Perioperative Nursing

You’ve just
purchased
You’ve just more
than
purchased a textbook! more
than a textbook!
Activate the complete learning
experience that comes with
your book
Activate thebycomplete
registering at:
learning
experience that comes with
http://evolve.elsevier.com/AU/Hamlin/perioperative/
http://evolve.elsevier.com/XXXXX
your book by registering at:
Once you register, you receive access to the following resources:
http://evolve.elsevier.com/XXXXX
Once you register, you receive access to the following resources:
For instructors only:
bulleted copy here bulleted copy here bulleted copy here bulleted copy here
Answer guide for case studies
Oncebulleted
you register, you
copy here receive
bulleted access
copy to the following
here bulleted copy here resources:
bulleted copy here
Answer guide for critical thinking exercises
bulleted
bulleted copy
copy here
here bulleted
bulleted copy
copy here
here bulleted
bulleted copy
copy here
here bulleted
bulleted copy
copy here
here
Image collection
bulleted
bulleted copy
copy here bulleted
bulleted copy
here questionscopy here
here bulleted
bulleted copy
copy here
here bulleted
bulleted copy
copy here
here
Self-assessment and answers
bulleted copy
For students andhere bulleted copy here bulleted copy here bulleted copy here
instructors:
bulleted
bulleted copy
copy here
here bulleted
bulleted copy
copy here
here bulleted
bulleted copy
copy here
here bulleted
bulleted copy
copy here
here
Case studies
Critical thinking exercises
Further readings
Glossary
Weblinks
Perioperative
nursing
AN INTRODUCTION
2nd edition
This page intentionally left blank
Perioperative
nursing
AN INTRODUCTION
2nd edition
EDITORS
LOIS HAMLIN ( LEAD EDITOR )
MENNA DAVIES
MARILYN RICHARDSON -TENCH
SALLY SUTHERLAND - FRASER
Elsevier Australia, ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
Copyright 2016 Elsevier Australia. 1st edition © 2009 Elsevier Australia

Reprinted 2017
All rights reserved. No part of this publication may be reproduced or transmitted

in any form or by any means, electronic or mechanical, including photocopying,
recording, or any information storage and retrieval system, without permission
in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notice
This publication has been carefully reviewed and checked to ensure that the
content is as accurate and current as possible at time of publication. We would
recommend, however, that the reader verify any procedures, treatments, drug
dosages or legal content described in this book. Neither the author, the
contributors, nor the publisher assume any liability for injury and/or damage to
persons or property arising from any error in or omission from this publication.
Cataloging-in-Publication Data
Hamlin, Lois, author.

Perioperative nursing : an introduction / Lois Hamlin ; Menna Davies ;
Marilyn Richardson-Tench ; Sally Sutherland-Fraser.
2nd edition.
9780729542333 (paperback)
Includes index.
Operating room nursing—Australia.
Post anesthesia nursing—Australia.
Surgical nursing—Australia.
Davies, Menna, author.
Richardson-Tench, Marilyn, author.
Sutherland-Fraser, Sally, author.
617.917
Senior Content Strategist: Libby Houston

Content Development Specialist: Elizabeth Coady and Natalie Hamad
Senior Project Manager: Anitha Rajarathnam
Cover and Internals Design by Lisa Petroff
Edited by Caroline Hunter, Burrumundi Pty Ltd
Proofread by Katie Millar
Index by Robert Swanson
Typesetting by Toppan Best-set Premedia Limited
Printed in China by 1010
Cover images from:

Top left (and chapter opener) image: Shutterstock.com, 215049751 © ChaNaWiT
Top Right image: Dreamstime.com, 35740672 © Pat Olson
Bottom image: Cover Image © Thompson Health
Contents
Foreword ix
Preface x
Editors xi
Contributors xiii
Reviewers xv
Acknowledgements xv
Chapter 1 Perioperative nursing 1

Introduction 2
The history and philosophy of perioperative nursing 2
The patient journey 2
Cultural safety 3
Patient advocate 3
Perioperative nursing roles 4
The regulatory environment 8
Influences for change in nursing practice 12
Informal and continuing professional development 12
Formal development 13
The role of professional associations 15
Research and evidence-based practice 17
The future of perioperative nursing practice 19
Conclusion 23
Resources 24
Chapter 2 The perioperative team and interdisciplinary collaboration 30

Introduction 30
The interdisciplinary team 30
The perioperative team and professional hierarchy 31
The culture and context of the perioperative environment 32
Human factors 32
Conclusion 43
Resources 44
Chapter 3 Perioperative patient safety 47

Introduction 48
Clinical governance 48
Patient safety and risk management in the perioperative environment 49
Safety and quality 52
Use of checklists 62
Medication management 63
Clinical audit 65
Conclusion 68
Resources 69
v
Contents
Chapter 4 Medico-legal aspects of perioperative nursing practice 74

Introduction 75
Accountability and advocacy 75
Statutes and common law 76
Regulatory action and disciplinary hearings 85
Confidentiality and privacy 89
Social media 91
Conclusion 93
Resources 94
Chapter 5 The perioperative environment 97

Introduction 97
Operating suite design 98
Traffic patterns 101
Operating suite zones 101
Operating suite layout 102
Technological advances in the operating suite 105
Operating suite environmental controls 105
Electrical safety 108
Laser 112
Workplace health and safety 113
Preparation of the operating room 120
Waste management 121
Conclusion 122
Resources 123
Chapter 6 Infection prevention and control 128

Introduction 129
Classification and types of microorganisms 129
Risk management of microorganisms 132
Normal body defences 133
Infection as an adverse event 134
Infection prevention and control practices 134
Asepsis and aseptic technique 141
Instrument cleaning, decontamination and sterilisation 150
Sterilisation 153
Conclusion 157
Resources 157
Video resources 158
Chapter 7 Assessment and preparation for surgery 160

Introduction 160
Pre-admission 161
Patient education and information 163
Factors affecting selection for surgery 171
Cultural sensitivity 174
Special population considerations 174
Preparation in the immediate preoperative period 177
Preoperative care in the operating suite 179
vi
Contents
Conclusion 187
Resources 188
Chapter 8 Patient care during anaesthesia 193

Introduction 194
Medical pre-anaesthetic assessment of the patient 194
Types of anaesthetics 196
Procedure for general anaesthesia 201
Airway emergencies and management 211
Other types of anaesthesia 214
Haemodynamic monitoring during anaesthesia 218
Fluid and electrolyte balance 221
Anaesthetic emergencies 223
Paediatric considerations in anaesthesia 224
Anaesthetic considerations for the elderly patient 226
Anaesthetic considerations for the bariatric patient 226
Conclusion 229
Resources 229
Chapter 9 Intraoperative patient care 232

Introduction 233
Patient positioning 233
Prevention and management of venous thromboembolism 251
Prevention and management of inadvertent perioperative hypothermia 255
Surgical complications and the elderly 256
Ensuring correct patient/site of surgery 256
Tourniquets 259
The management of accountable items used during surgery 260
Collection of specimens 263
Conclusion 265
Resources 265
Video resources 266
Chapter 10 Surgical intervention 269

Introduction 270
Historical surgical perspective 270
Sequence of surgery 271
Instruments 272
Sutures and needles 281
Sharps safety 291
Minimally invasive surgery 291
Conclusion 300
Resources 301
Video resources 301
Chapter 11 Wound healing 304

Introduction 304
Skin anatomy 305
Wounds 305
vii
Contents
Surgical incisions 306

Wound classification 309
The phases of wound healing 309
Types of wound healing 313
Factors affecting wound healing 314
Surgical haemostasis 315
Wound closure 319
Wound care 321
Technological advances in wound management 325
Conclusion 328
Resources 329
Video resources 329
Chapter 12 Postanaesthesia nursing care 331

Introduction 332
The role of the nurse and function of the PACU 332
PACU design features 332
Clinical handover from anaesthetist to nurse 334
Patient management in the PACU 335
Postanaesthesia and postsurgical complications 341
Management of pain in the PACU 347
Special populations 351
Discharge criteria 352
Patient handover from PACU nurse to ward nurse 352
Conclusion 354
Resources 355
Chapter 13 Evolving models of care in perioperative environments 358

