Surgical Techniques PDF

Surgical Techniques Surgical Techniques Section B: Patient Care Module 3-B Positioning and Prepping  Section B: Patient Care Module 3-B: Positioning and Prepping Module Objective After completing this module, you should be able to...

Surgical Techniques Surgical Techniques Section B: Patient Care Module 3-B Positioning and Prepping  Section B: Patient Care Module 3-B: Positioning and Prepping Module Objective After completing this module, you should be able to identify different surgical positions and their modifications and be able to catheterize and position and prep patients for various surgeries.  Objective 1 Terms and Definitions Air embolism Plantar Antimicrobial Pronate Brachial plexus Shearing Denature Supinate Dermis Thrombosis Edema Viscera Flank Hypothermia Hypovolemic shock Peroneal  Objective 2 Characteristics of Urinary Catheterization a. Indications Control bleeding after surgical procedures, such as TURP or TURB. Decompress or empty the bladder before a surgical procedure to prevent injury to the organ. Control incontinence. Keep urine from contact with the surgical wound which could result in a postoperative wound infection. Monitor output on patients who are having a major surgical procedure, such as a coronary artery bypass graft or craniotomy.  Objective 2 (cont.) Characteristics of Urinary Catheterization Prevent trauma to the bladder during the surgical procedure. Promote healing of surgical incision. Provide better visualization of the operative site to prevent injury to the genitourinary structures. Collect specimen for laboratory analysis. Prevent or relieve urine retention. b. Considerations Consider the duration or length of time that the catheter is needed. Provide privacy to protect the patient’s modesty when inserting the catheter.  Objective 2 (cont.) Characteristics of Urinary Catheterization b. Considerations (cont.) Check physician’s order or preference card before catheterization. Position patient and adjust lighting before beginning procedure. Select the appropriate size catheter for the size of the patient. Sterile technique must be maintained during the catheterization process to prevent microorganisms from entering the urinary tract.  Objective 2 (cont.) Characteristics of Urinary Catheterization c. Supplies (Catheter insertion kit/tray) Sterile gloves Sterile drapes Cleansing agent Cotton swabs Disposable forceps 10 cc syringe with sterile water to inflate the balloon Lubricant (water-based jelly) Foley catheter (Standard size is 16 Fr.) Collection bag and tubing  Objective 2 (cont.) Characteristics of Urinary Catheterization d. Procedure Washing your hands using the accepted technique prior to procedure is critical. Female catheterization: Insertion of the catheter is facilitated by having the patient lie down on her back with the buttocks at the edge of the examination table. Adequate exposure of the urethra is obtained by elevating and supporting the legs by stirrups or placing them in a frog-legged position. Finally, the labia are separated to expose the urethra. Male catheterization: A catheter is placed while lying down or in the frog-legged position. If there is a foreskin, it is retracted to its maximal limit.  Objective 2 (cont.) Characteristics of Urinary Catheterization e. Monitoring urine output Measuring the urinary output is important to ensure the kidneys are functioning normally. Fluid balance is the balance of the input and output of fluids in the body to allow metabolic processes to function. Assessment of fluid balance involves three elements: clinical assessment, body weight and urine output; and includes review of fluid balance charts and review of blood chemistry. Fluid intake and output measurements are recorded on a graph.  Objective 2 (cont.) Characteristics of Urinary Catheterization f. Safety and patient risks Care must be taken when positioning the female patient to prevent injury to nerves and the hip joint when placing the patient in the frog-legged position. Injury to the bladder or urethra can occur from rough or incorrect insertion of the catheter or from narrowing of the urethra caused by scar tissue or in a male patient from enlargement of the prostate gland. Urinary tract infections can occur when microorganisms enter into the urinary tract when the catheter is being placed or while the catheter remains in the bladder.  