Intraoperative Phase PDF

MODULE 2: INTRA-OPERATIVE PHASE Intra- Operative Phase Corresponds to the period in which anesthesia is administered, the operation is done and the client is transferred to the post anesthesia care unit. Aseptic Technique  A group of procedures that prevent...

MODULE 2: INTRA-OPERATIVE PHASE Intra- Operative Phase Corresponds to the period in which anesthesia is administered, the operation is done and the client is transferred to the post anesthesia care unit. Aseptic Technique  A group of procedures that prevent contamination of microorganisms through the knowledge of contain and control. Sterile Technique Methods by which contamination of an item is prevented by maintaining the sterility of an item/area involved with the procedure. Intra- Operative Phase  Practices Involving Aseptic Technique  Items in use may be sterile and unsterile.  Items are used for an individual patient only.  Items are not always used within a sterile field. The brush used in surgical scrub is not considered sterile at anytime during its use.  Contamination is contained.  Reusable items must terminally sterilized or high level disinfectant before reuse.  Items are not necessarily stored in a sterile condition. Intra- Operative Phase 1. THE STERILE TEAM WEARS STERILE ATTIRE Rationale Sterile attire prevents cross contamination between the wearer and the field. It also provides a protective barrier to strike-through contamination 2. WHEN IN DOUBT, DISCARD Rationale Unsterile instruments can serve as agents for infection when used during the surgery. The use of sterile instruments prevent nosocomial infection. 3. TABLES ARE STERILE ONLY AT TOP LEVEL It is impractical to sterilized the whole table. However, it can still be used during the operation by making the tabletop sterile. PRINCIPLES OF STERILE TECHNIQUE 4. STERILE-TO-STERILE; UNSTERILE-TO UNSTERILE Rationale Sterile persons touch only sterile items & occupy sterile spaces, while unsterile persons touch only unsterile items & occupy unsterile spaces. 5. ONCE OPENED, USE AT ONCE AND DO NOT REUSE Rationale Once the sterile solution is opened, it should be used only for the ongoing procedure. There is a great chance that the pouring edges will be contaminated when recapped. PRINCIPLES OF STERILE TECHNIQUE 6. BELOW THE TOP OF A STERILE TABLE IS UNSTERILE Rationale: There is no exact definition of the boundaries between sterile & unsterile areas. (Ex. The edges of wrappers on sterile packages & the caps on solution bottles) 7. A STERILE FIELD IS CREATED AS CLOSE AS POSSIBLE TO THE SCHEDULED TIME USE Rationale: The risk of contamination is approximately equal to the length of time in which sterile items are exposed to the environment. The longer the sterile field is exposed, the greater is the chance that it will be contaminated. PRINCIPLES OF STERILE TECHNIQUE 8. STERILE AREAS MUST BE CONSTANTLY KEPT IN SIGHT Rationale: Unintentional contamination of sterile areas must be anticipated. Watching over the sterile field ensures sterility. 8. STERILE PERSONS SHOULD MAINTAIN STERILITY Rationale: Sterile and nonsterile people are equally responsible for the maintenance of sterility of the instruments. However, because sterile persons are in direct contact with the sterile field, they possess a high level of surgical conscience for the safety of the patient. PRINCIPLES OF STERILE TECHNIQUE 10. STERILE PERSONS LIMIT CONTACT WITH STERILE AREAS Rationale It Minimizes the risk of breaching sterility. Sterile persons must allow a wide space during surgical procedure. 11. UNSTERILE PERSONS AVOID STERILE AREAS Rationale Unsterile persons should be aware at all times of what areas are sterile, unsterile, clean and contaminated and their proximity to each other. PRINCIPLES OF STERILE TECHNIQUE 12. ONCE THE STERILE PACK OR DRAPE IS DAMAGED, IT BECOMES CONTAMINATED Rationale The integrity of the sterile package or sterile drapes is destroyed by perforation, puncture or strike-through. 