NCM 118 - RLE Surgical Aseptic Principles & Procedures PDF

SURGICAL ASEPTIC PRINCIPLES 1. Only sterile items are used within the sterile field. 2. Items of doubtful sterility must be considered unsterile. 3. Whenever a sterile barrier is permeated, it must be considered contaminated 4. Sterile gowns are considered sterile in front from the chest to the le...

SURGICAL ASEPTIC PRINCIPLES 1. Only sterile items are used within the sterile field. 2. Items of doubtful sterility must be considered unsterile. 3. Whenever a sterile barrier is permeated, it must be considered contaminated 4. Sterile gowns are considered sterile in front from the chest to the level of the sterile field and at the sleeves from 2 inches above the elbow to the cuff. 5. Sterile drapes are used to create a sterile field. SURGICAL ASEPTIC PRINCIPLES 6. Items should be dispensed to the field in a manner that preserves the sterility of the item and the integrity of the sterile field. 7. Sterile individuals touch only sterile items or areas; unsterile individual 8. Movement within or around a sterile field must not contaminate the field. ls touch only unsterile items or areas. SCRUB NURSE – ROLES AND RESPONSIBILITIES 1. Checks room for availability and completeness of instruments, equipment and supplies 2. Dusts and disinfect tables, trays particularly each corner 3. Does the initial counting of sponges, instruments and needles with the circulating nurse SCRUB NURSE – ROLES AND RESPONSIBILITIES 4. Serves gown and gloves to surgeon and assistants 5. Anticipates the needs of the surgical team throughout the procedure 6. Coordinates with the circulating nurse for the surgeon needs SCRUB NURSE – ROLES AND RESPONSIBILITIES 7. Initiates counting with the circulating nurse prior to the closure of the cavity and inform the surgeon for completeness. If ever there is discrepancies, request for recount until everything is complete 8. Takes charge in the after care of instruments and proper disposal of sharps and contaminated items after each surgery SCRUB NURSE – ROLES AND RESPONSIBILITIES 9. Follows up specimen and sees to it that has been properly requested and labeled before sending to the laboratory 10.Sees to it that the room is properly cleaned, disinfected and ready for use in the next case CIRCULATING NURSE – ROLES AND RESPONSIBILITIES 1. Together with the scrub nurse, checks instruments, equipment and supplies for the assigned case 2. Checks the identification bands, consent with right procedures to be performed , right patient, diagnostic test and pre operative medication if any 3. Checks for the false eyelashes, dentures, contact lenses, prosthesis, jewelry and nail polished should be removed CIRCULATING NURSE – ROLES AND RESPONSIBILITIES 4. Provides and assist in cut down if any prior to surgery 5. Does initial count of sponges, needles, instruments , gauze etc. with the scrub nurse 6. Assist the surgeon and assistant in donning of gown 7. Assist the scrub nurse in positioning mayo table and the c table to complete the operative set up CIRCULATING NURSE – ROLES AND RESPONSIBILITIES 8. Ensures that the suction tubing and cautery cord are properly connected and attached 9. Coordinates with the scrub nurse during the operation and anticipates the need of the surgical team 10.Accomplishes records on surgical count prior to closure of the operative site CIRCULATING NURSE – ROLES AND RESPONSIBILITIES 11.Attends to post-operatively until properly transported to the recovery room 12.Assist in recover when necessary or assigned 13.Records all the necessary information about the patient to the prescribed logbook imposed by the institution. SURGICAL ASEPTIC PRINCIPLES SURGICAL ASEPTIC PRINCIPLES SURGICAL ASEPTIC PRINCIPLES SURGICAL POSITIONING SURGICAL POSITIONING SURGICAL DRAPING SURGICAL DRAPING TRAFFIC CONTROL DESIGNATED AREA FUNCTION/DESCRIPTION PROPER ATTIRE Unrestricted A central control point that is established to Street clothes are permitted monitor the entrance of patients, personnel and materials. Traffic is not limited. Semi Restricted Peripheral support areas of the surgical suite. It Surgical attire cover all head and facial hair has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas and corridors leading to the restricted areas of the surgical suite. Traffic in the area is limited to authorized personnel and patients Restricted Area Operating Rooms, procedure rooms and the clean core area Surgical attire Hair coverings are