The nursing team is composed by: nurse, nursing technician and nurse aid, being the nurse the responsible one for the team coordination.

The nurse is a professional with university graduation, responsible for the planning of the assistance that will be given to the patient. He is the responsible one for the resources management involving this assistance.

The nursing technician is a professional with technical graduation that needs to have complete highschool graduation and the course of nursing technician.

The nurse aid is a professional with technical graduation that needs to have the first highschool graduation and the course of nurse aid.

All the professionals of the nursing team, must have its register in the Nursing Regional Council (COREN) of the state where they develop its professional activities. The offitial law that regulates that action is the Law nº 7,498, of 25/6/1986 .

CENTER OF MATERIAL AND STERILIZATION - (CME)

The CME is an unit of technical support to to attend all assistential units; is responsible by the articles in the process, as instrumentals, surgical clothes, etc.... This process involves: the cleanness, the article preparation, the sterilization load preparation, the sterilization, the guard and distribution of articles to all the consumer units of the institution.

Resolution RDC nº 307, of November 14 th , 2002 (Brazil, 2002), considers the CME an unit of technical support, who has the purpose to supply health care articles adequately processed, providing, thus, conditions for the direct attendance and the health assistance to ill and healthy individuals.

Thus, we understand that the nursing team that works in this sector, gives an indirect assistance to the patient. This is so important as well as the direct assistance, that is carried through by the nursing team that takes care of to the patient.

The physical area of the CME must not only allow the establishment of a continuous and unidirectional article flow, preventing the crossing of dirty articles with the clean and sterilized ones, but as to prevent that the worker scaled for the contaminated area transits through the clean areas and vice versa (SOBECC, 2000).

For establishing an unidirectional flow, it is necessary to have physical barriers between the areas: dirty (expurgation), clean (material preparation and preparation of the sterilization load) and sterile (remove of sterile material of the sterilizer, keeping and distributing sterile material) see project below. The people access must be restricted to the professionals of the area.

In a CME with unidirectional flow, it is necessary to use double door equipments to carry through articles of an area to another.

The CME personnel must be composed by nurses, nursing technicians, administrative nurses aid and assistants, whose functions are described in the SOBECC recommended practices.

Spauding Classification:

Critical articles : are articles or products used in invasive procedures with penetration in skin and adjacent mucosae, subepiteliais tissues and vascular system, including also all the articles or products directly connected with these systems. The sterilization is the basic process that grants the use of such products in achieving the proposed objectives

Examples: intravenous needles, catheters, implantations, surgical instrument and injectable solutions

Semicritical articles : are articles or products that enter in contact with the not complete skin, restricted to its layers or those that enter in contact with complete mucosaes. They require high level disinfection or sterilization, to have guaranteed the quality of its multiple use. Examples: nasogastric sounding lead and respiratory equipment.

Non-critical articles : are articles or products destinated to the contact with the complete skin and also those that do not enter in direct contact with the patient. They require cleanness or disinfection of low or average level, depending on the use that it refers to or on the last use. Examples: thermometer and chamber pot.

Cleanness is the process that aims the removal of visible dirtiness (organic and inorganics) and, therefore, the reduction of the microbiologic load. Therefore, it refers to one-step essential and indispensable for the reprocess of all health care articles, being criticals, semicriticals or non-criticals.

Cleanness must always be prior to the disinfection or sterilization processes (R utala, 1990). Studies, as R utala (1993) and Z anon (1987), prove that the presence of organic substance protects the microorganisms, becoming the subsequent processes inefficient. The work of the mechanics action and adequate solutions increases the cleanness efficiency. If an article will not be adequately cleaned, this will make difficult the sterilization and disinfection processes.

Types of sterilizers :

Gravitational - the vapour injection in the internal chamber forces the cold air exit through a valve located in the inferior part. In this process, the formation of bubbles air can occur in the interior of the package, what hinders the occurrence of the sterilization.