Introduction 358
Growth of day surgery, endoscopy and interventional radiography 359
The patient journey in ambulatory care settings 363
Special populations and ambulatory settings 363
Advances in procedures performed in ambulatory care settings 365
Preoperative patient preparation 372
Postoperative nursing care following endoscopic and endovascular procedures 374
Post-discharge 375
Patient safety and risk management 375
Conclusion 378
Resources 379
Video resources 379
Glossary 383
Index 390
viii
Foreword
We all acknowledge that the principles of perioperative nursing practice are generally consistent across
the globe and that, whenever possible, the foundations of practice are based on the latest research and
evidence. This is so with the text, Perioperative nursing: An introduction 2e, which presents evidence-based
foundational perioperative care concepts written by leading Australasian perioperative nurse clinicians.
The editors have ensured that they have captured the expertise of well-respected academics, researchers,
educators and clinicians to provide a contemporary Australasian text. In addition, this second edition is
aligned with the Australian College of Operating Room Nurses (ACORN) and the Perioperative Nurses
College of the New Zealand Nurses Organisation (PNC NZNO), as well as the National Safety and Quality
Health Service (NSQHS) Standards, thus providing an outstanding resource that meets the gold standard
in perioperative practice.
This second edition has been extensively revised from the original with a focus on interprofessional teams,
communication, teamwork, patient and staff safety, risk management strategies and medico-legal consid-
erations. Cultural diversity has also been embedded throughout the text, helping raise awareness of the
perioperative needs of Indigenous and Māori peoples. Additionally, the needs of special populations, such
as the very young, the elderly, people with a mental illness and bariatric patients, are addressed. An over-
view of advanced roles in perioperative nursing is presented, and the changing and evolving settings that
perioperative nurses now work in, such as interventional radiography, endoscopy and short stay ambulatory
care units, are included, leading to a greater understanding of current and future models of care.
I highly applaud the editors for updating this text: the result is an outstanding perioperative resource. It
is one that I believe will be at the forefront of perioperative texts globally because it acknowledges equity
of access issues among specific groups within culturally diverse populations. In doing so, it pays tribute to
the World Health Organization’s Universal Health Coverage strategy, which highlights surgery as a basic
human right.
I know this text will be a valuable resource assisting perioperative nurses to provide safe, high-quality care
for their perioperative patients.
Ruth Melville
President
International Federation of Perioperative Nurses (IFPN)
ix
Preface
This second edition of Perioperative nursing: An introduction acknowledges the extensive changes and sig-
nificant developments that have occurred in healthcare over the past few years since publication of the
first edition. The book incorporates the national and international standards and guidelines current at the
time of writing. These include the World Health Organization (WHO) Surgical Safety Checklist, the Austral-
ian College of Operating Room Nurses (ACORN) and Perioperative Nurses College of the New Zealand
Nurses Organisation (PNC NZNO) Standards and, in Australia, the National Safety and Quality in Health
Service Standards and National Registration for Nurses.
The chapters have been fully revised and there are two new chapters focusing on the perioperative team
and perioperative patient safety. In addition to the foundational perioperative nursing concepts introduced
in the first edition, emphasis is placed on the concept of the patient journey, working within interprofes-
sional teams, communication and teamwork, patient and staff safety, risk management strategies and
medico-legal considerations. Other new features include research boxes, where appropriate, and feature
boxes that emphasise issues such as paediatric, geriatric or bariatric patient care.
Evolve has been further developed to feature:
• answers to the critical thinking exercises that appear in every chapter
• perioperative case studies and answer guides
• self-assessment multiple-choice and true/false questions with answers and rationales
• further readings
• web links
• glossary
• image collection.
An exciting development in relation to the new edition is its endorsement by the Australian College of
Operating Room Nurses. This is particularly gratifying for the editors, all of whom have played a role at
one time or another on the ACORN Board. We would like to thank ACORN’s current President, Jed Duff, for
initiating this process. ACORN has reverted to the use of the terminology postanaesthesia care unit, or
PACU, in line with conventional and contemporary global trends indicated in the current literature, as well
as to return emphasis to the notion of nursing care provided by qualified and skilled nurses while the
postoperative patient is recovering from the effects of anaesthesia.
The nature of perioperative procedures, settings and models of care described here reflects the understand-
ing and professional practice of our contributors contemporaneously. As perioperative care evolves con-
tinuously, readers are directed to use the resources provided in each chapter, as well as identifying and
utilising other sources.
Finally, as well has having a new title, this edition welcomes another editor, Sally Sutherland-Fraser, who
joins the original editorial team. Sally’s inclusion helps ‘future-proof’ the publication. Her thoughtful and
focused approach has been a great asset for this edition and is much appreciated by the rest of the team.
Lois Hamlin, Menna Davies, Marilyn Richardson-Tench, Sally Sutherland-Fraser
February 2016
x
Editors
DR LOIS HAMLIN
Lois is a former senior lecturer at the University of Technology, Sydney, where she was also the Director of
Postgraduate Nursing Programs and Coordinator of Perioperative Education. She worked in the operating
room for many years, as well as practising in coronary care, intensive care and high-dependency medical/
surgical ward settings. Her research interests include the role of professional perioperative associations,
competency development, advanced practice, and factors impacting on recruitment and retention in the
operating room.
Lois was a member of the executive committee of the NSW OTA Inc. for more than 10 years and President
in 1998/1999. She was the inaugural winner of the NSW OTA Excellence in Perioperative Nursing Award in
2004 and was made a life member of the Association in 2011. She has also served on the executive of the
ACORN Board and is an ACORN Foundation Fellow. She is past editor of ACORN Journal and a former
member of the Editorial Board of AORN Journal, and was the coordinator of that journal’s ‘Global perspec-
tives’ column from 2007 to 2011. She remains a reviewer for AORN Journal and Journal of Perioperative
Practice.
Lois has presented numerous papers locally, nationally and internationally; in addition, she has written
many journal articles and book chapters. She delivered the Judith Cornell Oration at the 2008 ACORN
Conference.
MENNA DAVIES
Menna is Director of Health Education & Learning Partnerships, a company she founded with Sally Suth-
erland-Fraser in 2013. The company provides education and consultancy services for the healthcare indus-
try and clinicians in metropolitan, rural and remote locations of Australia and the Pacific.
Menna previously held the position of Clinical Nurse Consultant at the Randwick Campus Operating Suite,
Prince of Wales Hospital. Menna previously worked as a Nurse Educator at Westmead Hospital and at the
(then NSW) Australian College of Nursing, during which time she assisted in the development of the first
postgraduate distance education perioperative nursing course in Australia, and coordinated the program
for 10 years.
Menna is an active member of the NSW Operating Theatre Association and served two terms as President.
Most recently, she was a member of the surgical plume working party, assisting in the development of
guidelines for the management of surgical plume in the perioperative environment. She was the NSW
representative on the ACORN Board and Conference Convener for the ACORN National Conference in 1995
in Sydney. Menna was a member of the ACORN Competency Working Party and has scripted and produced
a number of educational videos on behalf of ACORN, including on scrubbing, gowning and gloving.
Menna has presented papers at state, national and international perioperative nursing conferences, pub-
lished articles and contributed to perioperative nursing texts, received the inaugural ACORN Excellence in
Perioperative Nursing Award in 2004 and is an Honorary Fellow of ACORN. In 2012 she presented the
prestigious Judith Cornell Oration at the ACORN Conference.
DR MARILYN RICHARDSON-TENCH
Marilyn is an independent consultant in education and research. She has worked in perioperative nursing
nationally and internationally. She was a member of the Nursing Faculty at Victoria University and was
awarded the Inaugural International Research Visiting Fellowship at Glamorgan University, Wales, where
she worked with Professor Colin Torrance in the Simulation Centre exploring simulation in perioperative
nursing. At La Trobe University she coordinated the postgraduate perioperative and perianaesthesia courses,
during which time she produced an aseptic technique video, which was launched at the Royal Melbourne
Hospital.
xi
Editors
Marilyn has been an active member of the Victorian Perioperative Nursing Group and served three terms
as Treasurer. She is a past editor of ACORN Journal and a member of the editorial review panel of Journal
of Advanced Nursing, The Australian Journal of Advanced Nursing and Day Surgery Australia. She has pre-
sented papers at national and international perioperative and research conferences and has published
research papers and contributed to book chapters. Her PhD study explored operating room nursing practice.
Marilyn was a member of the collaborative research team whose research was used to develop the initial
Day Surgery Guidelines for Practice. Her current research projects cover areas such as day surgery, nursing
ethics and perioperative management of the elderly.
SALLY SUTHERLAND-FRASER
Sally has more than 30 years’ experience in perioperative practice in Australia and the United Kingdom. In
2013 Sally established Health Education & Learning Partnerships with Menna Davies to provide innovative
education and consultancy services for the healthcare industry and clinicians in metropolitan, rural and
remote locations of Australasia and the Pacific. Sally is a passionate advocate for education and professional
standards and has held executive positions in the NSW Operating Theatre Association and ACORN. In 2010,
Sally was the proud recipient of the ACORN Excellence in Perioperative Nursing Award.
Sally has an extensive record as a facilitator and speaker on subjects as diverse as error theory, medication
safety, models of care and pressure injury prevention. The latter was the subject of a research project at
the Nursing Research Institute, a collaboration between St Vincent’s Health Australia Sydney and the
Australian Catholic University. Sally was a contributor to the first edition of Perioperative nursing: An intro-
ductory text and is delighted to be part of the editorial team for the second edition.
xii
Contributors
AMANDA ADRIAN | RN, LLB, BA, FACN
Principal, Amanda Adrian and Associates, New South Wales, Australia
ANNE MAREE ALLANSON | RN, RM, BN, PGCert (Periop Nsg), MACORN
Perioperative Introductory Program for Medical, Redcliffe Hospital; Perioperative Introductory Program
Coordinator Nursing, Northside Perioperative Consortium, Queensland, Australia
KIM BRYANT | RN, BN, MEd, GradCert (Adult Ed), MACN

Deputy Executive Officer, Nursing and Midwifery Council of New South Wales, New South Wales, Australia
JANNELLE CARLILE | RN, PGCert (OR Nsg), Cert IV TAE, MACORN

