and the properties of physics are applied. Physiologic monitoring of the perioperative patient is described.
Section 10 focuses on the surgical site. Incisions, hemostasis, and wound closure are discussed in detail. Wound assessment, dressing, and healing throughout the perioperative care period are described.
Section 11 presents an expanded view of postoperative patient care. The postanesthesia care unit is explained. Prevention of patient complications is described. The death of a patient is discussed, and the importance of legal evidence is stressed.
Section 12 covers the surgical specialties. Salient surgical anatomy and procedures are described and illustrated in line drawings for clarity.
Preface to the First Edition
The material in this text is the outgrowth of the coauthors’ experience in the operating room—one as instructor of students, the other as head nurse with some responsibility for instructing and guiding students. It is an adaptation of the instructor’s teaching outline for which there have been many requests.
The aim of the book is to facilitate the nurse’s study of aseptic technique and care of the patient in the operating room. Although this text is intended primarily for the student, the authors hope it may prove useful to the graduate nurse as well.
Because it is assumed that the student has studied pathologic conditions necessitating surgical treatment, these conditions are not discussed. When applicable, and as a matter of emphasis, there is a reiteration of principles of sterile technique and safety factors for the patient. It is hoped this will aid in fixing the principles as patterns of thought and work.
Although operative routines vary in different hospitals, underlying principles are the same. Consequently, basic principles are emphasized, and the authors have endeavored to keep the material as general as possible. Principles must be adapted to suit the situations found in individual hospitals. Specific linen, equipment, and procedures are mentioned merely to serve as a framework on which to demonstrate principles or as samples for points of departure. However, the specific examples mentioned are workable procedures that have evolved. They are kept as uncomplicated as possible for student teaching and for use in the practical situation.
Instruments for operations are not listed and few are mentioned because each hospital has its instrument lists, standardized for each case, to which students can refer.
Emphasis is placed on meeting the psychological as well as the physical needs of the surgical patient. An endeavor is made where possible to correlate briefly the preoperative and postoperative care with the operative procedure, to give the student a complete concept of patient care.
The frequent use of the imperative mood is for the purpose of brevity, organization, and emphasis. Questions and assignments in each chapter are to aid the student in reviewing the material, in recalling pertinent facts, and in applying the principles to his or her specific situation.
Obviously, if the student starts scrubbing for cases with an older nurse after the first day or two in the operating room and if operating-room theory is given concurrently with the practice, much of the material in this book will have been covered by individual instruction before class discussion.
The authors have attempted to maintain simplicity and brevity and to present a concise outline for preliminary study. They suggest that the student supplement this material by reference reading.
The authors wish to express their grateful appreciation and thanks to those people who by their interest and cooperation supported them:
To Miss Edythe Angell, supervisor of the Operating Rooms at University Hospitals of Cleveland, for helpful suggestions during the preparation of the manuscript and for reading, critically, the entire manuscript. We are gratefully indebted to her because we have learned from her much of what appears in this text.
To Miss Janet McMahon, Educational Director, School of Anesthesia, University Hospitals of Cleveland, for valuable assistance in preparing Chapter 21. Also, to Dr. Edward Depp, anesthesiologist, Euclid-Glenville Hospital, Cleveland, who offered suggestions on this chapter and reviewed it.
To Dr. C.C. Roe Jackson, of the faculty of Western Reserve University School of Medicine, for constructive criticism in reviewing Chapter 17. To Dr. Howard D. Kohn, also of the faculty, who has been most helpful in reading the manuscript and offering suggestions.
To Mrs. Geraldine Mink, librarian, for her assistance; to Mrs. Leona Peck for her patience in typing the manuscript and for her helpful suggestions; to Miss Ruth Elmenthaler and Miss Margaret Sanderson of the operating-room staff for their assistance in making the photographs; and to Mrs. Anita Rogoff for drawing the illustrations.
Mary Louise Kohn Cleveland, Ohio 1955
Edna Cornelia Berry
This page intentionally left blank
Mary Louise Kohn, AB, RN, MN (1920-2019)
I first met Mary Louise Kohn, a leader in perioperative nursing education and authorship, several years ago in Dallas at the Association of Operating Room Nurses (AORN) annual congress. I moderated an educational session before a large group of specialty nurses. When the program finished, several participants came out of the audience to discuss the topic and ask questions. Mary Louise, a lovely, petite lady with blonde hair and sparkling blue eyes, introduced herself and complimented my presentation. On October 15, 1992, I had the opportunity to interview Mary Louise. Throughout the interview, her physical presence glowed with professionalism and dignity. The whole room seemed to reflect her persona. She explained how the events of the era in which she lived affected her career path.
