Presentation is loading. Please wait.

Presentation is loading. Please wait.

Surgical Technology Lecture Series 2000© Power-Point®

Similar presentations


Presentation on theme: "Surgical Technology Lecture Series 2000© Power-Point®"— Presentation transcript:

1 Surgical Technology Lecture Series 2000© Power-Point®

2 Draping the Surgical Patient - Part I Another Step in Creating the Sterile Field

3 Production Notes Author - Kevin Frey CST, MA Series Editor - Teri Junge MEd, CSFA, CST, FAST

4 Table of Contents Purposes of Draping Ideal Characteristics of Draping Material Types of Drapes and Draping Material Application of Sterile Technique

5 Purposes of Draping

6 Purposes General information Cover the patient to create a sterile barrier Maintain a sterile field throughout the surgical procedure Prevent migration of microbes from nonsterile to sterile areas Prevent surgical site infection (SSI)

7 Ideal Characteristics of Draping Material

8 Characteristics General information Blood and fluid resistant to prevent strike-through Resistant to punctures and tears Flexible to contour to patient’s body, surgical equipment, and furniture Flame resistant/retardant

9 Characteristics (continued) General information (continued) Lint free to prevent contamination of the surgical wound –Cellulose fibers can be the cause of granulomas and arterial emboli Antistatic to prevent sparks –Sparks can be cause of explosion in an oxygen-rich environment and anesthetic gases –Draping material must meet National Fire Protection Association (NFPA) standards

10 Types of Drapes and Draping Material

11 Non-woven Fabric General information Most frequently used type of fabric for manufacturing drapes Non-woven fabric drapes are disposable drapes Made of synthetic fibers combined with cellulose through chemical or mechanical means

12 Non-woven Fabric (continued) Advantages Resistant to tears and punctures Lint free (except when cut or torn releasing cellulose fibers that can become airborne) Antistatic (meets NFPA standards) Flame resistant/retardant Blood and fluid resistant Manufacturer sterilizes and packages; reduces expenses related to laundering, inspecting, mending, folding, and resterilizing drapes

13 Non-woven Fabric (continued) Disadvantage One-time use; cannot be cleaned and resterilized

14 Non-woven Fabric (continued) Features Some drapes have multiple layers of draping material surrounding the fenestration to aid in preventing strike-through Absorbable outer layer Impermeable inner layer Drape may have a pocket or loops to aid in retaining the suction and cautery apparatus within the sterile field

15 Non-woven Fabric (continued) Features (continued) Transparent plastic sheeting covers the fenestration –Prevents migration of microbes into the wound –Antimicrobial solution may be impregnated into the plastic sheeting –Surgical incision made through the plastic sheeting

16 Non-woven Fabric (continued) Features (continued) Pouches may be incorporated along the sides of a laparotomy drape or arthroscopy drape –Pouch collects fluid –Drainage port incorporated that can be connected to suction system

17 Laser-Resistant Drape General information Non-woven fabric is flame resistant, but once the cellulose is ignited it burns easily and quickly Polypropylene drapes do not ignite, but can melt and in the process injure the patient Aluminum-coated drapes are the best and safest to use in the presence of a laser

18 Thermal Drape Aluminum coated drape Reflects body heat back to the patient when the patient is covered by the drape Runners wrap themselves in these drapes after a race on a cold day (to give an idea of what the drape looks like) Available as a sterile or nonsterile product Note: Sterile must be used during the sterile draping procedure

19 Thermal Drape (continued) Aluminum coated drape (continued) Nonsterile –Placed on patient in preoperative holding area –Covered by sterile drapes and remains in position during the surgical procedure –Remains in place in PACU Note: Recommended for use when at least 60% of body can be covered and the procedure will last more than two hours

20 Plastic Drape General information Sterile, disposable transparent plastic sheets that can be applied to the skin The entire drape or only a portion of the drape around the fenestration is adhesive Skin incision is made through the plastic (referred to as “incise drape”

21 Plastic Drape (continued) Features Drapes may be impregnated with antimicrobial agent –Agent is usually iodophor –3M company is a popular manufacturer of these drapes; commercial name is Ioban® drape –Surgical team members often refer to the needed size of the drape by the 3M product number (eg 1040, 1080, etc)