Daily pay-vacuum – Through a vacuum bomb contained in the equipment, being able to have one, three or five pulsatives cycles, air is removed of the packages and from the internal chamber, allowing a dispersion and faster uniform penetration and of the vapour in all the packages that the respective load contains. After the sterilization, the vacuum bomb makes the suction of the vapour and the internal humidity of the load, becoming the drying fastest and completing the cycle;

Basic controls of the sterilization process can be carried through by the following forms:

a) Chemical controls (ISO.11.140)

• Class 1: process pointer - it shows if the material was displayed to the sterilization process
• Class 2 : pointer to be used specific tests – in relevant situations to the sterilization equipment
• Class 3: – pointers of UM parameter - monitorates one of the critical parameters of the sterilization process.
• Class 4: pointers of multiparameters – monitorates two or more critical parameters of sterilization process depending for which were calibrated.
• C lass 5: integrators pointers – monitorate all critical parameters of the sterilization process.
• Class 6: simulation pointers – monitorate all the critical parameters of the sterilization process, will not react until achieving 95% of the cycle.

b) biological Pointers

• Pointers of First generation : spore straps
• Pointers of 2 nd generation : keeps the spore ribbon and the blister with contained way of culture inside of a resistant plastic blister, that procedure  makes possible the accomplishment of the test and the reading in the proper sector without the necessity of sending it to the laboratory) needed to be kept at 56ºC , being the first reading in 24 hours and the second one in 48 hours.
• Pointers of 3rd generation: keeps the spore ribbon and the blister with contained way of culture inside of a resistant plastic blister, that procedure  makes possible the accomplishment of the test and the reading in the proper sector without the necessity of sending it to the laboratory), needed to be kept at 56ºC , being the reading taken after 3hours.

c) Thermal Qualification: it is carried through termocouples, in counsecutive cycles.  

Surgical Center (Preoperative Center) – (CC)

the SC is one of the most complex units of the hospital, not only for its specificity, but also for being a closed place that displays the patient and the team of health (doctors and the nursing) to stressfull situations. BRUNNER/SUDDARTH, 1992).

The multiprofessional team (doctors and the nursing) must deal with some relevant aspects to the technical competence, relationship and material resources, beyond the patient and its family interaction . To them the unkwon fear and the anxiety are hard factors that contribute to the environment complexity.

HUMAN RESOURCES In the SC

The professionals who act in the Surgical Center (Pre-operative) are: the medical teams (surgical and anesthesiology), nursing, administrative and hygiene, that has as objective to attend the necessities of the patient adequately. It is of extreme importance that components act in an harmonic and integrated way specially for the patient security and the efficiency of the surgery. It is also important that good human relationships and professionalism always prevail on stress, still inevitable in this kind of work.

In one team, all members have responsibilities and defined functions, as well as must be qualified for the activities that they play. The coordinating nurse functions, assistencial nurse, nursing technician , administrative assistant and nurse aid, are described in the SOBECC. recommended practices.

Giving the Nurse conditions to assist the patient in the surgery room, like: monitorization, security actions to prevent falls, help the anesthesiologist during the anesthetical induction; place the patient together with the surgical team in the surgical table; placing the cushions for giving comfort to the patient , and other specific actions, it is necessary to have that at least 1 assistencial nurse for each 4 surgery rooms, beyond the controlling nurse (coordinator) who is responsible for the administrative cases.

Surgery Schedule:

It is a complex activity that involves the material' mangements, instrumentals, equipments, adequate the room size to the procedure, assistant or nursing technician to give assistance during the surgery, and the general dynamics of the surgical and sector programs. Therefore, we recommend that the surgery schedule stays under the direct supervision of the Pre-operative nurse.

Nursing Peri-operative Systematization (SAEP)

the Nursing Peri-operative Systemization(SANP) must be carried out for all patient that will be submitted to a anaesthetic-surgical procedure and will be evaluated by the Surgical Center nurse with the application of the SAEP, that will have to be developed among the SAE rules , however with a specific approach to the surgical patient.

SAEP is, undoubtly the base that gives support to the nursing actions in the Surgical Center (Pre-operative), nowadays besides creating greater interaction in the nursing assistance in the daily pay, trans and postoperative (Possari, 2003). Such care, was sufficiently wronged in the sixties, when the nurse performance in the perioperative assistance was predominantly directed to the instrumental area, to attending the medical team requests and to administrative cases related to the development of the anaesthetic-surgical act.

Taking into consideration this former history of the nursing assistance in SC and the complexity of the administrative activities that the nurses made in this sector, since they are responsible by its management, is possible to understand the great difficulty that the perioperatives nurses have to apply the SANP . SAEP. Being this its main activity directed to the assistance in intra operative and the anesthetical recovery.

SAEP must be planned by the perioperatives nurses, with an adequate instrument to the reality of the institution to really takes care of its objectives and does not result in more difficulties on the activities of the rofessional performance .