Clinical Nurse Educator, Randwick Campus Operating Suite, Prince of Wales Hospital, New South Wales,
Australia
SERENA COLE | RN, Milit Cert (Periop Nsg), Cert (Anaes & Rec Room Nsg), MACORN
Registered Nurse, Nambour Hospital, Sunshine Coast, Queensland, Australia
MENNA DAVIES | RN, MHlthSc (Nsg), GradDip Hlth Law, Cert (Periop Nsg), Cert (Sterilising Tech),
FACN, FACORN
Education Consultant and Director of Health Education & Learning Partnerships, New South Wales, Australia
MARGARET EVANS | RN, RM, BHlthSc, MPH, CICP

Clinical Nurse Consultant Infection Prevention & Control, Royal Hospital for Women, New South Wales,
Australia
PAULA FORAN | RN, PhD, FACORN, MACN

ACORN Education Officer, Victoria, Australia
BRIGID M GILLESPIE | RN, PhD, FACORN

Professor, NHMRC Centre for Research Excellence in Nursing (NCREN), Menzies Health Institute Qld (MHIQ),
Griffith University, Queensland, Australia
LOIS HAMLIN | RN, BN, MN (Nurse Ed), DNurs, OTCert, ICCert, FACN, Foundation Fellow ACORN
Independent Perioperative Nursing Consultant; Former Senior Lecturer, (then) Faculty of Nursing, Midwifery &
Health, University of Technology, New South Wales, Australia
ZOE KUMAR | RN, MN, MACORN

Nurse Educator, Randwick Campus Operating Suite, Prince of Wales Hospital, New South Wales, Australia
TRACEY LEE | RN, MN (Hons)

Nurse Consultant Operating Rooms and Anaesthesia, Auckland District Health Board, New Zealand
BEN LOCKWOOD | RN, BN (Hons), MACORN

Perioperative Education Facilitator, Southern Adelaide Local Health Network, South Australia, Australia
MICHELLE LOVE | RN, BN, GradCert (Periop Nsg), MACN

Nurse Educator, Perioperative and Procedural Areas, The Prince Charles Hospital, Queensland, Australia
xiii
Contributors
CATIE McCULLAGH | RN, AdvDip (Nsg Stud)

Clinical Nurse, Perioperative Department, Cairns & Hinterland Hospital & Health Service, Queensland,
Australia
SHARON MINTON | RN, DipAppSc (Nsg), BAppSc (Nsg), GradDip Nsg (Op Suite), MN (Prof Studies Ed),
Cert IV TAE, MACORN
Clinical Nurse Educator, Perioperative Services, Hornsby Hospital, New South Wales, Australia
SONYA OSBORNE | RN, PhD, Centaur Fellow, MACN, MACORN

Post Graduate Coordinator, Senior Lecturer, School of Nursing, Queensland University of Technology,
Queensland, Australia; Standards Editor, Australian College of Operating Room Nurses (ACORN)
ANN PARKMAN | RN, GradCert (Periop Nsg), GradCert HE, MPET

(Previous) Post Graduate Perioperative Nursing Course Convenor, School of Nursing and Midwifery, Deakin
University, Victoria, Australia
LYNN RAPLEY | RN, GradCert (Periop Nsg), GradCert (Gastroenterology Nsg), MN (Clinical Practice
Periop), ACGEN, MACN
Associate Lecturer, Australian College of Nursing, New South Wales, Australia
MARILYN RICHARDSON -TENCH | RN, RCNT (UK), BAppSc (Adv Nsg), Cert Clin Teach (UK),
Cert Anaes (UK), Cert (OR Tech & Man), MEdStud, PhD
Education Consultant, Victoria, Australia
CATHERINE STEEL | RN, MN, BHSc, GradCert (Periop Nsg), Cert IV WH&S, FACORN
Clinical Nurse Consultant, Operating Theatres, Princess Alexandra Hospital, Brisbane, Queensland, Australia
SALLY SUTHERLAND - FRASER | RN, BEd (Adult Ed), MEd, Cert (Periop Nsg), Cert IV TAE, MACN, FACORN
Education Consultant and Director of Health Education & Learning Partnerships, New South Wales, Australia
JULIE WALTERS | RN, RM, GradCert (Anaes & Rec Room Nsg), Cert IV TAE, MACORN
Clinical Nurse Educator Anaesthetics, Randwick Campus Operating Suite, Prince of Wales Hospital, New South
Wales, Australia
VICKY WARWICK | RN, MN, GradCert (PNSA), FACORN

Staff Development Educator, Fremantle Hospital, Western Australia, Australia
xiv
Reviewers
ELYSE COFFEY | BN, MN (Perianaesthesia Care)
Lecturer, School of Nursing and Midwifery, Deakin University, Victoria, Australia
SANDRA DE ROME | RN, CNOR, BN, GradCert Mgt, CGHE

Clinical Nurse Educator, Operating Suite, Monash Health, Victoria, Australia
MEREDITH GIMBLETT | RN, BN, GradCert (Periop Nsg), Cert IV TAE, MACORN
Registered Nurse, Perioperative Suite, Sydney Hospital/Sydney Eye Hospital, New South Wales, Australia
ANGELA McKAY | RN, BN (Hons), GradDip (Periop Nsg)

Lecturer, School of Health Sciences, University of Tasmania, Tasmania, Australia
PATRICIA NICHOLSON | RN, RM, PhD, FACORN

Perioperative Course Director, School of Nursing and Midwifery, Deakin University, Victoria, Australia
JOSEPHINE M PERRY | RN, MSN (Nurse Educator), MACORN

Specialty Course Coordinator (Perioperative Nursing), School of Nursing, The University of Adelaide, South
Australia, Australia
Acknowledgements
We acknowledge our chapter contributors—thank you for your commitment in meeting deadlines while
developing the depth and quality of content that is both relevant and up to date. We also acknowledge the
work of our external reviewers, who provided insightful suggestions to improve the text. We feel sure that
the students and clinicians who use this book will benefit from the thorough approach that has been
adopted in the preparation and completion of this book.
We are especially grateful to many people at Elsevier Australia for their support throughout this project.
In particular, we would like to thank Libby Houston, Senior Content Strategist, Nursing, Midwifery and
Health Professions, for her leadership throughout the development of the second edition. Additionally, we
would like to thank Liz Coady and Natalie Hamad, Senior Content Development Specialists, and Anitha
Rajarathnam, Project Manager, for their support and guidance; and Caroline Hunter and Katie Millar, who
ensured that the quality of this book is of such a high standard.
Finally, to our respective loved ones—Chris, Ryan and Alex Lewis; Lorelle Kinsey; Edward and Matthew
Tench; and Jenni Wilkins—thank you for your patience and support throughout the writing of this book.
Lois Hamlin, Menna Davies, Marilyn Richardson-Tench, Sally Sutherland-Fraser
xv
Publisher’s acknowledgement
Elsevier would like to thank the following members of ACORN for their support and guidance throughout
the review and endorsement process:
Dr Jed Duff | RN, PhD, FACORN

President, Australian College of Operating Room Nurses (ACORN)
Dr Sonya Osbourne | RN, PhD, Centaur Fellow, MACN, MACORN

Standards Editor, Australian College of Operating Room Nurses (ACORN)
Dr Zaneta Smith | RN, BN, CERT IV BUSINESS, PG DIP, (Clin Prac-Periop), MNURS (Clin Prac-Periop with
DISTINCTION), PhD, FACORN
xvi
Chapter 1
PERIOPERATIVE NURSING
SALLY SUTHERLAND-FRASER, SONYA OSBORNE AND KIM BRYANT

EDITOR: SALLY SUTHERLAND-FRASER
LEARNING OUTCOMES
• Discuss the history and philosophy of perioperative nursing practice
• Describe the patient journey and the overlap of perioperative nursing roles in the management of the
patient
• Examine cultural safety and the nurse’s role as patient advocate within perioperative nursing practice
• Outline the role of professional perioperative nursing organisations
• Explore the regulatory environment within Australasia and the influences for change in perioperative
nursing practice
• Discuss the importance of research and an evidence-based approach to practice and the need for
professional development
• Define advanced practice and explore opportunities for expanded scopes of practice
KEY TERMS
accountability
advanced practice
advocacy
competency
continuing professional development
cultural safety
evidence-based practice
orientation programs
patient journey
perioperative
perioperative nursing roles
practice standards
professional associations
scope of practice
supervision
1
PERIOPERATIVE NURSING AN INTRODUCTION
optimal patient outcomes and research-based