22 Plastic Drape (continued) Iodophor drape (continued) –Iodophor is slowly released during surgical procedure –Inhibits growth of microbes on patient’s skin –Useful for procedures lasting 2 hours or longer

23 Plastic Drape (continued) Advantages Resident microbes are prevented from migrating to the surgical wound Microbes cannot penetrate the plastic material Drape is held securely in place with an adhesive Adhesive does not cause abrasions to the skin when removed Plastic conforms to the contours of the patient’s body Transparency allows visualization of anatomical landmarks and condition of the skin

24 Plastic Drape (continued) Disadvantages Non-porous plastic retains body heat of patient causing build-up of perspiration and prevents evaporation Perspiration and heat provide a medium for bacterial growth Perspiration can cause drape to lose adhesiveness No more than 10% of patient’s body surface should be covered with drape

25 Plastic Drape (continued) Drape application procedure Skin prep –Scrubbed area of body must be dry for adhesive to stick –Allow to dry by evaporation or blot excess with sterile towel –Alcohol may be applied to speeds the drying process by evaporation - follow electrocautery precautions Free end of drape grasped by surgical technologist Opposite end grasped by surgeon Plastic is incorporated in fenestration of drape; paper cover of adhesive is removed by STSR prior to drape application

26 Plastic Drape (continued) Drape application procedure (continued) Tension is kept on drape as it is applied to the skin in an even manner A folded woven hand towel is used to smooth the plastic as it is applied to the skin If extremity is draped; surgeon will wrap the drape in a circular fashion Excess drape can be removed with a bandage scissors Regular non-woven drapes can be applied over the plastic drape

27 Plastic Drape (continued) Aperture drape Opening in the drape for the eye or ear Adhesive surrounds the fenestration 3M is a popular manufacturer of aperture drapes Surgical team members often refer to the needed size of the drape by the 3M product number (eg 1020)

28 Plastic Drape (continued) Towel drape Square plastic drape with a single line of adhesive across one edge Available in a variety of sizes Uses –Wall off a contaminated area such as a stoma or the anus –Square off the incision site; used instead of woven towels or nonwoven blue bar drape

29 Plastic Drape (continued) Isolation drape Often used for orthopedic procedures such as hip nailing Isolates sterile field from equipment such as the C- arm Drape extends from the head of the patient to just past the feet Drape is suspended vertically over a steel pole attached to the OR table

30 Plastic Drape (continued) Isolation drape (continued) Drape may have a pocket or loops to aid in retaining the suction and cautery apparatus within the sterile field Pouch incorporated to collect fluids Incise area may be impregnated with antimicrobial solution

31 Equipment Drape Tourniquet drape Plastic towel drape is placed around the edge of the tourniquet and used to protect cuff from prep solution Microscope drape Plastic sterile drapes made specifically for microscope Allows sterile team members to move the microscope within the sterile field Fenestrations expose oculars

32 Equipment Drape (continued) X-ray cassette drape Sterile transparent plastic cassette holder –Resembles a Mayo stand cover (Mayo stand cover may be substituted) –Folded in a similar fashion to a Mayo stand cover –Gloved hands are placed within a protective cuff to apply drape to cassette Nonsterile team member (circulator or radiology tech places cassette inside of cover that STSR has prepared STSR completes the process of covering the cassette with the drape

33 Equipment Drape (continued) C-arm drape Plastic sterile drape made specifically to cover C- arm Allows C-arm to be placed over the sterile field Similar configuration to Mayo stand cover for ease of application to the C-arm

34 Equipment Drape (continued) Fiberoptic and power instrument cords –Long, sterile plastic tubes are available to contain fiberoptic cords or power instrument cords –Example: Arthroscopic camera and cable are placed in the sterile tube-like cover

35 Woven Towels Fan folded and stacked in packages of four or five towels Wrapped and sterilized in Central Sterile Supply Used to isolate the incision site Secured with towel clips –May be sutured or stapled in place

36 Woven Towels (continued) STSR prepares four wound towels in advance of need –Open towel –Folding one lengthwise edge downward approximately 1” creating a cuff –Fold three towels toward self –Fold one towel away from self –Stack towels in order of anticipated use Note: Instructor will demonstrate in lab setting

37 Fenestrated Drape General information Drape is positioned so that fenestration (opening) is placed over area of skin incision Fenestration will vary in size, shape, and direction of opening according to the type of needed drape Drape is usually long enough to cover the body from head to past the feet Drape is usually wide enough to cover both armboards