13. MICROORGANISM MUST BE AT MINIMUM LEVEL Rationale Though sterile technique is the ideal set up in the surgical environment, it is not absolute. Not all microorganism can be killed, but this is not the reason for not complying with strict sterile technique. PRINCIPLES OF STERILE TECHNIQUE  Preparation of Surgical Supplies  Decontamination – contaminates are removed either by hand cleaning or mechanical methods using specific solutions.  Disinfection- to used to destroy/kill/inhibit growth of microbes thru application of antiseptic solution. ❑2% activated aqueous glutaraldehyde soln (Cidex)- is the agent often employed for liquid disinfection ❑Must be immersed for 10hrs –sterilization ❑Must be thoroughly rinsed in sterile distilled water  Sterilization- rendering an item totally free of all living microorganisms including spores.  ORGANIZATION OF AREAS IN THE OPERATING ROOM The efficiency of the operating room depends much upon its physical organization and the organization of its personnel. The universal problem of environmental control to prevent wound infection exerts a great influence on the design of the operating room(OR) suite The design and size of the surgical suite is determined by the functions and needs of the institution and community it serves. The efficiency of the operating room depends much upon its physical organization and the organization of its personnel. Clean and contaminated areas should be well differentiated  Areas in the Operating Room A. Unrestricted Area Street cloths are permitted This area provides an entrance and exit from the suite for personnel, equipment, and patients. It serves as an outside-to-inside access area to communication with personnel and patients families outside the suite. Admission area, PACU, Dressing rooms, Surgeon lounge. B. Transition Zone Can enter in street clothing and exit into the semi- restricted area. Lockers serve as a transition zone between the outside and inside of a surgical suite. B. Semi- restricted Area Traffic is limited to properly attired (dressed) personnel Body and head coverings are required ( scrub suite, cap and masks) The patient may be transferred to a clean inside stretcher on entry to this area The patient’s hair must be covered This area includes peripheral support areas and access corridors to the operating rooms. C. Restricted Area surgical attire Sterile procedures are carried out in this area Operating Table POSITIONING EQUIPMENT POSITIONING EQUIPMENT  POSITIONING EQUIPMENT Anesthesia Screen  POSITIONING EQUIPMENT Body rests and braces-support maintain a lateral position  POSITIONING EQUIPMENT Adhesive Tape for anal procedure  POSITIONING EQUIPMENT Stirrups POSITIONING EQUIPMENT Headrests  POSITIONING EQUIPMENT Leg Prepper Clamps and Sockets Goals of Proper Positioning To maintain patient’s airway and avoid constriction or pressure on the chest cavity To maintain circulation To prevent nerve damage To provide adequate exposure of the operative site To provide comfort and safety to the patient  Factors to consider when positioning a client 1. Site of operation 2. Age and size of the patient 3. Type of anesthetic used » regional – position patient first » general – position patient last 4. Pain normally experienced by the patient upon movement 5. Must not hinder respiration and circulation General Considerations in Positioning a Client 1. OR bed is securely locked 2. The anesthesia provider guards the HEAD 3. Operative site must be adequately exposed. 4. Avoid undue exposure. 5. Strap the person to prevent falls. 6. Maintain adequate respiratory function.  General Considerations in Positioning a Client 7. The vascular supply should not be obstructed by an awkward position or undue pressure on a part. 8. There should be no interference with the patient’s respiration as a result of the pressure of the arms on the chest or constriction of the neck or chest caused by the gown.  General Considerations in Positioning a Client 9. Nerves must be protected from undue pressure. 