INTRODUCTION healthcare
This chapter introduces the beginning periopera- • ensures a safe physical environment for all
tive nurse to the key concepts and principles (ACORN, 2016).
informing perioperative practice within Australa-
sia. It describes the patient care roles of the nurse Perioperative nursing is one of the oldest nurs-
as well as the perioperative context and culture that ing specialties, dating back to the late 1800s when
inform the delivery of care during the surgical surgery was becoming more complex and required
patient’s journey. Aspects of the regulatory envi- qualified assistants: nurses were considered the
ronment are examined, such as advocacy, account- most qualified professionals to undertake that role
ability, delegation and scope of practice. In addition, (Wade, 2012). Despite this prestigious beginning,
the chapter explores the role of professional asso- educational, societal and political influences have
ciations and highlights the importance of practice led to the decline of perioperative nursing in the
standards for perioperative nursing. The role of undergraduate nursing curriculum (Wade, 2012).
evidence-based practice (EBP) is also acknowl- Nonetheless, medical advancements and changes in
edged. As this dynamic nursing speciality continues the healthcare system provide the professional
to evolve, the chapter concludes with a discussion nurse with a multiplicity of roles to practise in the
of emerging advanced-practice roles for periopera- perioperative environment—an environment that is
tive nurses. continually expanding its geographical boundaries
and is no longer confined to the operating room.
Furthermore, the perioperative nurse has an imper-
THE HISTORY AND PHILOSOPHY ative to explore strategies not only for professional
OF PERIOPERATIVE NURSING development through continuing education and
specialist postgraduate education but also for prac-
The term perioperative refers to the period of time tice development through engagement in research
between preparation for an anaesthetic, surgery and evidence-based practice.
or other procedure and recovery from these inter-
ventions (Australian College of Operating Room
Nurses [ACORN], 2016). The perioperative nurse is THE PATIENT JOURNEY
a skilled healthcare professional who provides care
to patients during this period, in collaboration with Advances in surgical technology and procedures,
other members of the healthcare team. The periop- improvements in anaesthetic techniques and
erative environment is one of the most complex changes in the healthcare environment have altered
work environments in healthcare. This complexity where and how surgery and invasive procedures are
is evident in the diversity of surgical procedures performed (these concepts are explored in following
performed, the specialised technology used and the chapters). The boundary of the patient undergoing
number of staff required to ensure safe patient care. surgery has shifted from the traditional geographi-
The nurse working in the perioperative environ- cal boundary of the operating room (OR) to the
ment may experience rapidly changing situations, broader perioperative environment, encompassing
requiring precision and coordination to manage the wider spatial and temporal boundaries of patient
patient care efficiently and effectively. The periop- care from assessment and care of the patient before
erative nurse also acts as a patient advocate during surgery (preoperatively), during surgery (intraop-
the perioperative journey when patients may feel eratively) and after surgery (postoperatively). In
physically and psychologically vulnerable (Cousley, addition, the patient’s surgical experience can
Martin & Hoy, 2014). The philosophy of periopera- extend far beyond admission and discharge. The
tive nursing encompasses a holistic, multidiscipli- patient journey may begin as early as the pre-
nary approach that: hospital onset and assessment of symptoms and the
decision to operate, will include the period of hos-
• acknowledges the dignity of persons with pital management and continue through the period
diverse physical, emotional and cultural of home recovery and rehabilitation in the commu-
backgrounds nity (see Fig. 1-1). Regardless of where the surgical
• promotes the knowledge and skills of all patient’s experience takes place, perioperative
multidisciplinary team members to deliver nurses have an imperative to do what nurses do
2
CHAPTER 1 | Perioperative nursing
Home
• Postoperative follow-up
Hospital • Community health services
• Admission
• Procedural and
Pre-hospital endoscopy rooms
• Interventional suites
• Doctor’s office • Medical imaging
• Surgeon consult departments
• Pre-admission • Preoperative holding
clinic • Anaesthetic bay
• Operating room
Home • Postanaesthesia
care unit (PACU)
• Stage 2 day surgery
or ward
FIGURE 1-1: The perioperative patient journey

Source: Osborne et al. (2015).
best—keep the focus on the patient. The whole by that person or family. Culture includes,
patient journey must be mapped out to ensure that but is not restricted to, age or generation;
patients move through their experience in as safe a gender; sexual orientation; occupation and
way as possible (Pearse et al., 2012). socioeconomic status; ethnic origin or migrant
The interplay of several factors is critical in experience; religious or spiritual belief; and
assisting perioperative nurses in their role as disability.
coordinator of patient care with the aim of the The consequences of globalisation and coloni-
best possible outcome for the patient. An increased sation on communities around the world include
awareness of patient safety issues and unfavourable health inequities, social marginality, poverty,
latent risk factors can help perioperative nurses stigma and racism, all of which are a central concern
minimise risk and maximise safety (van Beuzekom in Australia and New Zealand (NCNZ, 2011a;
et al., 2012)—these issues are addressed in more National Aboriginal Community Controlled Health
detail in Chapter 2. The knowledge and skills of spe- Organisation [NACCHO], 2011; Cox & Simpson,
cialist perioperative nurses and their role as patient 2015). It is important for healthcare professionals
advocate, underpinned by a culturally safe and to consider the cultural implications of their
ethically caring approach, contribute to ensuring a practice not only for the patients in their care,
safe patient journey and better patient outcomes. but also for their colleagues in culturally diverse
healthcare teams. Box 1-1 describes these concepts
CULTURAL SAFETY in more detail.
Perioperative nurses have a duty of care throughout

the patient journey to verify that the patient’s PATIENT ADVOCATE
needs are met (Lachman, 2012). Good nursing care An advocate is a person who puts forward a case on
requires the competence to individualise care not someone else’s behalf or publically supports a cause
only for the patient’s physical and psychological or policy (Oxford Dictionaries, 2015). Advocacy is
needs but also for the patient’s cultural and spir- an important perioperative nursing role when
itual needs, which at times may include the patient’s implemented judiciously. Acting as the patient’s
family (Vanlaere & Gastmans, 2011). The Nursing advocate has legal and ethical implications. Due to
Council of New Zealand ([NCNZ] 2011a, p. 7) defines their work environment, perioperative nurses have
cultural safety as: the added responsibility to advocate for their
The effective nursing practice of a person or patients. This is particularly so when patients are
family from another culture, and is determined sedated or unconscious during surgery or other
3
BOX 1-1 » CULTURAL SAFETY AND CULTURAL COMPETENCE

Cultural safety aims to decrease cultural dominance and racism in healthcare (McCleland, 2011). It
acknowledges that inherent power imbalances exist between the healthcare provider and the people
who use the healthcare service. Cox and Simpson (2015) suggest that these power imbalances can be
perpetuated by the actions (and/or inactions) of healthcare professionals. Patients are stripped of the
vestiges of their personal and social identities through the donning of a hospital gown, and by an
environment where medical technology is omnipresent and where healthcare professionals use the
impersonal language of surgery. Culturally competent healthcare services therefore seek the
contribution and involvement of patients in their own care, with the aim of restoring the balance of
power to the patient (Hamlin & Anderson, 2011).
invasive procedures and are unable to look after and is in conflict with national codes of conduct
themselves or communicate their needs or wishes and ethics (NCNZ, 2012a; Nursing and Midwifery
(Battié & Steelman, 2014). Whether it is their first Board of Australia [NMBA], 2013a, 2013b). It may
surgical experience or a return, patients may feel also place the perioperative nurse at risk of legal
vulnerable, fearful or insecure during their periop- proceedings and professional scrutiny. If faced with
erative journey (Cousley, Martin & Hoy, 2014). As this type of situation, the nurse must speak up. This
patient advocate, the perioperative nurse works to should be done in ‘a respectful, assertive manner
ensure that the patient’s physical and emotional that promotes high-quality care from the entire
needs are met and must be ready to intervene to team’ (Battié & Steelman, 2014, p. 537). The peri-
protect the patient’s safety. This may include speak- operative nurse may also seek advice from more
ing up when potential exists for injury or if correct senior colleagues to confirm the appropriate course
standards of perioperative practice or local policies of action, which may include escalation to the unit
are not being followed. manager. See Chapter 4 for further information on
Advocating for patients is not without its chal- the legal and ethical implications of advocacy.
lenges. To be an effective advocate the perioperative
nurse must understand and anticipate individual PERIOPERATIVE NURSING ROLES
patient needs (ACORN, 2016). However, the profes- Perioperative nursing is a highly skilled specialty,
sional relationship between the patient and the incorporating a number of subspecialties. Within
perioperative nurse is brief. Unlike colleagues in each environment, there are clearly defined peri-
other units, the perioperative nurse has a short operative nursing roles providing patient care
timeframe to assess, plan and implement indi within a large multidisciplinary team whose com-
vidualised care. Assessment tools assist the periop- bined goal is patient safety. Perioperative patient
erative nurse to efficiently gather relevant data care focuses on the core elements of the patient’s
including cultural, language and religious informa- physiological responses to surgery as well as the
tion. The perioperative nurse must allocate suffi- patient and family’s behavioural reactions to
cient time to communicate with patients, conduct surgery (Rauta et al., 2012). This requires periop-
the necessary assessments and communicate rele- erative nurses to be educated in nursing theory and
vant findings to the perioperative team. the health sciences and to have highly developed
Most commonly, the perioperative nurse advo- non-technical skills in interpersonal communica-
cates on the grounds of patient safety, because tion, teamwork, situation awareness and coping
safety is the primary concern of the perioperative with stress (Clayton, Isaacs & Ellender, 2014; Lyk-
team (Murphy, 2015, p. 16). This can be challenging, Jensen et al., 2014; Mitchell et al., 2011). Knowl-
especially if acting on behalf of the patient brings edge in relation to standards of perioperative
the perioperative nurse into conflict with col- practice is essential to perform all nursing roles
leagues, some of whom may be friends or more safely and effectively (e.g. infection prevention and
experienced senior colleagues. However, failure to control; aseptic technique; standards for cleaning,
speak up may compound the harm to the patient disinfecting and sterilising).
4
Perioperative nurses may function as clinicians after surgery. Specifically, the anaesthetic nurse
in principally hands-on roles, or as managers and provides nursing care to the patient and procedural
consultants, educators or researchers, while some support to the anaesthetic team during the prepa-
nurses skilfully combine these functions. The scope ration for and induction of anaesthesia, throughout
of perioperative nursing reflects the numerous dis- maintenance of anaesthesia and during emergence
crete clinical settings along the surgical patient’s from anaesthesia. The presence of an appropriately
journey, with roles including preadmission nurse, educated assistant to the anaesthetist—with the
anaesthetic nurse, circulating nurse, instrument requisite knowledge, skills and competence—is
nurse, surgical assistant roles, postanaesthesia care integral for the safe and efficient administration of
unit (PACU) nurse, as well as nurse practitioner (NP). anaesthesia (ACORN, 2016; New Zealand Nurses
Organisation [NZNO], 2014a; Australian and New
Zealand College of Anaesthetists [ANZCA], 2015a,
PREADMISSION NURSE
2015b). Both ACORN (2016) and the Perioperative
The preadmission nurse plays an important role in Nurses College of the NZNO (2014a) support the
the preparation of the patient for surgery by func- registered nurse (RN) undertaking this role. While
tioning in a screening role, detecting medical or in some facilities the role of assistant to the anaes-
physical conditions that may generate a referral to thetist may be assumed by an enrolled nurse (EN)
the surgeon, anaesthetist or perioperative nurse or technician (who may or may not be regulated),
practitioner. The responsibilities of the preadmis- both must work within their own defined scope of
sion nurse include communicating with patients practice under appropriate supervision as deter-
about preoperative tests and providing patient edu- mined by the relevant regulatory board authority
cation and resources about the planned procedure (ACORN 2016; NCNZ, 2012b). Some of the role
or surgery. See Chapter 7 for further information on responsibilities of the anaesthetic nurse are out-
the preadmission nurse’s role with patient assess- lined in Box 1-2.
ment and preparation for surgery.
CIRCULATING NURSE
ANAESTHETIC NURSE The circulating nurse (also known as the scout
The anaesthetic nurse is integral to the care of the nurse) is critical to the patient’s surgical outcome
perioperative patient and cares for the patient in and the patient and family’s experience. With the
the immediate time period prior to, during and prime aims of identifying risk and maximising
BOX 1-2 » ROLE RESPONSIBILITIES OF THE ANAESTHETIC NURSE