Objective 3 Purposes for Properly Positioning the Surgical Patient a. Provides optimum exposure of and access to the operative site b. Maintains circulation and respiratory function c. Provides for good body alignment d. Prevents skin or neuromuscular complications e. Allows access for the administration of anesthesia agents and intravenous drugs f. Provides optimum patient comfort and safety  Objective 4 Patient Positioning Guidelines a. Position selection The patient position is determined by the surgeon in consultation with the anesthesia provider with the following considerations. – Anesthesia types – Surgeon preference – Patient consideration – Physiological and anatomical considerations – Patient safety – Procedure/incision site  Objective 4 (cont.) Patient Positioning Guidelines b. Positioning responsibilities The circulator is primarily responsible for positioning the patient with assistance of the anesthesia provider and the surgeon. The surgeon assumes the responsibility for complex positions and for protecting unsplinted fractures during positioning. c. Timing The proper time to position a patient depends on the type of surgery, age and size of the patient, type of anesthesia, and whether the patient is experiencing pain with movement.  Objective 4 (cont.) Patient Positioning Guidelines For the supine position, the patient is usually anesthetized after the patient is positioned. The anesthetized patient is not moved until the anesthesia provider gives permission. d. Moving the patient into position Treat each patient as an individual, adjusting positioning to patient’s size, age, and physical state. Pay particular attention to any special needs. Carefully and slowly position anesthetized patients to allow the circulatory system time to adjust. Prevent pressure on nerves, blood vessels, skin, and bony prominences using pillows and other padding. Objective 4 (cont.) Patient Positioning Guidelines Avoid obstructing or dislodging intravenous lines and catheters. Avoid excessive pressure on the chest to prevent impairment of respiratory system. Avoid crossing the ankles and legs, which causes pressure on blood vessels and nerves and impairs circulation. Minimize undue body exposure to prevent hypothermia and to preserve patient dignity. Adjust the operating room table so that no body part extends past an edge. Objective 4 (cont.) Patient Positioning Guidelines Avoid hyperextension of the head, neck, and arms when using armboards to prevent strain or injury to the cervical or brachial plexus. Figure 1 Position palms up for supine positions to prevent pressure on the ulnar nerve. Radial, median, or ulnar nerve damage can occur if support to the elbow region is insufficient. Figure 2 Be gentle and pay close attention to limited range of motion when moving joints to avoid damage and pain. Ensure stirrups are adequately padded and properly placed. Failure to do so can cause pressure on the peroneal nerve, resulting in foot drop if damage is severe. Figure 3 Objective 4 (cont.) Patient Positioning Guidelines Have two people simultaneously raise legs when placing in stirrups to avoid dislocation of the hips. Simultaneously adjust stirrup height according to the length of the patient’s legs, then elevate to an equal height. After surgery, bring legs together and simultaneously lower very slowly to avoid a sudden drop in the blood pressure.  Objective 5 Basic Surgical Positions and Their Variations a. Supine variants Basic supine (dorsal recumbent)—Commonly used for procedures on the anterior surface of the body. – Most commonly used surgical position – Patient lies flat on back with face upward – Position the patient’s head on a small pillow or cushion to support good cervical alignment and to prevent strain on neck structures. – Place arms at patient’s sides, pronate palms and secure with arm sheet tucked under mattress. If an armboard is used, place arms with palms supinated on a padded armboard with the pad level equal to the operating table. – Position the armboard at less than a 90º angle to prevent stretching and injury to the brachial plexus. Objective 5 (cont.) Basic Surgical Positions and Their Variations Trendelenburg—Commonly used for lower abdominal and pelvic procedures, since it moves the abdominal viscera away from the pelvic area – This position allows for visualization of lower abdominal and pelvic organs. – Also utilized to improve circulation to the cerebral cortex when a patient is in hypovolemic shock. – The patient is in a supine position with knees over the break in the operating table. Lower the upper torso to a 45º angle. – Flex the knees by lowering the leg section of the operating table, which prevents pressure on the peroneal nerve and veins of the legs. – Place a safety strap across the patient’s thigh 2″ above the knees. Objective 5 (cont.) Basic Surgical Positions and Their Variations Trendelenburg (cont.) – Use shoulder braces to prevent the patient from sliding toward the head of the table and secure patient’s arms along each side of the body. – It is important to limit the use of this position to as short of time as possible. – Expect a drop in blood pressure if the return transition to supine is not slow and smooth. – Injury through shearing is a significant risk. – Areas of potential concern include circulatory and intracranial pressure, as well as respiratory congestion.. Figure 5 Objective 5 (cont.) Basic Surgical Positions and Their Variations Reverse Trendelenburg —Used to access head, neck, shoulders and upper abdominal cavity by facilitating gravitational pull of