10. Precautions for patient safety must be observed, particularly with thin, elderly, or obese patients. 11. The patient needs gentle restraint before induction, in case of excitement. 12. Maintain good body alignment. 13. Do not allow the persons extremity dangle over the sides of the table 14. Avoid excessive muscle strain.  Common Surgical Positions Dorsal Recumbent- for abdominal surgery such as bowel resection; chest surgery such as mastectomy Trendelenburg- for abdominal/ pelvic surgery as the intestines are displaced into the upper abdomen Dorsal lithotomy- for vaginal and rectal surgery Prone- for spinal or back surgery Kraske/ jack knife- for hemorrhoids or proctologic Reverse trendelenburg- for gall bladder or biliary tract procedure Neurosurgical sitting- for intra cranial procedures  SEQUENCE IN APPLYING PROTECTIVE GEAR uSe Camey hand and body soap in moisturizing your hand… Ca- cap M- mask Ey- eye goggles Hand- surgical scrubbing Body- sterile gown Hand – sterile gloves Sequence in Removing Protective Gear Gloves Mask Gown Eye goggles cap  SURGICAL SAFETY CHECKLIST (FIRST EDITION) Before induction of anaesthesia DOES PATIENT HAVE A: SIGN IN KNOWN ALLERGY? NO PATIENT HAS CONFIRMED YES IDENTITY DIFFICULT AIRWAY/ASPIRATION RISK? SITE NO PROCEDURE YES, AND EQUIPMENT/ASSISTANCE CONSENT AVAILABLE SITE MARKED/NOT APPLICABLE RISK OF >500ML BLOOD LOSS ANAESTHESIA SAFETY CHECK COMPLETED (7ML/KG IN CHILDREN)? PULSE OXIMETER ON PATIENT AND NO YES, AND ADEQUATE INTRAVENOUS FUNCTIONING ACCESS AND FLUIDS PLANNED  SURGICAL SAFETY CHECKLIST (FIRST EDITION) Before skin incision ANAESTHESIA TEAM REVIEWS: ARE THERE TIME OUT ANY PATIENT-SPECIFIC CONCERNS? NURSING TEAM REVIEWS: HAS STERILITY CONFIRM ALL TEAM MEMBERS HAVE (INCLUDING INDICATOR RESULTS) BEEN INTRODUCED THEMSELVES BY NAME AND CONFIRMED? ARE THERE EQUIPMENT ROLE ISSUES OR ANY CONCERNS? SURGEON, ANAESTHESIA PROFESSIONAL HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN AND NURSE VERBALLY CONFIRM WITHIN THE LAST 60 MINUTES? PATIENT YES SITE NOT APPLICABLE PROCEDURE IS ESSENTIAL IMAGING DISPLAYED? ANTICIPATED CRITICAL EVENTS YES SURGEON REVIEWS: WHAT ARE THE NOT APPLICABLE CRITICAL OR UNEXPECTED STEPS, OPERATIVE DURATION, ANTICIPATED BLOOD LOSS?  SURGICAL SAFETY CHECKLIST (FIRST EDITION) Before patient leaves operating room HOW THE SPECIMEN IS LABELLED (INCLUDING PATIENT NAME) SIGN OUT WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED NURSE VERBALLY CONFIRMS WITH THE SURGEON, ANAESTHESIA PROFESSIONAL TEAM: AND NURSE REVIEW THE KEY CONCERNS THE NAME OF THE PROCEDURE RECORDED FOR RECOVERY AND MANAGEMENT THAT INSTRUMENT, SPONGE AND NEEDLE OF THIS PATIENT COUNTS ARE CORRECT (OR NOT APPLICABLE) The surgical Team SURGICAL TEAM  Surgical Team A. Sterile Team: Surgeons: “Captain of the ship”; perioperative diagnosis ; performs the surgical procedure ; specific site for operation; surgical position First Assistant: Maintains visibility of surgical site; skin preparation; positioning; Handles tissues and instruments; the operating techniques Second Assistant: if needed Scrub Nurses: Roles before, during & after. Others: Student nurses, surgical intern, nurse trainee. B. Non-sterile Team Anesthesia provider Circulating nurse Nurse anesthetist Others: Nursing auxillary,biomedical technician, la. Or x-ray personnel Scrub Nurse Before the Operation With the help of the circulating nurse: 1. identifies the client. However, the nurse can also ask for the following; ❖ name of the surgeon, contemplated operation, signed consent, compliance to nothing per orem (NPO), and the removal of any prosthesis, jewelry, nail polish, and lipstick. Any inconsistentency should be corrected or validated. Check the following documents that are necessary for the operation; clearance for surgery, blood transfusion forms, and diagnostic results. Scrub Nurse 2. Validates with the surgeon his/her preference of sutures and surgical instruments/supplies. 