• Participate in patient identification and other processes outlined in the ‘Surgical Safety Checklist’
(SSC), commencing with the ‘Sign in’ checklist (see Chapter 9)
• Advocate for the patient
• Collaborate with and assist the anaesthetist during the preparation, induction, maintenance and
emergence phases of anaesthesia
• Anticipate and provide equipment/supplies for routine and emergency anaesthetic procedures
• Assist the patient to maintain a clear airway
• Assess and monitor the patient
• Assess and document fluid balance
• Assist with patient transfer and positioning before and after surgery
• Evaluate the effectiveness of planned care
• Collaborate with postanaesthesia care unit (PACU) staff to provide patient care (ACORN, 2016;
NZNO, 2014a)
5
BOX 1-3 » ROLE RESPONSIBILITIES OF THE CIRCULATING NURSE

• Participate in processes outlined in the SSC
• Anticipate the needs of the surgical team before and during surgery
• Monitor any breach in aseptic technique and initiate corrective action
• Perform the surgical count with the instrument nurse
• Ensure correct handling and labelling of surgically removed human tissue and explanted items
• Document intraoperative nursing care and patient outcomes (ACORN, 2016)
safety, the circulating nurse serves as patient advo- and scope of practice of the individual nurses within
cate while patients are least able to care for them- the team and the structure of the surgical team. For
selves. The focus of patient assessment before, instance, in some facilities it is the responsibility of
during and after the operation or procedure is on the anaesthetic nurse to check the patient’s details
the patient’s physiological, psychosocial and emo- (e.g. correct identity/surgical site, consent, allergies
tional needs. Both ACORN (2016) and the NZNO and so forth) on admission to the department,
(nd) support the RN undertaking this role. The cir- whereas this duty may be incorporated in the role
culating nurse’s role is complex, encompassing of the circulating or instrument nurse in other facil-
management of nursing care of the patient within ities. During surgery, the instrument nurse’s role
the OR and coordination of the needs of the surgi- should be distinct from, and not overlap with, the
cal team and other care providers necessary for the role of the first surgical assistant—that is, the person
completion of surgery. During the procedure, the assisting the surgeon. While there may be times
circulating nurse is mobile and observes the surgery when these roles overlap to ensure patient safety
and the surgical team from a broad perspective, (e.g. managing patient haemorrhage, difficult access
outside of the aseptic field, to assist the team in to the operative site), this should not occur rou-
creating and maintaining a safe and comfortable tinely. Box 1-4 highlights some of the responsibili-
environment for the patient. The circulating nurse ties associated with the instrument nurse role.
often has only a short timeframe in which to estab-
lish rapport and a therapeutic bond with the patient SURGICAL ASSISTANT NURSING ROLES
and his or her family or carers and can be central Changes in healthcare delivery have precipitated
in ensuring a ‘good experience’ for families by pro- the recognition of the advanced and extended
viding periodic updates of the surgery (Blum & practice role for RNs in the perioperative setting
Burns, 2013). Some of the role responsibilities of (ACORN, 2016), thus supporting the need for a
the circulating nurse are summarised in Box 1-3. highly skilled, knowledgeable and experienced sur-
gical assistant (Lynn & Brownie, 2015). With the
INSTRUMENT NURSE background of an instrument nurse, the periopera-
The instrument nurse (also known as the scrub tive nurse surgeon’s assistant (PNSA) in Australia
nurse) works directly with the surgeon within the and the registered nurse first surgical assistant
aseptic field, managing the instruments and other (RNFSA) in New Zealand (NZNO, 2015) are equipped
items needed during the procedure. The circulating to assist the surgeon primarily in the intraopera-
nurse and the instrument nurse have a dual role in tive phase with such duties as tissue retraction
checking to ensure that all appropriate sterile and dissection, haemostasis and wound closure, as
instrumentation and surgical supplies are available well as across all phases of the patient’s periopera-
and functional before the scheduled theatre operat- tive journey. Preoperatively, the PNSA can under-
ing room list commences (ACORN, 2016). The take preoperative assessment and history taking;
responsibilities of the circulating and instrument and postoperatively, assist in assessment of the
nurse may overlap with those of the anaesthetic patient’s physiological and behavioural response
nurse, depending on local policy, the competency to the operative procedure and preparation for
6
BOX 1-4 » ROLE RESPONSIBILITIES OF THE INSTRUMENT NURSE

• Participate in processes outlined in the SSC
• Prepare the instruments and equipment needed in the operation
• Anticipate the needs of the surgical team before/during surgery
• Work directly with the surgical team
• Adhere to and maintain aseptic technique throughout the procedure
• Monitor any breach in aseptic technique and initiate corrective action
• Perform the surgical count with the circulating nurse
• Ensure correct handling of surgically removed human tissue and explanted items
• Ensure documentation of intraoperative nursing care is accurate and complete, including patient
outcomes (ACORN, 2016)
BOX 1-5 » ROLE RESPONSIBILITIES OF SURGICAL ASSISTANT NURSES

• Undertake physical patient assessment, including medical history, and (in collaboration with the
surgeon) organise required clinical investigations
• Collaborate with the patient, surgeon and other healthcare team members to develop a clinical
pathway
• Develop education programs for patients/staff
• Assist with skin preparation, draping, haemostasis, cutting sutures/ligatures, retracting organs and
skin closure
• Provide postoperative (PO) care in wound management, education, dressing application and so forth
(ACORN, 2016; NZNO, 2015)
discharge planning (Lynn & Brownie, 2015). The following a surgical or other procedure, and usually
scope and role of the PNSA is determined by the including recovery from anaesthesia (ACORN,
local facility, usually meeting local credentialling 2016; NZNO, nd). The role of the PACU nurse is to
criteria. The lack of recognition of the PNSA role as ensure patient safety, following transfer of care
an advanced practice role by nursing regulatory from the OR to the PACU. Vigilance is crucial in
authorities (i.e. the Nursing and Midwifery Board achieving the intended outcome as the patient is at
of Australia [NMBA] and the Australian Health increased risk during this part of the journey, when
Practitioner Regulation Agency [AHPRA]) limits many serious physiological changes can occur
the scope and potential of PNSAs in practising as rapidly in the patient and there are great demands
independent practitioners (Lynn & Brownie, 2015). on both delivering and receiving staff for a smooth
Nonetheless, their importance to positive surgical transfer (Randmaa et al., 2015). In some healthcare
patient outcomes cannot be overlooked. Box 1-5 facilities, the PACU and anaesthetic nurse roles are
details some of the responsibilities undertaken by interchangeable, with nurses working across both
these RN roles. subspecialties. Enrolled nurses may be included in
the PACU nursing team, working under the super-
PACU NURSE vision of the experienced PACU nurse to provide
The PACU nurse (also known as the recovery room safe patient care (ACORN, 2016). Box 1-6 outlines
nurse) is an important member of the periopera- some of the role responsibilities performed by the
tive team, providing patient care immediately PACU nurse.
7
BOX 1-6 » ROLE RESPONSIBILITIES OF THE PACU NURSE