the viscera away from the diaphragm – Commonly used for procedures involving the head, neck, thyroid, and some rhinolaryngology procedures such as the nose. – Position the patient in a supine position with the head elevated and the foot section tilted toward the floor. – Routinely tuck arms to the side of the body, allowing closer access to the surgical site. – Use padded footboards to prevent the patient from sliding towards the tilt. – Place the safety strap across the patient’s thigh 2″ above knee. – Use small pillows or shoulder rolls to elevate and hyperextend the operative site. Objective 5 (cont.) Basic Surgical Positions and Their Variations Fowler’s (sitting) and Semi-Fowler (beach chair)— Commonly used for procedures involving the shoulder, face, breast, and nasopharyngeal areas – Position the patient in a supine position with the knees over the lower break in the table. – Lower the foot section of the operating table and flex the knee section. Flex the body section to a 45º or a 90º angle for a chair- like sitting position. – Place the patient’s arms on a lap pillow or armboards parallel to the operating table. – Place the safety strap across the patient’s thigh 2″ above the knee. – This position increases the risk of blood pooling in the legs and lower torso, which may result in venous thrombosis. Objective 5 (cont.) Basic Surgical Positions and Their Variations – Additional pressure is placed on the posterior pelvic girdle and coccyx, with potential impact on the sciatic nerve. – The risks of an air embolism may occur with the sitting position. Figure 7 Fracture table position—Used for hip and closed femoral nailing procedures – This position requires that the patient be anesthetized while on a transport stretcher. – During transfer to the fracture table, manual traction must be placed on the patient’s fractured leg, preferably by the surgeon. – Use the supine position on the fracture table and stabilize the pelvis against a padded center perineal post. – Place the affected extremity in traction by setting the foot in a well- padded, boot-like apparatus. Objective 5 (cont.) Basic Surgical Positions and Their Variations – Remove the lower section of the mattress and lower the leg section of the table to a 90º angle. – Secure the arms. – Various types of stirrups are available for the lithotomy position. – Check patient’s legs frequently for skin color, pulses and edema, since damage to skin, nerves, and circulatory structures can occur with this position. – Upon completion of the procedure, simultaneously remove patient’s legs from the stirrups and slowly lower to allow for gradual return of blood to the extremities. – Place the safety strap on the patient’s thigh prior to the emergence of anesthesia. Figure 9  Objective 5 (cont.) Basic Surgical Positions and Their Variations b. Prone variants Basic prone—Provides access to surgical sites on the posterior surface of the body – This position requires that the patient be anesthetized in a supine position while on a transport stretcher. – Care must be taken when turning the patient to prevent dislodging the endotracheal tubes, intravenous lines and monitoring devices. – A laminectomy frame, chest rolls, or bolsters placed lengthwise from the clavicles to the iliac crest are used to raise the chest and abdomen to permit the diaphragm to move freely facilitating respirations. – Secure arms at body sides or place on armboards. Objective 5 (cont.) Basic Surgical Positions and Their Variations – Check male genitalia and female breasts after final positioning to ensure they are free from pressure. – Pad the elbow and forearms to prevent pressure on the ulnar nerve. – Turn the head to one side and position on a small pillow or concave head headrest to prevent pressure on the face, eyes, and ears. – Place a foam cushion or a pillow under the ankles to support ankles and feet, prevent pressure on toes and aid in venous return. – Secure the patient by placing safety strap across the thigh. – Both circulatory and respiratory mechanisms may slow. Figure 10 Objective 5 (cont.) Basic Surgical Positions and Their Variations Kraske (jackknife)—Used for hemorrhoidectomy and pilonidal sinus procedures. – This position requires that the patient be anesthetized in a supine position while on a transport stretcher. – Position hips over center break in operating table. – Flex table at center break with head and foot section tilted downward to form an approximate 90º angle. – Position and support the patient’s head, chest, arms, and feet in the standard prone position. – During procedures on the rectal area, separate and secure the buttocks by attaching wide strips of adhesive tape to the undersurface of the operating table. Figure 11 Objective 5 (cont.) Basic Surgical Positions and Their Variations Knee-chest—Utilized primarily for sigmoidoscopies and some lumbar laminectomies – This position is a modification of the jackknife position. – Flex operating table at center break. Have the patient kneel on the lower section with knees flexed at right angles. Tilt the table towards the head so that hips and posterior pelvic area are exposed at the highest point. – Position and support the patient’s head, chest, arms, and feet in the standard prone position.  