Mary Louise came from a highly educated family. Her German father had a Ph.D. and was a Presbyterian minister who taught Hebrew and Greek to scholars of religion and literature. She had several cousins who had Doctorates in various fields. Both of her parents had passed away by the time she was 16 years old, and she lived on a small inheritance left to her by an uncle. She graduated in 1940 from the College of Wooster with a Bachelor of Arts in biology and psychology. She hoped to become a doctor, but money was tight and females were discouraged from entering medicine. She entered nursing so she could earn a living sooner.
During W.W.II, after the bombing of Pearl Harbor on December 7, 1941, only 7,000 Army nurses were on active duty, but within six months the ranks grew to 12,000. Women were rapidly taking a larger role in the war effort and she felt that her participation in civilian nursing was critical to the success of her country. She tried to fill in for the shortages wherever she could, especially for the nurses who were deployed overseas. She wanted to be an Army flight nurse, but her family discouraged her ambitions. She was unable to fulfill that dream and talked about it in a distantly sad way.
She received her Master of Nursing degree from the Francis Payne Bolton School of Nursing (FPB) at Western Reserve University (WRU) in 1943. After graduation, she took a staff nurse position in the operating room (OR) at University Hospitals of Cleveland (UH). She explained that only 35 graduate nurses were available to staff five hospitals for all three shifts.
She met the love of her life, Howard Kohn, MD, during his internship. He joined the Army Medical Corps so Mary Louise joined him at his duty station. They married on the army base in 1944 and lived at their own expense in a rooming house. Mary Louise took a private duty position in the civilian sector because it paid more money, five dollars per day.
Howard was stationed in Atlantic City at the Thomas M. England General Hospital, which consisted of several hotels converted into hospitals for wounded soldiers returning from the front. Mary Louise explained that registered nurses were in demand, so she took a position as Assistant Head Nurse on a 200 patient ward. Only
enlisted military nurses could be Head Nurses because the patients were wounded soldiers. Her responsibility included training civilian aides and orderlies, many of who were conscientious objectors or deferrees of the draft. Her workday consisted of 12 hour shifts with one hour for meals.
In 1943, Congress passed the Bolton Act sponsored by Francis Payne Bolton, enacting the U.S. Cadet Nurse Corps, spearheaded by Lucile Petry, to educate registered nurses for duty in the military. All educational expenses and a small stipend were paid for a nursing degree in return for 2 years of service in the Army Nurse Corps if needed. The Cadet Nurse Corps attracted 169,443 women to its service. Male nurses were not actively recruited. By 1944, formal rank as a commissioned officer, usually a Second Lieutenant (2LT) with equal privileges and pay was available to registered nurses. The last Cadet Nurses graduated in 1948.
At the end of the European war in 1945, the number of Army nurses was approximately 27,850. By the end of 1946, only 8,500 nurses remained in the Army Nurse Corps, none were male.
Mary Louise’s husband was discharged from the Army in 1946 and decided to specialize in ophthalmology at the Harvard Medical School, graduate program. He completed his training and returned to Cleveland to practice his specialty. Mary Louise became the OR Instructor at the University Hospitals (UH), after serving as head nurse on the surgical floor. UH was affiliated with Western Reserve University (WRU) and the Francis Payne Bolton School of Nursing.
Mary Louise was appointed to the teaching staff of WRU and assisted with the education of the Cadet Nurses. She was highly organized and began to put her original handwritten teaching notes in a retrievable format. Her educational programs and teaching syllabus were of great interest to educators from smaller hospitals in the United States. Many OR educators from other hospitals requested a photocopy of her teaching syllabus so they could standardize their own surgical programs. She found that her teaching material was a valuable tool. The Dean of Nursing at FPB encouraged her to publish because the volume of material was becoming too large to photocopy free of charge. She was approached by several publishers and accepted the offer presented by McGraw-Hill.