required. Mask are required where open sterile supplies or scrubbed persons are located PCS-ORNAP-SIS. (2020). The Philippines Operating Room Guidelines and Recommendations Covid-19 edition. FIVE MOMENTS OF HAND HYGIENE HAND WASHING HAND WASHING PREPARATION HAND SCRUBBING HAND DRYING GOWNING - SOLO SURGICAL GLOVE FLIP CLOSE GLOVING TECHNIQUE GOWNING - ASSISTED REMOVING GOWN AND GLOVES SURGICAL VERIFICATION CHECKLIST OPERATING ROOM PROCESS FLOW 1. Arrival of patient at the OR/DR • The circulating nurse will receive endorsement from the Ward or ER nurse • The orderly will place the patient to OR stretcher then transfer to OR 2. Circulating nurse takes initial VS and prepares the patient for anesthesia. The scrub nurse prepares the instruments and drapes and makes initial counting. 3. The Anesthesiologist inducts anesthesia to patient OPERATING ROOM PROCESS FLOW 4. Circulating nurse will prepare the patient for procedure (insert foley catheter, skin preparation). The scrub nurse assists surgeons in applying sterile drapes. 5. The circulating nurse will perform TIME OUT 6. The surgeons starts the procedure • If baby out, the scrub nurse carefully transfer baby to crib • If specimen out, scrub nurse collects the specimen OPERATING ROOM PROCESS FLOW 7. Final counting of instruments, sutures and gauze 8. Closure of skin done in layers after completing the surgical count 9. The nurse performs post op care 10.Patient will be transferred to recovery room SURGICAL COUNTING 1. The scrub person and the circulator count together (aloud) all items on the sterile field as the scrub person touches to each item. 2. The circulator immediately records the number (count) of each type of item. Keeping a record of the count is the legal responsibility of the circulator. 3. If there is any uncertainty regarding any count, it is repeated. SURGICAL COUNTING 4. As additional items (e.g., sponges or needles) are introduced to the sterile field during the procedure, the scrub person counts the item(s) with the circulator, who adds the item to the count in the record and initials it. 5. Nothing (including laundry, trash, instruments, or sponges) may be removed from an OR while a procedure is in progress until the final count is acknowledged to be correct SURGICAL COUNTING 6. Whenever there is a change of team members, a count is taken. The name of the replacement person(s) is documented on the intraoperative record. 7. When a package containing an incorrect number of items is opened, the items should be passed off the table, bagged, and labeled accordingly. SURGICAL COUNTING 8. Counts are taken before the procedure begins, before wound closure begins, and when skin closure is initiated. 9. An additional count is taken prior to the closure of an organ with a cavity (e.g., uterus, bladder, or bowel). SURGICAL COUNTING • Incorrect closure counts must be repeated immediately. If the count remains incorrect, the circulator alerts the surgeon, who will inspect the patient’s wound for the missing item. • If the item is not located, hospital policy must be followed, i.e., usually to include immediate x-ray examination. • Notification of the OR supervisor and an incident report must be filed as part of the chart, the permanent record. • Any item inadvertently left in a wound may become a source of infection and result in subsequent litigation. PARTS OF AN INSTRUMENT Main Components • Handles • Ratchets • Shanks • Joints • Jaws or blade • Tips INSTRUMENT CATEGORIZATION ACCESSORY CLAMPING AND OCCLUDING CUTTING AND DISSECTING is an instrument that does not fall into any of the other categories but has a specific function and is an integral part of the surgical procedure used to compress vessels and other tubular structures to impede or obstruct the flow of blood and other fluids used to incise, dissect, and excise tissues. GRASPING AND HOLDING are designed to grip and manipulate body tissues. They are often used to stabilize tissue that is to be excised, dissected, repaired, or sutured INSTRUMENT CATEGORIZATION PROBING AND DILATING are used to explore a structure, opening, or tract RETRACTING AND EXPOSING are designed to hold back or pull aside wound edges, organs, vessels, nerves, and other tissues to gain access to the operative site SUCTIONING AND ASPIRATING SUTURING AND STAPLING are used to remove blood, fluid, and debris from operative sites. are used to ligate, repair, and approximate tissues during a surgical procedure Accessory Instrument