Objective 5 (cont.) Basic Surgical Positions and Their Variations c. Lateral variants Lateral, lateral recumbent, lateral decubitus, or Sim’s position—Provides access to areas on the side of the body such as the upper chest, kidneys and hips – This position requires that the patient be anesthetized in a supine position then turned to the unaffected side. – After induction of anesthesia, ensure no less than four people assist in moving the patient to the operating room table to provide patient safety. – For procedures involving the left side of the body, the patient is lying on right side. For procedures involving the right side of the body, the patient is lying on the left side. – Flex the lower leg to stabilize the position and slightly flex or keep the upper leg straight. Place a pillow horizontally between the legs. Objective 5 (cont.) Basic Surgical Positions and Their Variations – Pad the lateral aspect of the lower leg to prevent pressure of the peroneal nerve. – Position the torso using sandbag, pillows, blanket rolls, or specialized surgical positioning systems. – Secure the patient on the table with a safety strap or 3″ wide tape placed over the hip or knee areas. – Place the arms on a padded double armboard, padded mayo, or on pillows with the upper arm slightly flexed and the lower arm positioned with the palm up. – Place a small roll or bolster under the axilla to facilitate chest expansion, prevent pressure and to protect the nerves and vessels in the brachial plexus area. Lateral chest—Allows access to the upper chest – Modifications in position include raising the arm above the head and support for the other arm on a pillow or raised armboard. Figure 12 Objective 5 (cont.) Basic Surgical Positions and Their Variations Lateral kidney—Allows access to the retroperitoneal area by providing gravitational force from the head and torso, which is opposed by the lower extremities – This position is commonly used for procedures on the kidney and distal ureters. – After induction of anesthesia, move the patient to the operating room table and position with the flank region over the kidney elevator. Raise the kidney elevator to the level of the iliac crest and flex the operating table to lower the head and foot section. – Positioning of the head, arms, and lower extremities is very similar to the lateral position. – Place the safety strap or 3″ wide tape over the hips and knee to secure and provide safety for the patient. – Excessive pressure, caused by the flexion of the table, may result in damage to the skin and underlying tissue. Figure 13  Objective 6 Equipment and Supplies Used in Positioning a. Operating room table Primary features – May be manual or remote-controlled – Versatile and adaptable to a number of diverse positions for all surgical specialties – Surface is divided into three sections, split by joints or “breaks.” – Head – Body – Leg sections Figure 14 Base controls – Trendelenburg control—Provides tilting of the table to lower the head for Trendelenburg position or to raise the head for reverse Trendelenburg position Objective 6 (cont.) Equipment and Supplies Used in Positioning – Posture control—Governs all four positioning mechanisms – Flex (and reflex) positioning mechanism—Allows back and hip sections to move downward (for flex) or upward (for reflex) – Foot positioning mechanism—May be lowered to any angle or fully retracted, but cannot be raised above a natural position – Side positioning mechanism—Allows lateral tilting to left or right – Back positioning mechanism—Allows head and back section elevation or lowering to table limitations – Power pedal(s) – Remote control (not available for manual version) Figure 15 Figure 16 Objective 6 (cont.) Equipment and Supplies Used in Positioning Procedure-specific attachments – Anesthesia screen—A metal bar attached to the head section of the operating table to hold drapes off the patient’s face, and is used to separate the non-sterile area from the sterile field Figure 17 – Armboard—An essential positioning apparatus used for supporting the arms when giving intravenous fluids, when the site of the operation is the arm or hand, when the arm would be in the way of the operative area, and for a very obese patient when there is no space on the table beside the patient Figure 18 – Kneeholder—Used to secure the knee, most often for knee surgery Figure 19 – Drawsheet (patient lifter or arm holder)—A double layer of a heavy fabric placed horizontally across the middle of a clean sheet on the operating table Objective 6 (cont.) Equipment and Supplies Used in Positioning – Hand table or upper extremity table—Used when performing surgery on the hand or arm; surgeon commonly sits