In 1951, with the birth of her only daughter, Mary Louise decreased her hours at the hospital and focused on formalizing her written material. She eventually included a co-author, Edna Berry, RN, AD, who was formerly affiliated with UH. Mary Louise was family oriented and found this working arrangement with a co-author to be a help and a hindrance. Edna, who was unmarried, did not have a family so planning writing schedules around a co-author with an infant and a husband was difficult.
The original manuscript was written by hand. Mary Louise did not type and had to hire typists at ten dollars per page to meet deadlines. She diligently had each chapter reviewed by a physician,
and got Edna’s agreement before sending any work to print. They contracted artists for line drawings and illustrations and paid to have the book professionally evaluated. There were no professional organizations to lend guidance or standards so they drew from their own resources for the first technique-oriented textbook for OR nurses. The first edition was published in 1955 and contracted for revisions every five years.
During the early sixties, The Association of Operating Room Nurses (AORN) was founded. AORN founders contacted Mary Louise and asked her to be part of the organization as Education Director. She joined the organization, but explained that she could not devote the time needed to become a founder. When AORN created the standards and recommended practices that are the basis of all worldwide perioperative nursing practices, they used Berry and Kohn’s Operating Room Technique as a reference.
Edna Berry died before the sixth edition was finished. Mary Louise took Lucy Jo Atkinson, RN, MS as co-author for its completion. Berry and Kohn’s Operating Room Technique had grown into a well-known international OR text. It had been translated into
Spanish and Chinese and was the main text of the armed forces surgical training programs. When Mary Louise retired her authorship, Lucy Jo became the solo author of the seventh edition. Mosby purchased the publishing rights for the seventh and subsequent editions of the text from McGraw-Hill. Lucy Jo and Nancymarie Fortunato-Phillips, PhD, MEd, BSN, RNFA, CNOR co-authored the eighth edition and Nancymarie became the solo author for the ninth through thirteenth editions. Nancymarie co-authored the fourteenth edition with Anita Hornacky, RN, BS, CST, CNOR, who will assume solo authorship with the fifteenth edition as part of the Elsevier family of publishing.
Mary Louise lived to be 99 years old and passed away in the spring of 2019. She met with Nancymarie and Anita several times during the production of the thirteenth edition and gave her opinions of the fourteenth edition before she died. Mary Louise and her work as an educator and author was truly the cornerstone of what perioperative nursing is today. Her experience and dedication inspired many perioperative caregivers. She was a wonderful friend and mentor.
Acknowledgments
I want to thank so many people who have made this fourteenth edition possible. First, I want to thank all of the reviewers of the previous editions for their time in review and for their input. The identified needs of this group provide the baselines for the growth and effectiveness of this work. The reviews were very detailed and appropriately critical.
I am so grateful to the many nurses, surgical technologists, and readers of previous editions who wrote to me or called requesting specialty topic coverage in this edition. We welcome feedback at all times and can be contacted by the email address listed at the bottom of this page.
I want to thank our ongoing students in all disciplines (perioperative nursing, registered nurse first assistant, and surgical technology) for asking hard questions and forcing us to step beyond the classroom to satisfy their learning needs. We see them as the future of patient care and the representatives of the high standards described in this text.
I want to thank my perioperative nursing and surgical technologist colleagues for their professionalism and for making the task of revision exciting and fresh. A special thank you to Joe Fortunato, Jr., who created much of the art for this edition and other authorship projects.
I want to thank Sandra Clark, Executive Content Strategist; Danielle Frazier, Senior Content Development Specialist; and Grace Onderlinde, Project Manager, for their support and patience during the production of this edition. Their support made this project possible.
We want to thank Mary Lou Kohn, RN, who trusted us with her wonderful creation. She is the epitome of the perioperative nurse we should strive to be. We put her foremost in mind before we commit any word to paper. We ask ourselves, “How would Mary Lou describe this?” Or, “What would Mary Lou think about adding this?” We do this not only out of reverence for her trust but also because she still exemplifies the highest standards of patient care despite being long retired. Mary Lou is a delightful human being and forever a perioperative nurse.