38 Fenestrated Drape (continued) General information (continued) Drape is marked with directions to indicate head and foot of drape –Orientation may be indicated by arrows, labels, or outline of a body Fenestrated drapes are unfolded according to manufacturers instructions and facility policy

39 Fenestrated Drape (continued) Laparotomy drape Simply referred to as a lap sheet or drape Available in adult, pediatric, and infant sizes Longitudinal fenestration with reinforcement around the opening Used for vertical abdominal or spine incisions

40 Fenestrated Drape (continued) Chest Drape Similar to lap sheet except the fenestration is much larger to provide more exposure Used for procedures of the breast(s) and chest (median sternotomy)

41 Fenestrated Drape (continued) Thyroid drape Similar in size to the lap sheet except the fenestration is transverse and nearer to the top of the drape Used for neck procedures

42 Fenestrated Drape (continued) Kidney or lateral drape Similar in size to the lap sheet and fenestration is in the same location Fenestration is transverse to accommodate the transverse lateral or flank kidney incision

43 Fenestrated Drape (continued) Laparoscopy drape Combination of a laparotomy and perineal drape Abdominal fenestration is smaller than that of a lap sheet Second fenestration is in the perineal region to expose external genitalia Leg covers may be incorporated into the drape Used when patient is in lithotomy position

44 Non-fenestrated Drape 1/2 and 3/4 sheets Square sheet Multi-purpose purpose –Drape a table to create sterile surface –Place under an extremity to create a sterile surface –Wrap around the surgeon’s waist during a procedure in which the surgeon is seated (patient is in lithotomy position; arthroscopy of the knee) –Cover an area of the sterile field that has become contaminated –Wrap around an extremity to permit manipulation of the extremity

45 Non-fenestrated Drape (continued) Leg drapes or covers (leggings) Must use separate leg drapes if perineal or laparoscopy drape does not have leggings incorporated Drape is folded in such a manner that the proximal end is open and the distal (toe) end is closed Proximal end is folded to create a cuff in which to protect sterile gloved hand to apply drape

46 Non-fenestrated Drape (continued) Split sheet Drape is cut up the middle about 1/3 of the way to create two tails Called a U-drape when the upper end of the split is “U” shaped Split sheet usually nonwoven material U-drape usually plastic

47 Non-fenestrated Drape (continued) Split sheet (continued) Edges of tails has adhesive to stick to the skin or other drapes Placement under an extremity with tails wrapped around the extremity to expose circumference of extremity Used when draping patient for hip procedure to isolate perineum Term “place one up/one down” refers to use of two split sheets to expose a lengthy site

48 Non-fenestrated Drape (continued) Stockinette Tubular drape used to cover an extremity Opening for incision can be cut through the layers of the stockinette to accommodate the incision Two types –One type is made of knit material and is porous so it is not considered a barrier to microbes –Second type has two layers Inner layer is porous stockinette Outer layer is plastic

49 Application of Sterile Technique NEVER reach across the OR table to drape the opposite side of the patient –Walk around to the other side of the table DO NOT hand drapes, towels or towel clips across the O.R. table to the surgeon –Carry them to the side of the table where the surgeon is standing DO NOT unfold the drape before laying it on the patient

50 Application of Sterile Technique (continued) Before the patient is draped, maintain a safe distance from the nonsterile OR table –The sterile surgical gown has a tendency to bulge outwards increasing the chance of contamination by brushing up against the OR table

51 Application of Sterile Technique (continued) Prepare to place the drape on the patient –Hold the drape approximately ” above the intended skin incision site –Do not contaminate the drape or gloved hands on the overhead surgical lights –Estimate placement so fenestration is evenly distributed over the incision site

52 Application of Sterile Technique (continued) Placing the sterile drape –The STSR removes paper cover over adhesive surrounding fenestration –Place the drape on the patient –DO NOT adjust a drape once it is placed –If the drape is placed incorrectly the circulator will remove the drape and obtain another drape for the sterile team members to use

53 Application of Sterile Technique (continued) Placing the sterile drape (continued) –Protect the gloved hands by cuffing the drape over them –A drape that falls below the sterile level is considered contaminated –If drape unfolds before use; discard the drape