Figure 20 – Footboard or table extension—Used to extend length of table; may be placed at head or foot end of table Figure 21 – Horseshoe headrest—A padded horseshoe-shaped device that provides a cushion but rigid support for the patient’s head with cushion support running parallel to the sides of the patient’s face or the back of his or her head Figure 22 – Kidney rest—A concave metal attachment that is attached on the body elevator of the operating table used to stabilize the body in the lateral kidney position Figure 23 – Safety strap (thigh strap)—Used to secure the patient during all inductions and most positions except the lithotomy position; placed at approximately mid-thigh level; should remain secure but not tight Figure 24 Objective 6 (cont.) Equipment and Supplies Used in Positioning – Shoulder braces—Used to prevent the patient from slipping when the head of the operating table is tilted down, such as in the Trendelenburg position Figure 25 – Stirrups—Raise and support the legs in lithotomy position. The most common types are the boot-type, candy cane and knee crutch stirrups. – Boot-type stirrups—Support the foot and the calf, distribute pressure more evenly, and reduce the risk of extreme localized pressure on areas of the foot and leg. Figure 26 – Candy cane—Candy cane-shaped bars with straps that wrap around the ankles and the plantar surface of the foot. Figure 27 – Knee crutch—The weight of the leg rests solely on the knee support. Figure 28 – Wilson Frame—An adjustable arched spinal frame used when the patient is placed in the prone position Figure 29  Objective 6 (cont.) Equipment and Supplies Used in Positioning b. Surgical vacuum positioning system—Frequently used for the lateral position Figure 30 This system contains soft pads filled with tiny plastic beads that are placed under and around the body part to be supported. A vacuum is created inside the pad by attaching suction to withdraw air. This allows the pad to become firm and mold to the patient’s body.  Objective 6 (cont.) Equipment and Supplies Used in Positioning c. Pressure–minimizing mattress—Used during lengthy surgical procedures to minimize pressure on nerves, blood vessels and bony prominences Circulating-water thermal mattress Dry polymer pad Foam rubber mattress Gel pad Positive-pressure mattress  Objective 6 (cont.) Equipment and Supplies Used in Positioning d. Accessories Bolsters or “chest rolls”—Commercially manufactured or created using a solid roll of blankets and placed under each side of the chest to facilitate respirations or to elevate the chest in the prone position Donuts—Ring-shaped pads filled with foam or silicone gel to position and protect pressure points on the head, ears, knees, and elbows Figure 31 Gel pads —Filled with silicone or polymer gel to reduce shearing and pressure on skin and bony prominences Pillows, pads, and beanbags—Various sizes and shapes are used frequently to support, immobilize and protect body parts during positioning.  Objective 6 (cont.) Equipment and Supplies Used in Positioning e. Complementary supplies Sequential compression device—Sleeves wrap around the patient’s extremity and connect to a compressor that applies pressure to the extremity to prevent venous stasis, thereby reducing the risk of venous thrombosis Thermal control unit—Delivers warm air into a disposable blanket which covers the non-operative area Figure 32 “Bair Hugger”  Objective 7 Purposes of a Surgical Skin Prep a. To render the operative site as free as possible from transient and resident microorganisms, skin oil, and gross dirt and debris b. To reduce the risk of postoperative wound infections  Objective 8 Patient Preparation for a Surgical Procedure a. Bathing—Mechanical cleaning, bathing, and showering using antimicrobial soap reduces microorganisms on the skin. “Orthopedic surgery” b. Hair removal or shaving —Determined by incision site and nature of the operation; hair can harbor microorganisms. Always refer to the surgeon’s order concerning special instructions about hair removal. Objective 8 (cont.) Patient Preparation for a Surgical Procedure Options for removing hair—Include clippers, wet shave, or depilatory cream. – Electrical or battery-operated clippers—The most common method of hair removal, since it is safest, simplest and least irritating – Wet shave—Less common, since there is a significant risk of breaking the skin surface – Depilatory cream—Patients may be sensitive to chemicals in the depilatory. Shaving technique – Prep shaving should be performed outside of the operating suite to minimize the potential of the bacteria laden hairs getting into the operating environment. – Good shaving technique requires the avoidance of skin abnormalities. Objective 8 (cont.) Patient Preparation for a Surgical Procedure – Injuries to the patient’s skin may occur during hair removal. – The time between the prep shaving procedure and the surgery should be minimized so that the exposure of the unprotected dermis is for the shortest practical time. “30 minutes” – Skin preparation for the patient with a severe traumatic wound may be done after the induction of anesthesia. – After shaving, the skin should be wiped clean with a towel, inspected, and any uncut hairs removed. – Eyebrows are not shaved unless specifically ordered by the surgeon. – Preparation for head and neck surgery may be done in the operating room after the induction of anesthesia for psychological reasons.  