Nancymarie Howard Phillips nancymphillips@aol.com Anita Hornacky anitahornacky@aol.com
This page intentionally left blank
Section 1: Fundamentals of Theory and Practice
1 Perioperative Education, 1
The Art and Science of Surgery, 2 Perioperative Learner, 2 Perioperative Educator, 5 Application of Theory to Practice, 9 Expected Behaviors of Perioperative Caregivers, 10 Realities of Clinical Practice, 12 Evolve Website, 13
2 Foundations of Perioperative Patient Care Standards, 15 Surgical Conscience, 16 Patient Rights, 16 Accountability, 16 Standardization of Patient Care, 17 Recommended Practices, 20 Professionalism, 25
Professional Perioperative Nursing, 25 Evidence-Based Practice, 25 Nursing Process, 26 Standards of Perioperative Nursing Practice, 28
Clinical Competency of the Perioperative Nurse, 31 Scope of Perioperative Nursing Practice, 32 Surgical Technology, 32
Clinical Competency of the Surgical Technologist, 33 Continual Performance Evaluation and Improvement, 33 Evolve Website, 34
The Joint Commission and Sentinel Events, 39 Consent, 42 Documentation of Perioperative Patient Care, 44 Legal Aspects of Drugs and Medical Devices, 47 Ethical Issues, 48 Evolve Website, 51
Section 2: The Perioperative Patient Care Team
4 The Perioperative Patient Care Team and Professional Credentialing, 52 Dependence of the Patient on the Qualified Team, 53 Credentialing of Qualified Caregivers, 53 Perioperative Patient Care Team, 53 Evolve Website, 59
5 The Surgical First Assistant, 60 First Assistant’s Knowledge and Skill Level, 61 What Does the First Assistant Do?, 62 Disciplines Associated with First-Assisting in Surgery, 69 Evolve Website, 73
6 Administration of Perioperative Patient Care Services, 74 Establishing Administrative Roles, 74 Interdepartmental Relationships, 79
Patient Care Departments, 79 Patient Services Departments, 80 Departmental Service Divisions, 81 Coordination Through Committees, 82 Surgical Services Management, 86 Budgeting and Financial Responsibility, 89 New Product and Equipment Evaluation, 91 Evolve Website, 92
Section 3: The Patient as a Unique Individual
7 The Patient: The Reason for Your Existence, 93 The Patient as an Individual, 93 The Patient with Individualized Needs, 96
The Patient with Cancer, 103
The Patient with Chronic Comorbid Disease, 110
The Patient Who Is a Victim of Crime, 112 End-of-Life Care, 116 Death of a Patient in the Operating Room, 116 Evolve Website, 117
8 Perioperative Pediatrics, 118
Indications for Surgery, 118
Considerations in Perioperative Pediatrics, 119
Perioperative Assessment of the Pediatric Patient, 120
Preoperative Psychologic Preparation of Pediatric Patients, 127
Pediatric Anesthesia, 128
Intraoperative Pediatric Patient Care Considerations, 132
Common Surgical Procedures, 134
Postoperative Pediatric Patient Care, 152
Evolve Website, 152
9 Perioperative Geriatrics, 153
Perspectives on Aging, 153
Perioperative Assessment of the Geriatric Patient, 156
Intraoperative Considerations, 166
Postoperative Considerations, 167
Evolve Website, 167
Section 5: Surgical Asepsis and Sterile Technique
14 Surgical Microbiology and Antimicrobial Therapy, 230
Microorganisms: Nonpathogens versus Pathogens, 231 Types of Pathogenic Microorganisms, 235
Antimicrobial Therapy, 245 Evolve Website, 250
15 Principles of Aseptic and Sterile Techniques, 251 What Is the Difference between Aseptic and Sterile Techniques?, 252
Transmission of Microorganisms, 253
Human-Borne Sources of Contamination, 253 Nonhuman Factors in Contamination, 254 Sources of Infection, 255
Environmental Controls, 255
Section 4: The Perioperative Environment
10 Physical Facilities, 169
Physical Layout of the Surgical Suite, 170
Transition Zones, 171
Peripheral Support Areas, 172 Operating Room, 175
Special Procedure Rooms, 185
Construction or Renovation of the Surgical Suite, 186
Evolve Website, 188
11 Ambulatory Surgery Centers and Alternative Surgical Locations, 189
Ambulatory Surgical Setting, 189
Alternative Sites Where Surgery Is Performed, 198 Evolve Website, 202
12 Care of the Perioperative Environment 203 Guidelines for Cleanliness in the Surgical Environment, 203
Establishing the Surgical Environment, 203 Room Turnover Between Patients, 204