54 Application of Sterile Technique (continued) Perforating towel clip –If a towel clip is fastened through the drapes; the points are contaminated –DO NOT move the towel clip to be fastened at another area of the drape –If the towel clip must be removed hand it off to the circulator; do not touch the points –Cover the area from which it was removed from with a sterile drape

55 Application of Sterile Technique (continued) Hole discovered in the drape –Small hole is covered with a sterile drape –Large hole may require that the drape be replaced Circulator responsible for removing the drape and provide another sterile drape New sterile drape is placed by the sterile team members

56 Application of Sterile Technique (continued) Hair discovered on sterile field –Remove the hair with a hemostat –Hand of the hemostat to the circulator –Cover the area with a sterile drape

57 Surgical Technology Lecture Series 2000© Power-Point®

58 Draping the Surgical Patient - Part II Procedural Steps for Draping Various Parts of the Body

59 Production Notes Author - Kevin Frey CST, MA Series Editor - Teri Junge, MEd, CSFA, CST, FAST

60 Table of Contents Slide Format Draping the Abdomen and Back Draping the Head Draping the Eye Draping the Chest and Breast Draping the Shoulder Draping the Arm and Hand Draping for a Laparoscopy Draping the Hip Draping for a Knee Arthroscopy Draping the Leg and Foot

61 Slide Format

62 The normal draping procedure (sequence) is presented Key items are accented when you see the word REMEMBER in red Based on this author’s experience and the experience of others, VARIATIONS in the draping procedure are presented at the end of some procedures and will be shown in blue

63 Draping the Abdomen and Back

64 Procedure/Sequence 4 woven towels (towel clips optional) are used to “square” off the intended incision site –Remember: Three towels with cuff folded toward you, one away Place the laparotomy sheet with fenestration evenly distributed over the area outlined by the towels –Remember: Look at the directional instructions printed on the drape to ensure proper placement

65 Procedure/Sequence (continued) Unfold the lap sheet according to manufacturers instructions and facility policy –Remember: Use the cuff of the drape to protect the hands to maintain sterility –Remember: Be certain that the arm boards are covered; may have to use an extra 1/2 sheet or towel to cover some of the arm board

66 Variations After placement of the towels, 3/4 sheets x 2 may be added –One up (toward the head) and one down (towards the feet) –Place the edge of the 3/4 sheet along the upper edge of the towel –Provides an extra thickness of draping material in the areas where instruments and sponges tend to be placed when not in use

67 Variations (continued) Instead of using woven towels for squaring off the incision, non-woven bar drapes that are provided in the back table pack will be used If the lap sheet does not have incise sheeting incorporated into the fenestration, surgeon may want an incise drape placed either first or over the 4 towels isolating the incision site

68 Draping the Head

69 Procedure/Sequence Depending on the surgical site, 3 or 4 towels are placed around the head –Towels are held in place with towel clips, sutures, or skin staples –If x-rays will be taken during surgical procedure, suture must be used and will be prepared in advance by the STSR Towel clips or staples will be visible on the X-ray and may prevent visualization of the intended structure(s)

70 Procedure/Sequence (continued) Place 3/4 sheet over the head of the OR table, below the surgical area and at the edge of the towel Use a drape sheet in which the fenestration is not as large as that found in a lap sheet, place over the surgical area and unfold

71 Variations Some neurosurgical procedures require the use of an overhead instrument table (Mayfield) –The fenestrated drape can be unfolded over the instrument table to create a continuous sterile field from the instrument table to the surgical site

72 Variations (continued) A split sheet may be used instead of the fenestrated drape sheet –The bottom part of the split or “U” area is placed around the patient’s chin or neck –The tails are extended toward the head of the OR table –The tails are draped around the patient’s head and secured with the adhesive or towel clips

73 Draping the Eye

74 Procedure/Sequence STSR prepares the head drape in advance –1/2 sheet with towel placed in the center The non-operative eye is covered with a sterile eye pad Nonsterile team member lifts the head slightly Surgeon places the head drape under the head

75 Procedure/Sequence (continued) The towel and sheet are drawn up around the side of the face and laid over the forehead at the hairline Other side is drawn up, laid over the forehead overlapping the first part and secured with a towel clip An aperture drape is placed around the eye Cover the patient’s body with a long drape