ELECTROSURGICAL PENCIL Bovie, cautery, monopolar cautery, diathermy, electrocautery Use(s): Monopolar cautery uses electrical current to coagulate and cut blood vessels and tissues to provide homeostasis; it is also used for dissection. Clamping and Occluding HALSTEAD FORCEPS Mosquito forceps, Hartman forceps Use(s): Used for occluding bleeders in small or superficial wounds before cauterization or ligation. Used often for delicate or small confined procedures. Some examples are plastic, pediatric, thyroid, and hand procedures Clamping and Occluding KELLY FORCEPS Hemostat, Crile forceps, clamp Use(s): A curved or straight clamp with horizontal serrations that run about half the length of the jaws. Used for occluding bleeders before cauterization or ligation Clamping and Occluding PEAN FORCEPS Péan, Mayo, Kelly-Péan forceps Use(s): Used for occluding larger blood vessels and tissue before ligation, usually in a deeper wound or on heavier tissue. Clamping and Occluding MIXTER FORCEPS Right angle forceps, Gemini forceps, Lahey forceps, obtuse clamp, ureter clamp Use(s): Is used to clamp, dissect, and occlude tissue. Is often used to place a tie or vessel loop under and around a tubular structure such as a vessel or a duct, enabling the surgeon to grasp the ligature or loop and pull it up and around the structure to either ligate or retract Clamping and Occluding CORD CLAMP Fine needle holder, fine needle driver Use(s): The cord clamp is used to clamp the cord of the neonate Cutting and Dissecting STRAIGHT MAYO SCISSORS Suture scissors Use(s): Used for cutting sutures. Cutting and Dissecting CURVED METZENBAUM SCISSORS Metz scissors, tissue scissors Use(s): Dissect and undermine delicate tissues Cutting and Dissecting NO. 3 KNIFE HANDLE A no. 3 handle holds blades 10, 11, 12, and 15. Use(s): Knife handles are used to hold various blades to create a scalpel. Scalpels are used to make skin incisions or whenever a fine precision cut is necessary Cutting and Dissecting NO. 7 KNIFE HANDLE A no. 7 handle holds blades 10, 11, 12, and 15. Use(s): Used when precision cutting is needed in a confined space or a deep wound. Surgical Blades for No. 3 and 7 BLADE #10 Used for making skin incisions BLADE #11 Used for puncturing the skin or to initiate the opening of an artery BLADE #12 Sickle Knife BLADE #15 used during tonsillectomies, parotid surgeries, septoplasties, and cleft palate procedures Used for creating small precise incisions Cutting and Dissecting NO. 4 KNIFE HANDLE The no. 4 handle will hold blades no. 20, 21, 22, 23, 24, and 25 Use(s): Used with the no. 20 blade to create a larger and/or deeper incision in heavy tissue areas. Cutting and Dissecting UTERINE CURETTE Use(s): Used for bluntly removing uterine contents after sharp curetting. Grasping and Holding ADSON TISSUE FORCEPS Adson dressing forceps Use(s): Used for grasping delicate tissue Grasping and Holding TOOTHED ADSON TISSUE FORCEPS Adson with teeth, rat tooth Use(s): Aligns the edges of the wound during stapling of the skin; grasps superficial tissues so that Steri-Strips can be placed Grasping and Holding PLAIN TISSUE FORCEPS Semken dressing forceps, smooth forceps, tissue forceps without teeth Use(s): Used for grasping tissue and dressing application Grasping and Holding TOOTHED TISSUE FORCEPS Semken tissue forceps, rat tooth, tissue forceps with teeth Use(s): Used for grasping moderate to heavy tissue and used during wound closure Grasping and Holding DEBAKEY TISSUE FORCEPS DeBakey’s, DeBakes Use(s): Grasps numerous types of tissue; commonly used in cardiac, vascular surgery, and gastrointestinal procedures Grasping and Holding TOWEL CLIP (PENETRATING) Backhaus towel clip, Roeder towel clip, Jones towel clip Use(s): Used for holding towels in place when draping, when grasping tough tissue, and during reduction of small bone fractures Grasping and Holding NONPENETRATING TOWEL CLIP Atraumatic towel clamp Use(s): Used for attaching Bovie and suction to the drapes Grasping and Holding FOERSTER SPONGE FORCEPS Fletcher sponge forceps, sponge stick forceps, ring forceps Use(s): Used for creating a sponge stick, for grasping tissues such as the lungs, or for removing uterine contents Grasping and Holding ALLIS FORCEPS Use(s): Used for lifting, holding, and retracting slippery dense tissue that is being removed. Commonly used for tonsils; for vaginal, breast, and thyroid tissues; or for grasping bowel during a resection. Grasping and Holding BABCOCK FORCEPS