3. Prepares protective attire such as eyegear or apron. 4. Accounts for all sponges, sharps, and instruments before and after the procedure. 5. Checks and labels the drugs and syringes that will be used in the operation. Scrub Nurse During the Operation 1. Prepares and arranges sterile instruments and supplies needed during the surgery. 2. Establishes and maintains the integrity, safety, and efficiency of the sterile field throughout the procedure. 3. Anticipates plans for, and responds to the needs of the surgeon and other team members. 4. Informs the surgeon of the drug used during the surgery. 5. If two scrub nurses are necessary, one may prepare the supplies that will be used during the operation while the other passes instruments and supplies to the surgeon. Circulating Nurse Before the Operation 1. With the help of the scrub nurse, identifies the client by checking the following data and requirements; name, age, name of attending surgeon, contemplated operation, date and time of surgery, signed consent, compliance to NPO, and the presence of prosthesis, jewelry, nail polish, and lipstick. Any inconsistency should be corrected, validated, or reported to the surgeon. 2. Accompanies the client when he/she is transferred to the OR. 3. Identifies and reports any potential danger in the environment or stressful situation involving the client. 4. Keeps personal items of the client, such as religious articles, hearing aid, eyeglasses, dentures, jewelry, and the like if the client is alone; otherwise, endorses these items to the relatives. Circulating Nurse 5. With the scrub nurse, sets up the operating room and positions the equipment appropriately: a. Ensures that the OR table is draped, and lifting linen or board, armboard covers, safety straps, headcover and leggings for the client is brought to the OR. b. Ensures that OR lights and negatoscope are functioning. 6. Records all the sponges, sharps, and instruments to be used during the operation. 7. Ensures the safety and comfort of the client on the way to and from the OR. Circulating Nurse a. Checks for the effectiveness and safety of the equipment, e.g., monitoring equipment, electrocautery machine. b. Ensures that the OR table is locked. c. Applies necessary straps/restraints on the client and places him/her in a comfortable position. d. Provides rolls or pads necessary to avoid pressure on the client. e. Checks if the stretcher to be used is functioning well. Circulating Nurse 8. Assists the anesthesiologist in inducting anesthesia. 9. Helps the first assistant or nursing assistant in placing the client in the desired position. 10. Prepares equipment needed for skin preparation. 11. Performs skin preparation if the policy of the institution requires it. 12. Directs all activities of all learners, e.g., orientees and students, in the OR. 13. Applies electrosurgical pads as needed. Circulating Nurse During the Operation 1. Provides promptly any supply, instruments and equipment as needed. 2. Provides assistance to any member of the OR team. 3. Acts as a communication link between events, and between team members in the sterile field and persons who are not in the OR but are concerned with the outcome of the surgical procedure. 4. Directs or supervises the scrub nurse when necessary. 5. Requests for blood products when needed. 6. Ensures that everyone complies with the principle of sterile Tecnique. 7. Ensures patient safety throughout the procedure. Circulating Nurse After the Operation 1. Determines the outcome of the final counts as correct or incorrect, including the need for a radiograph to look for a lost item. 2. Writes an incident report on counts that remain unresolved. 3. Records any medications the surgeon used in the surgical site, such as antibiotics on local anesthesia. 4. Makes the pathology request and conducts proper documentation and labeling of specimens to be sent to the laboratory for safekeeping. 