• Conduct patient assessments and monitor vital signs
• Perform resuscitation
• Manage the patient’s acute pain, nausea and vomiting
• Monitor and manage the patient’s haemodynamic status
• Document nursing care and patient outcomes
• Respond promptly to and report any aberrant changes in the patient’s condition to the anaesthetist
and/or surgeon
• Provide a comprehensive clinical handover to the nurse caring for the patient in the receiving PO
unit (ACORN, 2016; NZNO, nd)
BOX 1-7 » ROLE RESPONSIBILITIES OF THE NP

• Undertake a comprehensive health assessment and make decisions using diagnostic capability
• Order and interpret diagnostic and laboratory tests
• Plan care and engage others, working in partnership with patients, families and communities
• Prescribe and implement therapeutic interventions
• Refer to other healthcare professionals for management outside of NP scope of practice
• Evaluate patient outcomes and improve practice (ACORN, 2016; NMBA, 2013c; NCNZ, 2014)
PERIOPERATIVE NP authority. Box 1-7 details some of the role respon-

The nurse practitioner in Australia is an advanced sibilities undertaken by the NP.
practice nurse (APN) with title protection, working
in an extended practice role with legislated author-
ity to diagnose, prescribe medications and other
THE REGULATORY ENVIRONMENT
therapeutic interventions, order diagnostic investi- The practice of nurses and other health profession-
gations and refer patients to other health profes- als is regulated to protect the public. In Australia,
sionals (ACORN, 2016). It is an expectation of each state and territory has enacted a version of
endorsement that NPs are competent and capable the Health Practitioner Regulation National Law
in the specific area of practice required to meet the (AHPRA, 2015), known simply as the National Law,
needs of their client group (NMBA, 2011). In the while the Health Practitioner Competence Assur-
perioperative environment, the extended parame- ance Act 2003 regulates nursing practice in New
ters of NP practice contribute to continuity of care Zealand (Parliamentary Council Office, 2013). In
for a smooth perioperative patient journey. NPs Australia, the NMBA is the statutory decision-
practising at an advanced level in a specific area of making body under the National Law responsible
practice were first introduced in New Zealand in for registering nurses and ensuring that they are
2000 and the NZNO provides a framework and competent and fit to practise. This includes regis-
program for the mentorship of RNs to prepare for tered nurses (RNs) and enrolled nurses (ENs, known
NP registration (NZNO, 2014b). In Australia, there as Division 2 registered nurses on the register in
are National Standards underpinning NP practice. Victoria). In New Zealand, the equivalent decision-
In both Australia and New Zealand, nurse practi- making body is the Nursing Council of New Zealand
tioners must be Masters prepared and endorsed or (NCNZ) (see Fig. 1-2). Nursing practice in Aus
registered to practise by the relevant regulatory tralasia is further informed by national codes of
8
Health Practitioner Regulation National Law

NMBA The Nursing and Midwifery Board of Australia is responsible for
registration, ensuring competence and fitness to practise, national codes of
conduct and ethics, policies and guidelines
ACN and ANMF The Australian College of Nursing and the Australian
Nursing & Midwifery Federation are key national professional nursing
organisations; ANMF is also the industrial body
ACORN The Australian College of Operating Room Nurses is the
national professional organisation for perioperative nurses and
produces the ACORN Standards for Perioperative Nursing
Health Practitioner Competence Assurance Act

NCNZ The Nursing Council of New Zealand is responsible for registration,
ensuring competence and fitness to practise, national codes of conduct and
ethics, policies and guidelines
NZNO The New Zealand Nurses Organisation is the key national professional
nursing organisation and industrial body
PNC The Perioperative Nurses College is the national professional
organisation for perioperative nurses and produces the PNC Standards.
PNC members also have access to AORN's Guidelines for Perioperative
Practice
FIGURE 1-2: Summary of Australasian regulatory and professional entities of relevance for perioperative nurses
professional conduct and ethics (NCNZ, 2012a; comprises a majority of regulated health profession-
NMBA, 2013a; 2013b), as well as policies and guide- als (e.g. RNs and ENs, doctors and allied health
lines regarding areas such as professional bounda- workers such as radiographers), as well as non-
ries and decision making. See Chapter 4 for further regulated ancillary staff in supporting roles (e.g.
information on the medico-legal aspects of the assistants-in-nursing [AINs], patient care assistants
regulatory environment. [PCAs], orderlies and sterilisation technicians).
Medical, allied health and/or nursing students may
An important aspect of regulation in the health-
also be present in the perioperative environment
care sector is the protection of titles including
and can contribute to the patient’s safe periopera-
those of ‘nurse’ and ‘nurse practitioner’ (NMBA,
tive journey when working under the direction of
2014). This protects the public by ensuring that
the supervising RN (ACORN, 2016). Such a team has
only those who possess the necessary qualifications
the capacity to provide the surgical patient with
and competence to practise are accepted to the
holistic care (ACORN, 2016). The effective perform-
register (NMBA, 2014). New perioperative nurses
ance of this diverse perioperative team within a
should note that while it takes many years of train-
regulated practice environment depends on each
ing for a doctor to specialise in surgery, the title
individual’s competency, accountability and scope
‘surgeon’ is not protected. Feature box 1-1 high-
of practice. Decision making about the appropri
lights the risks that this anomaly in the regulatory
ateness of delegations and the supervision of dele-
system can pose for healthcare consumers.
gated activities also influence performance. These
Surgical patients encounter a mix of healthcare concepts and how they apply to the perioperative
workers during their perioperative journey. This mix nurse are explored in the following sections.
9
FEATURE BOX 1-1 » INCONSISTENCIES IN THE REGULATORY SYSTEM
In 2015, three separate incidents were referred for investigation by the Health Care Complaints
Commission (HCCC) NSW. Each incident occurred in a small private clinic during an invasive pro-
cedure performed by cosmetic surgeons, with two of the patients requiring admission to intensive
care units for resuscitation and further treatment.
A media report of the incidents highlighted the risks associated with cosmetic surgery, which is
largely unregulated in New South Wales, advising healthcare consumers to ‘ask if the clinics they
attend record and independently investigate adverse events’ (Patty, 2015, p. 3). The report also
drew attention to inconsistencies in the regulatory system, noting: ‘Doctors registered as plastic
surgeons undergo at least 5 years of specialist training and are required to record adverse events.
Cosmetic surgeons are not required to have full plastic surgery training with the Royal Australasian
College of Surgeons and are not required to report adverse events’ (Patty, 2015, p. 3).
The incidents prompted the NSW Opposition spokesperson for health at the time, Walter Secord,
to call for a review of such titles, saying ‘Currently, practitioners have free rein to give themselves
the title of surgeon, even though they may only have the most basic medical qualification—a
Bachelor of Medicine’ (Patty, 2015, p. 3).
COMPETENCY The NCNZ’s extended definition of accountability

Competency refers to the combination of an indi- is presented in Box 1-8.
vidual’s skills, abilities and knowledge along with RELATIONSHIP BETWEEN ACCOUNTABILITY,
attitudes and personal values that enable effective DELEGATION AND SUPERVISION
performance (NCNZ, 2007; NMBA, 2013c). The
Being accountable means that perioperative nurses
importance of competency in perioperative set-
(both RNs and ENs) must be answerable to others
tings becomes apparent if, for example, a circulat-
(such as their patients, colleagues, employers and
ing nurse is allocated to the anaesthetic nurse role
regulatory bodies) for their actions and behaviours,
and finds that she or he is required to assist with a
as well as for any decisions they make during the
difficult intubation. If this nurse has no prior expe-
performance of their role (ACORN, 2016). A common
rience in this role or lacks competency for the activ-
example of accountability is when an RN delegates
ity, the individual nurse may be performing outside
an EN to the role of instrument nurse. In demon-
her or his personal scope of practice at that time.
strating accountability, the delegating RN must
The nurse can request additional instruction or
supervise the EN’s performance and evaluate the
support before accepting such a delegation.
outcomes of the delegated activity to ensure that
they meet expected professional standards (ACORN,
ACCOUNTABILITY
2016). This is so because of the ‘delegation rela-
In all of their activities, nurses remain accountable tionship’ (NMBA, 2013d):
for their practice and, along with advocacy, this
concept is enshrined in national codes of conduct [this relationship exists when] one member of
(NCNZ, 2012a; NMBA, 2013a). This is so whether the multidisciplinary health care team dele-
the nurse is an RN or an EN who works under the gates aspects of consumer care, which they are
supervision and direction of an RN (ACORN, 2016). competent to perform and which they would
The NCNZ defines accountability as answering for normally perform themselves, to another
one’s decisions and actions (2012b), a requirement member of the health care team from a differ-
that applies equally to RNs and ENs. The NCNZ ent discipline or to a less experienced member
has produced two guidelines for RNs that highlight of the same discipline (NMBA, 2013d, p. 17).
the important connection between accountability Each delegation needs to be judged on the cir-
and the practice of delegation to ENs (NCNZ, cumstances and the outcome of the delegation
2012b) and healthcare assistants (NCNZ, 2012c). needs to be assessed (NCNZ, 2012b; NMBA, 2013d).
10
BOX 1-8 » UNDERSTANDING ACCOUNTABILITY: THE NEW ZEALAND PERSPECTIVE