Daily Terminal Cleaning, 208 Evolve Website, 209
13 Potential Sources of Injury to the Caregiver and the Patient, 210
Environmental Hazards, 210
Physical Hazards and Safeguards, 211
Chemical Hazards and Safeguards, 223
Biologic Hazards and Safeguards, 225
Risk Management, 227
Evolve Website, 228
Standard Precautions, 257 Principles of Sterile Technique, 259 No Compromise of Sterility, 265 Evolve Website, 265
16 Appropriate Attire, Surgical Hand Hygiene, and Gowning and Gloving, 266
Appropriate Operating Room Attire, 267
Surgical Hand Hygiene, 276 Gowning and Gloving, 278
Evolve Website, 285
17 Decontamination and Disinfection, 286
Central Processing Department, 286
Central Service Personnel, 287
Instrument Cleaning and Decontamination, 287 Disinfection of Items Used in Patient Care, 291 Methods of Disinfection, 292 Disposable Products, 300 Evolve Website, 302
18 Sterilization, 303
Sterilization versus Disinfection, 304
Sterilization, 304
Assembly of Instrument Sets, 306
Packaging Instruments and Other Items for Sterilization, 307
Thermal Sterilization, 311
Chemical Sterilization, 317
Radiation Sterilization, 323
Control Measures, 324 Custom Packs, 326 Evolve Website, 327
Section 6: Surgical Instrumentation and Equipment
19 Surgical Instrumentation, 328 Fabrication of Metal Instruments, 328 Classification of Instruments, 329 Handling Instruments, 346 Evolve Website, 349
21 Preoperative Preparation of the Patient, 368 Hospitalized Patient, 368 Preoperative Preparation of All Patients, 368 Transportation to the Operating Room Suite, 379 Admission to the Operating Room Suite, 379 Evolve Website, 383
22 Diagnostics, Specimens, and Oncologic Considerations, 384
Diagnosing Pathology, 385 Specimens and Pathologic Examination, 385
Radiologic Examination, 388 Magnetic Resonance Imaging, 393
Surgical Drug and Pharmaceutical Sources, 415 Pharmacologic Forms Used in Surgery, 417 Potential Complications Caused by Pharmaceuticals and Herbal Medicine, 419 Evolve Website, 420
24 Anesthesia: Techniques and Agents, 421
The Art and Science of Anesthesia, 422
Choice of Anesthesia, 422
Anesthesia State, 422
Knowledge of Anesthetics, 423
Types of Anesthesia, 423
Alternatives to Conventional Anesthesia, 452
Evolve Website, 453
Section 9: Intraoperative Patient
Care
25 Coordinated Roles of the Scrub Person and the Circulating Nurse, 455
Division of Duties, 455
Efficiency of the Operating Room Team, 483
Evolve Website, 486
26 Positioning, Prepping, and Draping the Patient, 487
Preliminary Considerations, 487
Anatomic and Physiologic Considerations, 493
Equipment for Positioning, 494
Surgical Positions, 500
Physical Preparation and Draping of the Surgical Site, 506
Evolve Website, 521
27 Physiologic Maintenance and Monitoring of the Perioperative Patient, 523
Monitoring Physiologic Functions, 523
Evolve Website, 537
Section 10: Surgical Site Management
28 Surgical Incisions, Implants, and Wound Closure, 538
The Surgical Incision, 538
Surgical Landmarks, 543
Wound Closure, 546
Evolve Website, 568
29 Wound Healing and Hemostasis, 569
Mechanism of Wound Healing, 570 Types of Wounds, 571
Factors Influencing Wound Healing, 572
Hemostasis, 575
Wound Management, 584
Complications of Wound Healing, 590
Postoperative Wound Infections, 592
Wound Assessment, 592
Basic Wound Care, 593
Evolve Website, 593
Section 11: Perianesthesia and Postprocedural Patient Care
30 Postoperative Patient Care, 596
Postanesthesia Care, 596
Admission to the Postanesthesia Care Unit, 598
Discharge from the Postanesthesia Care Unit, 600
Evolve Website, 601
31 Potential Perioperative Complications, 602
Potential for Complications during and after Surgery, 602
Respiratory Complications, 603
Cardiovascular Complications, 606
Fluid and Electrolyte Imbalances, 617
Blood Volume Complications, 619
Shock, 626
Metabolic Crises, 627
Iatrogenic Injury, 631
Evolve Website, 631
Section 12: Surgical Specialties
32 Endoscopy and Robotic-Assisted Surgery, 632
Eight Essential Elements of Endoscopy, 632
Knowledge and Skill for a Safe Endoscopic Environment, 640
Types of Endoscopic Procedures, 640
Hazards of Endoscopy, 642
Care of Endoscopes, 643
Considerations for Patient Safety, 644
Duties of the Assistant for Flexible Endoscopy, 644