76 Procedure/Sequence (continued) Remember: If patient receives local anesthetic, the drapes must be raised off the patient’s nose and mouth –Permits free breathing –Prevents feelings of claustrophobia Remember: When draping, do not dislodge oxygen delivery or airway maintenance devices (eg nasal cannula, ET tube, etc)

77 Variations Following placement of the aperture drape, a split sheet may be placed –Tails toward the head with the split placed around the chin of the patient –STSR may use a sterile Mayo tray Place Mayo stand over patient Cover the patient and the Mayo stand with the long drape Place Mayo tray on top of drape to hold in place (instruments are already on tray)

78 Variations (continued) The surgeon may request that the aperture drape be cut in half –Surgeon places one portion near lower eyelid to aid in retraction –Places the other portion on upper eyelid to also aid in retraction

79 Draping the Chest and Breast

80 Procedure/Sequence Following the skin prep, the circulator continues to elevate the arm on operative side A 3/4 sheet or Mayo stand cover is placed over the armboard Patient’s hand is grasped with a sterile stockinette –Stockinette is unrolled to within 2-3” of the axillary region and the arm placed on the draped armboard

81 Procedure/Sequence (continued) Chest/breast region is squared off with towels –Remember: Not just the incision area is draped; the entire breast must be draped Towel laid transverse across the neck region Towel laid vertically using the sternum as the land mark Towel laid across lower border of breast Towel laid along border of axillary region Towels kept in place with towel clips

82 Procedure/Sequence (continued) Laparotomy drape or breast sheet is placed –Remember: Drape must be placed as to allow adequate exposure of the axillary region for the dissection that takes place –Remember: two 3/4 sheets may be needed to drape the other armboard and the patient’s feet in their entirety

83 Variations The arm on the operative side may be suspended from an IV pole with finger traps and then draped

84 Draping the Shoulder

85 Procedure/Sequence After the skin prep is completed, the circulator continues to elevate the arm A sterile stockinette is placed over the arm and rolled up to within 2” to 3” of the axillary region –Coban or Ace wrap may be used to keep the stockinette in place A 3/4 sheet or plastic sheet is placed under the arm if patient is supine –Do not need if patient is in lateral position

86 Procedure/Sequence (continued) Towels are used to outline surgical area and secured with towel clips A 3/4 sheet is placed transversely across the chest region –Remember: The edge of the sheet should be placed as evenly as possible along the edge of the towel that is placed laterally along the axillary region

87 Procedure/Sequence (continued) Place another 3/4 sheet that covers the neck and head; nonsterile team member will secure drape to the IV pole to keep the drape from covering the patient’s face Place a 3/4 sheet longitudinally to cover the lower portion of the patient’s body Extremity drape is placed –Patient’s arm is pulled through the fenestration

88 Variations If patient is in the lateral position, 3/4 sheet across the chest region and extremity drape are eliminated; two split sheets will be used –one up; one down After placing the extremity drape or split sheets, the surgeon may use an incise drape placed over the exposed surgical area

89 Draping the Arm and Hand

90 Procedure/Sequence After the skin prep is completed, the circulator continues to elevate the arm A Mayo stand cover or impervious drape is placed over the extremity table Surgeon places towel around lower edge of tourniquet and secures with a towel clip –Remember: STSR may fold towel in thirds lengthwise and roll to facilitate placement Sterile stockinette is placed over the hand and arm and unrolled to the covered edge of the tourniquet

91 Procedure/Sequence (continued) Extremity drape, laparotomy drape, or hand drape is placed –Arm is pulled through the fenestration –Drape may not have to be pulled all the way up to the lower edge of the tourniquet in order to limit the exposed area Remember: drape will probably not be long enough to cover all of the patient’s lower body; use a 3/4 sheet

92 Draping for a Laparoscopy

93 Procedure/Sequence Under the buttocks drape is placed –Impervious drape –Drape has cuffed area to protect the sterile gloves Two towels prepared in advance by STSR in a triangular manner –Placed over lower portion of each thigh using the inguinal crease as a guide

94 Procedure/Sequence (continued) One towel folded in half placed across the perineum, covering the anal region –Two perforating towel clips handed to surgeon by STSR –Clips attached to triangular towels to keep the third towel in place –Remember: Use caution when placing the towels, due to the limited amount of room between the legs, it is easy to contaminate the surgical gown