Objective 8 (cont.) Patient Preparation for a Surgical Procedure c. Surgical skin preps It is impossible to sterilize the skin because new bacteria growth is constantly being brought to the surface of normal skin. Expose only the area of the skin that is to be prepped. Supplies needed to complete a surgical prep – Sterile gloves – Prep set, disposable or non-disposable – Basins for antiseptic soap and prep solution – Various applicators such as gauze sponges or cotton tip swabs – Towel used for drying and to absorb excess prep solution – Barrier prep pad to collect excess solution Objective 8 (cont.) Patient Preparation for a Surgical Procedure Always confirm any patient allergies before proceeding with the surgical prep. If the patient is awake for the surgical prep, the circulator should explain the procedure and take care to avoid excessive exposure to protect the patient’s modesty. The basic rule to follow when prepping the skin is to proceed from the cleanest area to the least clean area. Start the skin prep at the proposed incision site in a circular direction gradually working to the outer periphery. Figure 33 Use enough pressure and friction to remove microorganisms, dirt and oil from the skin and pores. After reaching the periphery, obtain a new sponge and repeat the procedure, starting at the incision site.  Objective 8 (cont.) Patient Preparation for a Surgical Procedure d. Special considerations For a skin graft, use separate prep setup for the donor and recipient sites. For cancer patients, the surgeon may prefer to have antiseptic painted over the cancerous area rather than scrubbing. The duration of skin prep depends on the antiseptic solution being used and the area being prepped. Clean the eyelid, eyebrow and pre-orbital area with a non- irritating antiseptic solution and then rinse with warm, sterile water. Contaminated and open traumatic wounds should be irrigated to flush out debris. Objective 8 (cont.) Patient Preparation for a Surgical Procedure Separate prep kits should be used when multiple procedures are being performed on the patient. Chemical burns can occur if the prepping solution is allowed to pool under the patient. Flammable solutions must be allowed to evaporate before drapes are applied to prevent accumulation of fumes, which decreases the possibility of fire if electrocautery is used. Final prep areas – Prep last with a separate sponge sites that contain a sinus or a body orifice, an open wound, stoma or skin ulcer. – The umbilicus is considered a contaminated area and should be scrubbed last with a separate sponge or cleaned first with separate sponges and applicators. Objective 8 (cont.) Patient Preparation for a Surgical Procedure – Areas with high microbial counts are considered contaminated and should be prepped last with a separate sponge. – The vaginal area prep includes the vagina, pubis, vulva, labia, perineum, anus, and the inner aspect of the thighs. The skin prep should be documented on the operative report with information such as the skin condition both preoperatively and postoperatively, hair removal technique, the prep solution used and the person performing the prep. Following the procedure, prep solution should be removed to prevent irritation and possible burns on the patient’s skin.  Objective 8 (cont.) Patient Preparation for a Surgical Procedure e. Safety concerns Allergies to prep solution Burns from warmed prep solution Chemical burns from prepping agent Flammability of prepping solution Pooling of prep solution under the patient Interference with the visibility of the skin site mark  Objective 9 Antiseptic Agents Used for Surgical Skin Preps a. Chlorhexidine gluconate (Hibiclens®) —Non-toxic, rapid-acting, broad-spectrum, antimicrobial agent Binds to the negative charges of the microbial cell wall and produces death to the microbe Effective against most viruses and provides a minimal activity against spores, yeast, and tuberculosis Good alternative for those patients who are allergic to iodophor (iodine) Is not absorbed through intact skin, but is an irritant to the eyes and is contradicted for facial antisepsis Leaves a residual effect for at least 4 hours  Objective 9 (cont.) Antiseptic Agents Used for Surgical Skin Preps b. Iodine-based agent May be combined in a solution with water or alcohol Is irritating to the skin c. Iodophors (Betadine®) —A complex of iodine and detergent used as a broad-spectrum virucidal and sporicidal agent will stain fabric and the skin Produces an antimicrobial effect by penetrating the cell proteins Use as a disinfectant or antiseptic for skin and tissue. Most common iodophor agent is povidone-iodine (PVP). Iodophor agents are non-toxic, non-irritating and staining.  