5. Gives health teachings to the client or his/her relatives. Circulating Nurse 6. Assists in transferring the patient from the OR table to the PACU. 7. In some institutions, monitors the health situation of the client in the PACU. 8. Helps in the after care of the OR suite. Anesthesia Anesthesia - Is an induced state of partial or total loss of sensation, occurring with or without loss of consciousness. To permit the performance of surgery or other painful procedures. Purposes of Anesthesia To produce muscle relaxation To produce analgesia To produce artificial sleep or to cause loss of consciousness To block transmission of nerve impulses To suppress reflexes  Common Anesthetic Technique Minimal Sedation  Patient remains conscious  Protective reflexes remain intact  Can respond to verbal commands Moderate Sedation -state of depressed level of consciousness that does not impair patient’s ability to maintain a patent airway and to respond to physical stimulation and verbal commands. Deep Sedation - Drug induced state during which the patient cant be easily aroused but can respond purposefully after repeated stimulation  TYPES OF ANESTHESIA A. GENERAL ANESTHESIA 1. Intravenous 2. Inhalation 3. Muscle relaxants B. Regional Anesthesia ( Blocks pain stimulus at it’s origin) 1. Local Anesthesia a. Topical Application b. Local Infiltration  TYPES OF ANESTHESIA Regional Anesthesia ( Blocks pain stimulus along its afferent neurons) 1. Field Block 2. Peripheral Nerve Block Regional Anesthesia ( Blocks pain stimulus along the Spinal Cord) 1. Spinal Anesthesia 2. Epidural Anesthesia 3. Caudal Anesthesia  GENERAL ANESTHESIA Is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system General anesthetics are agents that block the pain stimulus at the cortex where interpretation of pain takes place Produces a state of the ff: Analgesia Amnesia Unconsciousness characterized by loss of reflexes and muscle tone TechniquesGeneral Anesthesia in Administering Anesthesia: 1. Inhalation – via mask or endotracheal tube 2. Intravenous Injection (GIV) Stages of General anesthesia Stage 1: Onset or Induction or Beginning anesthesia Description 1. Begins with induction and ends with loss of consciousness 2. Client feels drowsy and dizzy, has a reduced sensation to pain and is amnesic 3. Hearing is exaggerated Stage 2 (Excitement, delirium)- extends from the time of loss of consciousness to the time of loss of lid reflex. Description Characterized by struggling, shouting, laughing, singing or crying--- maybe prevented if anesthetic is administered smoothly and quickly Client may have irregular breathing, increased muscle tone, and involuntary movement of the extremities during this stage Laryngospasm or vomiting may occur Pupils becomes dilated but contract if exposed to light Stage 3 ( Operative anesthesia, surgical anesthesia)- This stage extends from the loss of lid reflex to the loss of most reflexes and depression of vital organs 1. Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital function 2. Pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed 3. The jaw is relaxed, and there is quite, regular breathing. 4. The client cannot hear 5. Sensations are lost Stage 4 (Danger)- This stage is reached when too much anesthesia has been administered Description 1. Begins with depression of vital function and ends with respiratory failure, cardiac arrest, and possible death 2. Respiratory muscles are paralyzed; apnea occurs 3. Pupils are fixed and dilated.  