95 Procedure/Sequence (continued) Leg drapes placed over each leg –Leg drapes have a cuff to protect the gloved hands –Follow the directions printed on the drape showing the toe region and where to place the hands Place the laparoscopy drape –Two fenestrations; one for the perineum and one for the abdomen

96 Variations Leg coverings may be incorporated into the laparoscopy drape Some surgeons may place a fourth towel covering the pubic region when squaring off the perineum

97 Draping the Hip

98 Procedure/Sequence Patient is in the lateral position –Remember: If the leg must be manipulated during the surgical procedure, the hip and leg must be draped in such a manner as to allow the manipulation –Remember: If the procedure does not call for the leg to be manipulated, refer to the variations for draping the hip

99 Procedure/Sequence (continued) The circulator continues to elevate the leg after the skin prep is completed A large sheet, plastic or non-woven, is placed under the leg up to the crease of the buttock –The sheet is laid over the non-operative leg as a cover

100 Procedure/Sequence (continued) A roll towel, prepared by the STSR, is placed around the border of the pneumatic tourniquet –The towel is held in place with one perforating towel clip –If tourniquet not used, the towel is still placed around the thigh, approximately 3” above the surgical site

101 Procedure/Sequence (continued) The surgical site is squared off with 4 towels held in place with perforating towel clips Sterile stockinette is placed over leg –Stockinette is rolled up over the knee joint to within approximately 3” of the surgery site –Coban or Ace is wrapped around stockinette to keep it in place

102 Procedure/Sequence (continued) One 3/4 sheet is placed over the upper body of the patient –Lower edge of the sheet covers the roll towel –Nonsterile team member may use the sheet to create a temporary barrier by clipping it to the IV poles

103 Procedure/Sequence (continued) Surgeon uses two non-woven split sheets –Lower split sheet - tails are placed along the sides of the patient on each side of the iliac crest U-shaped portion of drape placed along lower edge of surgical site –Upper split sheet - tails overlap lower split sheet U-shape is placed along border of iliac crest This drape is clipped to the IV poles to create a barrier for remainder of procedure

104 Variations One split sheet may be used –Sheet is placed under the operative leg and the tails are crossed over the leg toward the patient’s head –Manipulation of leg not necessary Hip drape can be used –Surgeon may use two incise drapes to wrap the leg and cover the surgical site

105 Draping for a Knee Arthroscopy

106 Procedure/Sequence Non-operative leg –May be in a leg holder positioned laterally slightly away from the OR table, or –Foot of table is lowered; the leg is allowed to bend and lay against the table with proper padding under the knee and leg Circulator continues to elevate the leg after the skin prep is completed

107 Procedure/Sequence (continued) 3/4 sheet or impervious sheet is placed under the leg up to the bottom edge of the buttocks –Sheet covers the unaffected leg Roll towel is placed along bottom edge of tourniquet and kept in place with perforating towel clip

108 Procedure/Sequence (continued) Stockinette, preferably impervious, is placed over the leg up to the bottom edge of the roll towel Arthroscopy drape is placed over the leg –Arthroscopy drape contains a fluid pouch that may be connected to the suction to be drained –Arthroscopy drape contains numerous pockets and loops to aid in securing various equipment

109 Variations Before arthroscopy drape is placed over the leg, a 3/4 sheet may be placed over the abdomen Other drapes that can be used instead of the arthroscopy drape are the laparotomy sheet or extremity sheet

110 Draping the Leg and Foot

111 Procedure/Sequence Circulator continues to elevate the leg after the skin prep is completed 3/4 sheet or plastic sheet is placed under the leg –Sheet covers the unaffected leg Roll towel is placed around the lower edge of the tourniquet and secured with a perforating towel clip

112 Procedure/Sequence (continued) Stockinette, preferably impervious, is placed over the foot and rolled up to the middle of the calf Foot is placed through the fenestration in the extremity drape to the desired level and then unfolded to cover the patient’s body

113 Variations 3/4 sheet placed over upper part of legs before extremity drape is placed Other drapes that can be used instead of the extremity drape are the laparotomy sheet or foot drape If both feet/legs are going to be operated upon, a bilateral extremity sheet is commercially available; it contains two fenestrations


Download ppt "Surgical Technology Lecture Series 2000© Power-Point®"

Similar presentations


Ads by Google