Robotic-Assisted Endoscopy, 644
Evolve Website, 647
33 General Surgery, 648
Special Considerations for General Surgery, 648
Breast Procedures, 650
Abdominal Procedures, 654
Liver Procedures, 657
Splenic Procedures, 659
Pancreatic Procedures, 659
Esophageal Procedures, 660
Gastrointestinal Surgery, 661
Intestinal Procedures, 666
Colorectal Procedures, 670
Abdominal Trauma, 673
Anorectal Procedures, 674
Hernia Procedures, 676
Amputation of Extremities, 677
Evolve Website, 679
34 Gynecologic and Obstetric Surgery, 680
Anatomy and Physiology of the Female Reproductive System, 681
Gynecology: General Considerations, 684
Diagnostic Techniques, 685
Vulvar Procedures, 689
Vaginal Procedures, 690
Abdominal Procedures, 694
Perioperative Obstetrics, 697
Complicated Birth, 701
Assisted Reproduction, 705
Nonobstetric Surgical Procedures and the Pregnant Patient, 707
Evolve Website, 711
35 Urologic Surgery, 712
Anatomy and Physiology of the Urinary System, 712
Special Features of Urologic Surgery, 715
Surgical Procedures of the Genitourinary System, 720
Male Reproductive Organs, 730
Endocrine Glands, 739
Transsexual Surgery (Sex Reassignment), 739
Postoperative Complications of Urologic Surgery, 740
Evolve Website, 741
36 Orthopedic Surgery, 742
The Art and Science of Orthopedic Surgery, 742
Anatomy and Physiology of the Musculoskeletal System, 743
Special Features of Orthopedic Surgery, 746
Extremity Procedures, 751
Fractures, 752
Joint Procedures, 756
Repair of Tendons and Ligaments, 764
Cast Application, 765
Complications after Orthopedic Surgery, 768
Evolve Website, 769
37 Neurosurgery of the Brain and Peripheral Nerves, 770
Anatomy and Physiology of the Brain, 770
Special Considerations in Neurosurgery, 772
Patient Care Considerations for Craniotomy, 775
Surgical Procedures of the Cranium, 779
Peripheral Nerve Surgery, 785
Evolve Website, 787
38 Spinal Surgery, 788
Anatomy and Physiology of the Spinal Cord and Vertebral Column, 788
Special Considerations for Spinal Surgery, 791
Pathology of the Vertebrae and Spinal Cord, 796
Surgical Procedures of the Spine, 800
Evolve Website, 805
39 Ophthalmic Surgery, 806
Anatomy and Physiology of the Eye, 806
Ophthalmic Surgical Patient Care, 807
Special Features of Ophthalmic Surgery, 809
Ocular Surgical Procedures, 812
Eye Injuries, 823
Ophthalmic Lasers, 825
Evolve Website, 825
40 Plastic and Reconstructive Surgery, 826
Special Features of Plastic and Reconstructive Surgery, 826
Skin and Tissue Grafting, 829
Head and Neck Plastic and Reconstructive Procedures, 836
Plastic and Reconstructive Procedures of Other Body Areas, 839
Burns, 846
Evolve Website, 850
41 Otorhinolaryngologic and Head and Neck
Surgery, 851
General Considerations in Ear, Nose, and Throat Procedures, 851
Ear, 854
Nose, 859
Oral Cavity and Throat, 863
Neck, 866
Face and Skull, 875
Evolve Website, 881
42 Thoracic Surgery, 882
Anatomy and Physiology of the Thorax, 882
Special Features of Thoracic Surgery, 885
Thoracic Surgical Procedures, 893
Chest Trauma, 895
Intrathoracic Esophageal Procedures, 896
Complications of Thoracic Surgery, 898
Evolve Website, 898
43 Cardiac Surgery, 899
Anatomy of the Heart and Great Vessels, 899
Physiology of the Heart, 901
Special Features of Cardiac Surgery, 902
Cardiac Surgical Procedures, 909
Mechanical Assist Devices, 916
Complications of Cardiac Surgery, 921
Evolve Website, 922
44 Vascular Surgery, 923
Anatomy and Physiology of the Vascular System, 923
Vascular Pathology, 925
Diagnostic Procedures, 926
Special Features of Vascular Surgery, 928
Conservative Interventional Techniques, 931
Vascular Surgical Procedures, 934
Evolve Website, 943
45 Organ Procurement and Transplantation, 944
Types of Transplants, 944
Tissue Transplantation, 944
Organ Transplantation, 947
Evolve Website, 962
Index, 963
This page intentionally left blank
Berry & Kohn’s Operating Room Technique
This page intentionally left blank
Perioperative Education 1 SECTION 1 Fundamentals of Theory and Practice
CHAPTER OUTLINE
The Art and Science of Surgery, 2
Perioperative Learner, 2
Perioperative Educator, 5
CHAPTER OBJECTIVES
After studying this chapter the learner will be able to:
• Compare and contrast the art and science of surgery.