Regional Anesthesia A. SPINAL - also called spinal analgesia , spinal block or sub- arachnoid block (SAB), is a form of regional anaesthesia involving injection of a local anaesthetic into the subarachnoid space, generally through a fine needle, usually 9 cm long (3.5 inches). Produces a nerve block in the subarachnoid space by introducing a local anesthetic at the lumbar level, usually between L4 and L5. Autonomic nerve fibers are the first affected and the last to recover B. Epidural- achieved by inducing an anesthetic agent into the epidural space. C. Caudal Anesthesia- produced by injecting local anesthesia into the caudal or sacral canal Complications of Spinal and Epidural Anesthesia 1. Spinal Headache 2. Ruptured nucleus pulposus 3. Respiratory paralysis 4. Hypotension  LOCAL ANESTHESIA Injection of a solution containing anesthetic into the tissues at the planned incision site. Briefly disrupts sensory nerve impulse transmission form a specific body area or region. Types of Local Anesthesia 1. Topical anesthesia – topical agents are applied directly to the area of skin or mucous membrane surfaced to be anesthetized 2. Local infiltration – is the injection of an anesthetic agent directly into the surrounding nerve of the tissue around an incision, wound, or lesion. Local Conduction Blocks Brachial plexus block- produces anesthesia of the arm Para vertebral anesthesia- produces anesthesia of the nerves supplying the chest, abdominal wall and extremities Transsacral (caudal) block – produces anesthesia of the perineum and occasionally the lower abdomen SKIN PREPARATION The removal of as many bacteria as possible from the patient’s skin through shaving, mechanical, washing, and chemical disinfection Nursing Consideration 1. Determine the area to be shaved and its extent; know the operation to be done; the organ involved and its location and the proposed incision.  Nursing Consideration 2. Practice modesty and provide privacy 3. Ask the patient’s permission in cutting the eyelashes and hair. Nursing Consideration 4. Examine the area to be shaved for any signs of irritation or any abnormal condition. 5. Do not cut the patient’s skin. 6. In abdominal operations, pay particular attention to the umbilicus. Nursing Consideration 6. Shave the operative site before the operation Discard soiled sponges in your kidney basin. 7. In shaving, follow the direction of the growth of the hair while free hand exerts an opposite force by pulling the skin to the opposite direction. If a wound is present on the area to be shaved, start from the clean area to the dirty area. Surgical incision Abdominal Incisions Incisions for Ceasarian Section Layers of the Abdomen Sutures and needles SURGICAL SUTURES CLASSIFICATION: 1. Absorbable 2. Non-absorbable TYPES: 1. Atraumatic / Non-traumatic 2. Traumatic  SURGICAL SUTURES Absorbable sutures Non-Absorbable sutures Chromic Gut ----Brown Silk ---------------- Black Plain Gut -------- Yellow Prolene -----------Royal Blue Vicryl ------------ Purple Nylon -------------Green Cotton ------------white Different Types Of Needles Surgical Scrub Surgical scrub – is the process of removing as many microorganisms as possible from the hands and arms through mechanical & chemical antisepsis. Surgical scrubbing of hands and arms are done just before gowning and gloving for each surgical procedure. Materials Preparations Prior to Scrub 1. Skin must be free from breaks or cuts. 2. No jewelry. 3. Hair covered by headgear. 4. Adjust mask to fit snugly over nose & mouth. 5. Adjust eyeglasses. 6. Adjust water temperature. Length of Scrub Accdg. to Phillips (2004) ✓ a study revealed that microorganism decreases by 50% with each six minute scrub. ✓A vigorous 5 minute w/ a reliable agent is effective as a 10 minute scrub. Methods of Surgical Scrub: 1. Five-Minute Scrub – by anatomical area 2. Alcohol-based Surgical Hand Scrub Product Drying of Hands and Arms ✓Done right after scrubbing. This prevents strike-through contamination of the gown by microorganism from skin and scrub attire. ✓The gown package of must contained one sterile towel Gowning and Gloving Sterile gown & gloves are worn to prevent the skin from contaminating & to create a barrier between sterile & unsterile areas. Gloving A. Gloving by Closed-Glove Technique Draping Draping 1. Self-adhering plastic sheeting 2. Non-woven fabric drapes 3. Woven Textile fabrics TYPES OF DRAPES The Basic Surgical Instruments Cutting and Dissecting  Grasping and Holding  Retracting and Exposing  Clamping and Occluding  Miscellaneous Thank you!