‘Nurses hold positions of trust and responsibility within the community. As registered health
practitioners, nurses are answerable for their decisions and actions. They are professionally accountable
to the Nursing Council and accountable under legislation for their actions. They must also answer to
their employer and to health consumers, and must be able to justify their decisions. Registered nurses
use their professional knowledge, judgment and skills to make decisions in partnership with health
consumers based on their best interests. Registered nurses are responsible for ensuring enrolled nurses
have the knowledge and skills to undertake delegated nursing activities. They should inform health
consumers when they are delegating aspects of nursing care to enrolled nurses.
‘Both registered and enrolled nurses accept responsibility for ensuring their nursing practice and
conduct meet the standards of professional, ethical and relevant legislative requirements. Enrolled
nurses must accept responsibility for their actions and decision making within the enrolled nurse scope
of practice. Enrolled nurses are responsible for ensuring they have the knowledge and skills to perform
nursing care before accepting responsibility’ (NCNZ, 2012b, p. 5).
BOX 1-9 » EXAMPLES OF THE PERIOPERATIVE RN’S ACCOUNTABILITY FOR DELEGATED

DECISIONS
• The RN monitoring a nursing student’s placement of a forced-air warming device on a patient
in the anaesthetic bay
• The RN assessing a patient’s skin integrity after the orderly has removed the pneumatic tourniquet
cuff from the patient’s thigh
• The RN examining the functionality of the flexible scope after reprocessing by the sterilising
technician before releasing it to the proceduralist
• The RN supervising the nursing student attending to the recovery patient’s hygiene and comfort
See Chapter 4 for the legal and ethical implications of accountability, particularly in relation to the
surgical count and with documentation.
SOURCE: ACORN, (2016).
By supervising the activity, the delegating RN can the broader nursing profession; that is, ‘the full
monitor whether the EN requires additional support spectrum of roles, functions, responsibilities, activ-
and instruction in his or her performance; it also ities and decision-making capacity that individuals
means that the RN will be in a position to respond. within that profession are educated, competent
ACORN (2016) identifies supervision as a specific and authorised to perform’ (NMBA, 2013d, p. 1).
responsibility for the perioperative RN. For example, Perioperative nurses as individuals, however, nec-
ACORN stipulates that the circulating nurse working essarily have their scope of practice more specifi-
with the EN instrument nurse must be an RN for cally defined than that of perioperative nurses as
performance of the surgical count (see Chapter 9 a group, or indeed the nursing profession as a
for further information). The RN may also be whole. For example, RN anaesthetic nurses in Aus-
required to coordinate patient care activities by tralia can administer medications to the patient,
supervising, overseeing or directing the activities of while EN anaesthetic nurses cannot unless they
other members in the team, such as the ancillary have graduated from a Board-approved EN medi-
staff. Box 1-9 provides further examples of supervi- cine administration course (NMBA, 2015a) and
sion and the RNs accountability in the perioperative are supported by the organisation to do so. Along
environment. the same lines, the RN in the PACU cannot order
a chest X-ray or PO opioid analgesia for the
SCOPE OF NURSING PRACTICE patient, but an endorsed NP can do so if working
Specialist nurses such as perioperative nurses in the authorised role of a perioperative NP
must function within the scope of practice of (NMBA, 2011).
11
BOX 1-10 » GUIDE FOR NURSING PRACTICE DECISIONS: STATEMENTS OF PRINCIPLE

1. The primary motivation for any decision about a care activity is to meet clients’ health needs or to
enhance health outcomes.
2. Nurses are accountable for making professional judgements about when an activity is beyond their
own capacity or scope of practice and for initiating consultation with, or referral to, other members
of the healthcare team.
3. Registered nurses are accountable for making decisions about who is the most appropriate person
to perform an activity that is in the nursing plan of care.
4. Nursing practice decisions are best made in a collaborative context of planning, risk management
and evaluation (NMBA, 2013d, pp. 6–7).
BOX 1-11 » INFLUENCES FOR CHANGE IN NURSING PRACTICE

• Legislative or technological changes
• Community expectations
• Professional development
• Changes in education
• Resource changes, including availability of healthcare workers and an ageing workforce
• Work practice changes (NMBA, 2013d)
Scope of practice is an important considera- initiated by organisations or professional groups,

tion when delegating care. The NMBA’s national changes in other health professions or emergent
decision-making framework (DMF) comprises a set new healthcare roles (NMBA, 2013d) (see Box 1-11).
of nationally agreed principles with the purpose of The development of advanced practice roles for
guiding nurses (and midwives) to make consistent RNs such as the PNSA and NP roles are examples
and appropriate decisions about patient care and of how these influences for change have shaped
who is best suited to provide that care (NMBA, perioperative nursing practice in Australia during
2013d). Box 1-10 outlines the DMF statements the past decade (specific examples of these roles
of principle that should guide nursing practice are explored later in this chapter). The develop-
decisions, particularly in relation to allocation of ment of the EN instrument nurse role is another
care roles. outcome of the influence for change on periopera-
More information about the DMF, including tive nursing practice. Once considered an advanced
template tools, a decision flowchart and summary practice role for ENs, the EN instrument nurse
guide, can be sourced from the NMBA website at is accepted as part of the perioperative nursing
www.nursingmidwiferyboard.gov.au. model in Australia. Allocation of the instrument
role (and indeed all nursing roles) remains depend-
INFLUENCES FOR CHANGE IN ent on the specific patient’s needs and the knowl-
edge, skills and scope of practice of the individual
NURSING PRACTICE nurse, whether the allocation is an RN or an EN
Nursing practice is dynamic and ever-changing and (ACORN, 2016).
nurses need to be flexible and adjust to changes in
the healthcare environment in ways that are ben- INFORMAL AND CONTINUING
eficial for patients (NMBA, 2013d). Influences for
change in nursing practice arise for several reasons,
PROFESSIONAL DEVELOPMENT
not the least of which may be work practice changes, Progress along the nursing career pathway requires
such as the introduction of new models of care a commitment to lifelong learning (NMBA, 2015b).
12
This commitment is even more important in spe- supports the view that specialist educational prep-
cialty areas such as perioperative nursing, where aration underpins safe patient care and provides
patient safety depends on nurses’ knowledge of the theoretical basis for the specialist clinician
technology, health policy and nursing practice (ACORN, 2016). Furthermore, ACORN recommends
(ACORN, 2016). As part of the national registration that RNs complete postgraduate studies and
process for all health professionals (AHPRA, 2015), encourages graduates to consider research activi-
nurses must meet a number of requirements to ties as a means of advancing perioperative nursing
maintain an annual authority to practise. This practice (ACORN, 2016).
includes the need to demonstrate recency of prac- RNs seeking to enhance their perioperative
tice and meet a prescribed level of continuing pro- knowledge and clinical skills can choose from a
fessional development (CPD). In Australia, under number of postgraduate studies, including graduate
the National Law, nurses are required to participate certificates and diplomas up to Masters and doc-
in a minimum of 20 hours CPD each year. Under toral level. While courses for advanced practice
the Health Practitioners Competence Assurance roles and NP roles begin at Masters level, there are
Act 2003, nurses in New Zealand are required to many postgraduate certificates providing speciali-
complete 60 hours of professional development sation in the circulating and instrument nurse roles,
over 3 years. Nurses are responsible for recording anaesthetics, postanaesthesia care, pain manage-
their CPD activities, which may include: ment and critical care nursing. Other areas such as
• formal education programs or certified courses health management, safety and quality, infection
• workplace learning, including mandatory prevention, or teams and communication may also
education activities be relevant to the perioperative clinician or the
aspiring nurse academic (see Research boxes 1-1
• self-directed activities such as journal reading, and 1-2 later in the chapter, which include recent
which should be relevant to the nurse’s area of perioperative practice areas of interest to nurse
practice and matched to individual learning researchers).
goals (NMBA, 2015b).
There are many providers of tertiary qualifica-
Neither authority mandates the process or the tool tions in Australia, including universities in every
for recording CPD activities, but each stipulates state as well as the Australian College of Nursing
that nurses should describe how the activity has (ACN, formerly The College of Nursing), which
contributed to their professional development offers fully online postgraduate certificate pro-
(NMBA, 2015b; NCNZ, nd). Box 1-12 depicts the use grams (ACN, 2015). The Queensland University of
of the NMBA template for documenting CPD activi- Technology offers a Master of Nursing program
ties by perioperative nurses with different experi- specialising in endoscopy, the first postgraduate
ence levels. program of its kind in Australia (Queensland Health,
Other professional organisations and nursing 2014). This advanced practice RN role is discussed
colleges provide members with resources for docu- later in the chapter. Postgraduate nursing programs
menting CPD; for example, the NCNZ provides a are provided by a range of universities in New
downloadable template for recording evidence of Zealand, as well as polytechnics and institutes of
CPD activities (NCNZ, 2011b) (see www.nursing technology. The NCNZ accredits and monitors
council.org.nz/Nurses/Continuing-competence). postgraduate courses, including those that contrib-
Professional portfolios can also be used to record ute to a program of study towards registration as
CPD activities and will, more importantly, provide an NP (NCNZ, 2015). The Whitireia Community
an effective mechanism for the nurse to reflect on Polytechnic is one such provider, offering a periop-
practice. The ACORN Standards identify the essen- erative postgraduate certificate on an accredited
tial values that underpin CPD for perioperative pathway leading to registration as an NP.
nurses (see Box 1-13). Prior to July 2010 and the introduction of
national registration in Australia, state-based qual-
ifications for ENs lacked standardisation, particu-
FORMAL DEVELOPMENT larly in relation to medication administration.
While nurses may gain entry to the perioperative Since then, the entry-level qualification for ENs has
workforce without specialist qualifications, ACORN changed from certificate IV to diploma level on the
13
14
BOX 1-12 »
(a) CPD records for RN team leader in the operating suite
SOURCE DESCRIPTION OF REFLECTION ON