The main objectives of the SAEP are :

•  To implant the integral nursing assistance individualized and registered in the daily pay phases, trans and postoperative

•  To raise and analyze the individual necessities of the patient to be submitted to the anaesthetic-surgical procedure;

•  To help the patient and its family to understand the health problem, preparing them for the surgical procedure

•  To reduce at the maximum the inherent risks to the surgical environment;

•  To reduce the patient fidget and anxiety, contributing for its recovery .

•  Basic assistance to the surgical patient during the trans/intra-operative period .

•  To receive the patient in the SC, introduce itself, verify the bracelet of identification and the handbook;

•  As security behaviors, confirm previous information on fast (hour indication), allergies, illnesses

•  Conduct the patient to the surgery room;

•  Place the patient in the surgical table in comfortable and safe way

•  Monitorize the patient and keep it warm;

•  Monitorize the patient and keep it warm;

•  A ssist the anesthesiologist during the anesthetical induction;

•  A ssist the surgical team to locate the patient for surgery;

•  Protect the patient skin during the antisepsis with chemical products;

•  K eep the patient warm, with blanket or thermal blanket (the thermal blanket propitiates a controlled and more efficient heating);

•  P lace the massage device and/or elastic stocking in the inferior members, as prophylactic for deep venosa Trombosis (TVP);

• Carry out the catheterism vesicle , when necessary

•  R egister all nursing cares given to the patient and the evolution;

•  P reserve the patient physical and emotional security ;

•  R eview nursing prescription and modifying it, if necessary

• C arry out nursing prescription to the postoperative at the end of the procedure.

•  Keep the family informed about the ongoing surgery.

Anesthetical Recovery (RA) or Recovery after anesthetical (RPA)

Nowadays, the RA is the destined place to receive the patient in the immediate period postoperative and will stay under observation and constant cares of the nursing team . until the recovery of the conscience, stability of the vital signals, prevention of the episodes if it will happen . During this phase the anesthesiologist is the responsible physician for the patient assistance being his high performance very important .

HUMAN RESOURCES IN THE RA

The assistance given to the patient in the RA requires constant cares because it is in a delicate phase of the postoperative, asking for a constant monitorization and evolution control .

. The team must be trained and qualified to give high complexity individualized cares to the patient in immediate postoperative period, assuring the prevention of risks and decurrent complications of the anaesthetic-surgical act .

Therefore the nursing team must be composed by nurse and nursing, technician even though if there is only one patient.

The assistencial nurse functions, the administrative nursing technician and the assistant, are described in the SOBECC recommended practices.

Some of the nursing team functions :

• Receive the information about how was the anesthesic-surgical act from the technician or nurse aid together with the anesthesiologist ;
• Make a physical examination of the patients in the admission and at the release of the anesthetical recovery ;
• Prepare a plan of cares, supervising its execution and carring out the complex Nursing cares using of the Perioperative Nursing Systematization of the Assistance, since admission until the release of the patient in the RA;
• Give the Nursing care to the patient, as planned;
• Use the Aldrete and Kroulik index to evaluate the conditions of the patient throughout its stay at the hospital;
• Evaluate and register the clinical evolution of the patient in anesthetical recovery
• Evaluate and register the clinical conditions of the patient released and send it to the unit of origin with security;
• Do and register the postoperative evaluation of the given assistance;
• Take part of studies and research programs as collaborator or responsible researcher;
• Identify, quantitatively and qualitatively, the materials and equipments necessity, observing and following its conservation principles;
• Inform the Coordinator about the occurrences related to the patients and the auxiliary staff under its responsibility ;
• Cooperate with the nurse-coordinator in the elaboration of scales of recesses and vacation ;
• Elaborate and supervise the schedule of monthly, weekly and daily work scales
• Control the narcotics as far as the use in patients of the unit and replacement request ;
• Take part of the patients and their families;
• Inform and guide the families about the clinical conditions of the patients under their responsability;
• Make the continued education and the qualification of the auxiliary staff;
• To be responsible for the sizing of the work group, as the necessities of the unit and the of patients dependence degree (children, eldery people, etc);
• Give technical opinion about materials and equipments together with the nurse-coordinator of the Surgical Center unit.

For evaluation of the release conditions is common the use of the Aldrete & Kroulik index , being that score for intrahospital release is fom 8 the 10.

Aldrete & Krolik Index .

  Obs: The patient release who is in anesthetical recovery is privative of the anesthesiologist.