• Identify three characteristics of adult learners.
• Name five educational resources available for the learner.
• Define the difference between andragogy and pedagogy.
KEY TERMS AND DEFINITIONS
Andragogy Teaching and learning processes for mature adult populations.
Behavior Actions or conduct indicative of a mental state or predisposition influenced by emotions, feelings, beliefs, values, morals, and ethics.
Disruptive behavior (bullying) Power imbalance that involves intimidation, oppression, or aggression and results in a counterproductive atmosphere.
Cognition Process of knowing or perceiving, such as learning scientific principles and observing their application.
Competency Creative application of knowledge, skills, and interpersonal abilities in fulfilling functions to provide safe, individualized patient care.
Critical thinking The mental process by which an individual solves problems.
Disease Failure of the body to counteract stimuli or stresses adequately, resulting in a disturbance in function or structure of any part, organ, or system of the body.
Environmental factors Water, air, soil, and food. Contamination and exposure of any of these factors can lead to disease.
Evaluation A process by which the educator measures performance by standardized indicators established by a school, employer, or professional organization.
Knowledge Organized body of factual information.
Learning style Individualized methods used by the learner to understand and retain new information. These may be visual, auditory, tactile, sensory, kinesthetic, or performance-oriented behaviors.
Mentoring A nurturing, flexible relationship between a more experienced person and a less experienced person that involves trust, coaching, advice, guidance, and support. A sharing relationship guided by the needs of the less experienced person.
Application of Theory to Practice, 9
Expected Behaviors of Perioperative Caregivers, 10
Realities of Clinical Practice, 12
• Describe how adult learning principles apply to patient teaching.
• Discuss the problems associated with disruptive behavior in the perioperative environment.
Objectives Written in behavioral terms, statements that determine the expected outcomes of a behavior or process.
Occupational hazard A workplace hazard that can cause physical, biologic, or chemical injury, leading to disease or death.
Orientation Period during which a student or new employee becomes acquainted with the environment, policies, and procedures of a professional environment.
Pedagogy Teaching and learning processes for immature and/or pediatric populations. A very directed style is used.
Perioperative Total surgical experience that encompasses preoperative, intraoperative, and postoperative phases of patient care.
Preceptor A person who observes, teaches, and evaluates a learner according to a prescribed format of training or orientation.
Psychomotor Pertaining to physical demonstration of mental processes (i.e., applying cognitive learning).
Role model A person who is admired and emulated for good practices in the clinical environment. The relationship between a role model and a learner can be strictly professional without personalized mentoring.
Skill Application of knowledge into observable, measurable, and quantifiable performance.
Surgery Branch of medicine that encompasses preoperative, intraoperative, and postoperative care of patients. The discipline of surgery is both an art and a science.
Surgical conscience Awareness that develops from a knowledge base of the importance of strict adherence to principles of aseptic and sterile techniques.
Surgical procedure Invasive incision into body tissues or a minimally invasive entrance into a body cavity for either therapeutic or diagnostic purposes; protective reflexes or self-care abilities are potentially compromised during such a procedure.