Use(s): Used for grasping and encircling delicate structures such as the ureters, fallopian tubes, bowel, ovaries, and appendix. Grasping and Holding KOCHER FORCEPS Koch forceps, Ochsner forceps Use(s): Used for grasping tough, fibrous, slippery tissues such as muscle and fascia Retracting and Exposing ARMY-NAVY RETRACTOR Army’s, Navy’s, U.S. retractor Use(s): Used for retraction of small superficial incisions to allow better exposure Retracting and Exposing SENN RETRACTOR Cat paw retractor Use(s): Used for retraction of skin edges and deeper tissues of small incisions Retracting and Exposing RIBBON RETRACTOR Malleable retractor Use(s): Used for retraction of organs and intestines in a wound Retracting and Exposing RICHARDSON RETRACTOR Use(s): Used for retraction of wound edges Retracting and Exposing BLADDER RETRACTOR used for retracting various incisions. Its special shape makes it ideal for complex surgeries including gynecological, general as well as urological surgeries. Retracting and Exposing DEAVER RETRACTOR Used for deep retraction of organs and viscera. POST ANESTHESIA CARE UNIT (PACU) • Formerly known as Recovery room • Designed to provide care for patients recovering from anesthesia, whether it be general, regional or local anesthesia PACU Standards • All patients who have received general, regional or monitored anesthesia care should receive post anesthesia management • The patient should be transported to the PACU by a member of the anesthesia care team that is knowledgeable about the patient’s condition. • Upon arrival in the PACU, the patient should be re-evaluated and a verbal report should be provided to the nurse. • The patient shall be evaluated continually in the PACU • A physician (anesthesiologist) is responsible for discharge of the patient Standards for Postanesthesia Care. Retrieved from American Society of Anesthesiologists: https://www.asahq.org/standards-and-guidelines/standards-for-postanesthesia-care Equipment Routine Monitoring • After general anesthesia, most patients take 15-30 minutes to become fully awake, to be breathing normally and to be physiologically stable • Until a patient is awake and stable, vital signs and blood oxygenation saturation are measured every 15 minutes • Temperature is measured and recorded at least once early in PACU stay Oxygen supplementation • All patients recovering from General Anesthesia should receive 30-40% oxygen during their emergence • Patients have a greater than normal risk of developing hypoxemia and may need supplemental oxygen during their entire stay in PACU. • Older adults • Patient’s with pre-existing lung problems • Thoracic or upper abdominal surgery Pain • Assess and record pain and its characteristics • Use pain assessment scale • Administer analgesics to promote optimum pain relief as ordered Pain • Opioid Analgesics • The most potent analgesics used in the management of moderate to severe pain • Frequently used opioids • Morphine • Meperidine (Demerol) • Pethidine • Fentanyl Sign and symptoms of narcotic toxicity • Unresponsiveness to physical stimulation • RR less than 7 per minute • Bradycardia • Pinpoint pupils NALOXONE – a pure antagonist, used to counter act the effects of a narcotic overdose Shivering • Not uncommon • Mechanism – decrease in body temperature, uninhibited spinal reflexes • Nursing Management • Warm blankets • Air blankets (bair hugger) • Demerol (Meperidine) as ordered for extreme shivering Nursing Management • Oxygen administration • See the patient • Assess vital signs and respiratory rate • Evaluate airway • Prepare for intubation • Look for causes of hypoxia (ABG,CBC or CXR) Discharge Criteria • General Anesthesia – fully awake • Spinal – moving (bend knees) and able to feel legs • Vitals stable • Pain is controlled • Normal body temperature • Aldrete’s Scoring • Discharge by anesthesiologist when criteria is met Reference • Nemitz R. (2019). Surgical Instrumentation, An Interactive Approach. Third Edition, Elsevier • Goldman M. (2008). Pocket guide to the operating room. Third Edition. F.A. Davis Company • Anesthesiologists, A. S. (2019, October 23). Standards for Postanesthesia Care. Retrieved from American Society of Anesthesiologists: https://www.asahq.org/standards-andguidelines/standards-for-postanesthesia-care • PCS-ORNAP-SIS. (2020). The Philippines Operating Room Guidelines and Recommendations Covid-19 edition. • Rothrock, J. C. (2015). Alexander's Care of the Patient in Surgery. Elsevier.