Objective 9 (cont.) Antiseptic Agents Used for Surgical Skin Preps Available in solutions, sprays, and a thick gel form which only requires painting the agent onto the area to be prepped. Betadine® surgical scrub and Betadine® skin cleanser contain detergents, and must be rinsed off. d. 3M Duraprep™—A safe and effective patient skin prepping agent, which kills microbes fast, forming a film that resists removal during surgery and inactivation by blood or saline A patient skin prepping solution in a self-contained applicator that combines two broad-spectrum antimicrobials “ Alcohol and Betadine”  Objective 9 (cont.) Antiseptic Agents Used for Surgical Skin Preps e. Alcohol (Isopropyl 70%) —A broad-spectrum agent that denatures cell proteins For skin disinfection, a 70% concentration is satisfactory for skin antisepsis. Should not be used on mucous membranes or open wound because alcohol coagulates proteins Volatile and flammable! f. Hexachlorophene (Phisoderm®) —Develops a cumulative action after a period of frequent use Effective against gram-positive microorganisms, but ineffective against gram-negative microorganisms and fungi Neutralized by alcohol  Objective 9 (cont.) Antiseptic Agents Used for Surgical Skin Preps g. Parachlorometaxylenol (PCMX)—Is a highly effective broad-spectrum antimicrobial agent which is effective against bacteria and fungi It is bacterial in addition to bacteriostatic, and is used to formulate a variety of antimicrobial hand wash preparations.  Objective 10 Common Surgical Sites to Be Prepped a. Head procedures —Exclude chlorhexidine and use iodophors with caution for facial preps, since they can cause severe damage Cleanse the external ear or nostril with a cotton swab. The prepped area in the following figure extends from the brow line over the head including the ear and the anterior and posterior neck regions to the clavicular level, excluding the face area. Figure 34 b. Neck procedures Both shoulders and axillae are included. The anterior prep area should begin at the earline, including the chin, and extend to the level of the nipples. The posterior prep area should extend from the hairline to the lower level of the scapula. Figure 35  Objective 10 (cont.) Common Surgical Sites to Be Prepped c. Shoulder and upper extremity procedures The prepped area extends from the neck to the lower level of the thoracic cage and to the midline both anteriorly and posteriorly. The affected shoulder, axillae, and circumference of the arm to the forearm are included. Figure 36 d. Abdominal procedures The prepped area extends from the level of the nipples to the upper thigh including the external genitalia. Laterally the prep extends downward toward the operating table on each side of the body. Figure 37  Objective 10 (cont.) Common Surgical Sites to Be Prepped e. Forearm, elbow and hand procedures The prepped area should include the full circumference of the arm from the axillae to the fingertips. Figure 38 f. Procedures on lumbar region of the back The prepped area extends from the level of the axillae downward to include the buttocks and anal region. Laterally the prep extends downward toward the operating table on each side of the body. Figure 39 “Laminectomy” g. Posterior cervical procedures The prepped area extends from the hairline to the waistline, including the shoulders and axillae. Laterally the prep extends downward toward the operating table on each side of the body. Figure 40  Objective 10 (cont.) Common Surgical Sites to Be Prepped h. Gynecological and genitourinary procedures The prepped area extends from the level of the nipples to the upper level of the thighs. Laterally the prep extends around the curve of the body downward toward the operating table on each side of the body. The external genitalia and the perineal region are included. Figure 41 i. Minor vaginal procedures The prepped area covers the perineal region. Anteriorly it extends from a point just above the pubis and posteriorly to the point just beyond the anal region. The inner aspect of both thighs is included. Figure 42  Objective 10 (cont.) Common Surgical Sites to Be Prepped j. Hip and upper thigh procedures The prepped area extends from the level just below the umbilicus, covering the affected site of the abdomen, hip, buttock, and circumference of the entire lower extremity. The external genitalia may be included if preferred by the surgeon. Figure 43 k. Knee and lower leg procedure—The prepped area should cover the circumference of the entire leg region from the mid-thigh to the distal toes. Figure 44 l. Ankle, foot and toe procedures —The prepped area extends from the knee and covers the circumference of the entire lower leg including the toes. Figure 45  Module 1B: Positioning and Prepping Questions?