The main focus of this chapter is to establish the baseline or framework for an in-depth study of perioperative patient care and support the educational process of the learner. Consideration is given to the perioperative educator, who may not have had a formal education in the teaching of adult learners. Both learners and educators should understand that the same learning and teaching principles apply to patient education. The key terms are commonly used terms that the learner should understand as the basis for learning about and participating in the art and science of surgery
The Art and Science of Surgery
Health is both a personal and an economic asset. Optimal health is the best physiologic and psychological condition an individual can experience. Disease is the inability to adequately counteract physiologic stressors that cause disruption of the body’s homeostasis. Additional influences, such as congenital anomalies, infection, trauma, occupational hazard, or environmental factors, interfere with optimal human health and quality of life. As both a science and an art, surgery is the branch of medicine that comprises perioperative patient care encompassing such activities as preoperative preparation, intraoperative judgment and management, and postoperative care of patients. As a discipline, surgery combines physiologic management with an interventional aspect of treatment. The common indications for surgical intervention include correction of defects, alteration of form, restoration of function, diagnosis and/or treatment of diseases, and palliation. Table 1.1 describes some of the most common indications for surgery.
In the 1930s the English physician Lord Berkeley George Moynihan (1865–1936) said, “Surgery has been made safe for the patient; we must now make the patient safe for surgery.” Surgical intervention is becoming a safer method of treating physiologic conditions. Most of the former contraindications to surgery that were related to patient age or condition have been eliminated because of better diagnostic methodologies and drug therapies. More individuals are now considered for surgery; however, each patient and each procedure is unique. Perioperative caregivers should not become complacent with routines but should always be prepared for the unexpected. Surgery cannot be considered completely safe all the time, and patient outcomes are not always predictable.
A surgical procedure may be invasive, minimally invasive, minimal access, or noninvasive. An invasive or minimal access procedure enters the body either through an opening in the tissues or by a natural body orifice. Noninvasive procedures are frequently diagnostic and do not enter the body. Technology has elevated the practice of surgery to a more precise science that minimizes the “invasiveness” and enhances the functional aspects of the procedure. Recovery or postprocedure time decreases, and the patient is restored to functional capacity faster. Improvements in perioperative patient care technology are attributed to the following:
• Surgical specialization of surgeons and teams
• Sophisticated diagnostic and intraoperative imaging techniques
• Minimally invasive equipment and technology
• Ongoing research and technologic advancements
TABLE 1.1
Common Indications for Surgical Procedures
Indication for Surgical ProcedureExample
AugmentationBreast implants
DebulkingDecreasing the size of a mass
IncisionOpen tissue or structure by sharp dissection
ExcisionRemove tissue or structure by sharp dissection
DiagnosticsBiopsy tissue sample
RepairClosing of a hernia
RemovalForeign body
ReconstructionCreation of a new breast
PalliationRelief of obstruction
AestheticsFacelift
HarvestAutologous skin graft
ProcurementDonor organ
TransplantPlacement of a donor organ or tissue
Bypass/shuntVascular rerouting
Drainage/evacuationIncision into abscess
StabilizationRepair of a fracture
ParturitionCesarean section
TerminationAbortion of a pregnancy
StagingChecking of cancer progression
ExtractionRemoval of a tooth
ExplorationInvasive examination
DiversionCreation of a stoma for urine
ImplantationInserting a subsurface device
ReplantationReattaching a body part
AmputationRemoving a large structure
StentingUsing an implant as a supporting device
NeoconstructionFace transplant
Surgical procedures are performed in hospitals, in surgeons’ offices, or in freestanding surgical facilities. Many patients can safely have a surgical procedure as an outpatient and do not require an overnight stay at the facility. The types of surgical procedures performed on an outpatient basis are determined by the
complexity of the procedure and the general health of the individual. Procedures performed on patients who remain overnight in the hospital vary according to the expertise of the surgeons, the health of the patient, and the availability of the equipment. The purpose of this text is to provide a baseline for learning the professional and technical patient care knowledge and skill required to provide safe and efficient care for patients in the perioperative environment.
Perioperative Learner
The learner in the perioperative environment may be a medical, nursing, or surgical technology student enrolled in a formal educational program, or the learner may be a newly hired orientee. Medical students have a surgical rotation that includes participation