OR IDENTIFIED TOPIC/S COVERED ACTIVITY AND
PROVIDER LEARNING DURING ACTIVITY SPECIFICATION EVIDENCE CPD
DATE DETAILS NEEDS ACTION PLAN TYPE OF ACTIVITY AND OUTCOME TO PRACTICE PROVIDED HOURS
August NMBA RN Need to clarify Self-directed Reviewed the scope As a team leader Refer to 2 hours
2015 Competency responsibility for Review DMF from the of practice for my working in the portfolio
standard 1. aspects of care National Board profession and that operating room I
Practises in with other website: of me as an will be able to
accordance members of the www.nursingmidwif individual. apply the nursing

with health team. eryboard.gov.au/Codes Gained an decision-making
legislation Unsure of my GuidelinesStatements/ appreciation of the framework when I
affecting delegation CodesGuidelines.aspx principles I need to allocate staff to
nursing responsibilities in apply when making patient care and
practice and the workplace. decisions about my delegate tasks as
health care Plan: Access and nursing practice and they arise during
review NMBA when and how I a shift.
decision-making decide to delegate
framework (DMF) activities to other
RNs and ENs.
(b) CPD records for a newly qualified nurse during orientation to the operating suite
DESCRIPTION OF REFLECTION ON
SOURCE OR IDENTIFIED TOPIC/S COVERED ACTIVITY AND
PROVIDER LEARNING TYPE OF DURING ACTIVITY SPECIFICATION TO EVIDENCE CPD
DATE DETAILS NEEDS ACTION PLAN ACTIVITY AND OUTCOME PRACTICE PROVIDED HOURS
August Perioperative Orientation to Department Mixed Clinical handover I will use ISBAR when Program 2 hours
2015 educator perioperative orientation Workshop, receiving patients into objectives and
suite folder clinical the suite and when certificate in
Principles of Copy of instruction, taking patients into PACU portfolio
perioperative timetable and self-directed Scrubbing, gowning I learnt a new technique 3 hours
nursing objectives in learning and and gloving for ‘open-gloving’ and will
portfolio reading … practise this at home
SOURCE: ADAPTED FROM NMBA SAMPLE TEMPLATE FOR DOCUMENTING CPD (NMBA, 2015b).
BOX 1-13 » ACORN’S ESSENTIAL VALUES FOR PERIOPERATIVE NURSES’ PROFESSIONAL

DEVELOPMENT
• There should be an emphasis on continuous learning, which is the foundation for the overall
approach to staff development
• Nurses are accountable for providing quality care through safe, ethical and effective practice and
maintaining competence for practice
• Professional development assists nurses to maintain the highest standard of clinical practice
• Nurses should become self-directed learners to ensure personal and professional growth through
– Self-assessment of learning gaps
– Evaluation of self and others
– Critical thinking
– Critical appraisal (ACORN, 2016)
Australian Qualification Framework (AQF). The • consultation with government on policy issues
next level on the AQF is the Advanced Diploma of • development of standards for use within their
Nursing, which enables the EN to specialise in peri- sphere of practice
operative practice (ACN, 2014). ENs may also choose
to complete an RN conversion program to access a • educational activities, such as conferences,
more diverse education pathway leading to post- public seminars and ongoing professional
graduate qualifications. education
• accreditation of independent provider
education programs
THE ROLE OF PROFESSIONAL • scholarships for study and grants for research
ASSOCIATIONS
• credentialling, accreditation or recognition of
The primary purpose of professional associations the contribution of members to the specialty.
is to protect, enhance and advance the common
interests of the organisation and its professional PROFESSIONAL NURSING ASSOCIATIONS
and non-professional members (Hamlin, 2012). The International Council of Nurses (ICN) is a
Professional associations in nursing are vital to federation of more than 130 national nurse asso
maintain a robust profession that advocates for the ciations, representing more than 16 million nurses
needs of nurses and their patients or clients, and worldwide. Founded in 1899, the ICN is the world’s
affirms the public trust (Matthews, 2012). Profes- first and widest reaching international organisation
sional associations operate at local, state, national for health professionals. Operated and led by nurses
and international levels and perform a number of internationally, the ICN aims to enhance nursing
functions, including gaining support through polit- such that it is a respected profession comprising
ical lobbying, providing education and resources for competent and satisfied nurses, which it achieves
members and the public, and developing standards via the development of sound health policies and
for professional practice (Hamlin, 2012). While pro- the advancement of nursing knowledge on a global
fessional associations have a key role in developing scale (ICN, 2013).
standards for professional practice (Nerland &
Karseth, 2015), they also provide some or all of the In Australia and New Zealand, more than 70
following opportunities for their members: professional nursing organisations represent clini-
cal, managerial, educational, research-based and
• networking and mentoring opportunities industrial interests. In Australia, two of the most
• political lobbying on behalf of members and significant national nursing organisations are the
opportunities to contribute to policy-making Australian College of Nursing (ACN) and the
15
Australian Nursing & Midwifery Federation (ANMF). it achieves primarily by publishing professional
The ACN is a key national professional nursing practice standards but also by overseeing the devel-
organisation that aims to focus on nursing leader- opment of a range of educational activities (e.g.
ship (ACN, nd), has a strong focus on influencing conferences, seminars and the publication of a
health policy nationally and provides formal educa- journal). The individual state- and territory-based
tion courses. In contrast, the ANMF is an industrial organisations maintain their own identity and peri-
body representing those who perform nursing and operative nurses become members of ACORN via
midwifery work across Australia (ANMF, 2014). membership of their local organisation.
In New Zealand, there is one coalition of nurses’
organisations, the New Zealand Nurses Organisa- PERIOPERATIVE NURSES COLLEGE OF THE NEW
tion (NZNO). It serves the professional and indus- ZEALAND NURSES ORGANISATION (PNC NZNO)
trial needs of more than 46,000 nurses and health The Perioperative Nurses College (PNC) is the pro-
workers and embraces Te Tiriti O Waitangi, ‘[seek- fessional organisation of perioperative nurses in
ing] to improve the health status of all peoples of New Zealand and is legally affiliated with the
Aotearoa/New Zealand through participation in NZNO. The mission of the PNC is to support safe
health and social policy development’ (NZNO, and optimal care of patients undergoing operative
2014d, para. 3). The NZNO has a number of sections and other invasive procedures and it achieves this
or colleges, made up of groups of members with a by promoting high standards of nursing practice
focus on a specific field or subspecialty of nursing through education and research (NZNO, 2014c).
(e.g. the Perioperative Nursing College). See Figure Specific functions of the PNC include:
1-2. Both the ACN and the NZNO are members of
• developing standards for perioperative nursing
the ICN.
• providing leadership and representation
PERIOPERATIVE NURSING ASSOCIATIONS • promoting perioperative nursing
Perioperative nursing associations (PNA) have a • developing and delivering education programs
much shorter history but otherwise have the same and resources
remit as the professional associations mentioned
• providing a mechanism for communicating
above. Initially, they functioned at local, state
with members on perioperative trends and
and then national levels but a more recent develop-
issues via a journal and newsletters and
ment has been the formation of international enti-
organisation of national and international
ties whose membership comprises national PNAs
conferences (NZNO, 2014c).
(Hamlin, 2012).
The PNC has a core set of six standards as well
AUSTRALIAN COLLEGE OF OPERATING ROOM as a number of guidance statements and service
NURSES (ACORN) guidelines. Perioperative nurses use these docu-
ments in conjunction with the NCNZ Competencies
State- and territory-based PNAs began to emerge
for Registered Nurses (NCNZ, 2007). Members of
in Australia during the 1950s and 1960s. The
the PNC NZNO are also guided in their periopera-
concept of a national body representing periopera-
tive practice by the Association of periOperative
tive nurses was envisaged in 1975, when a group of
Registered Nurses’ (AORN) Guidelines for Periop-
nurses from around the country gathered in Mel-
erative Practice (NZNO, nd), which the association
bourne (ACORN, 2013). Two milestone decisions
makes available for its members.
came out of that initial meeting: to hold a national
conference and to establish a national body with
responsibility for developing and monitoring stand- INTERNATIONAL PERIOPERATIVE ASSOCIATIONS
ards of practice. In 1977, both outcomes were There are hundreds of PNAs worldwide and it is
achieved with the first national conference held beyond the remit of this book to explore more than
in Canberra and the founding of the (then) Austral- several key associations. AORN is one of the oldest
ian Confederation of Operating Room Nurses. PNAs globally and is well-established and success-
ACORN became the Australian College of Operat- ful. It offers a wide range of educational and other
ing Room Nurses in 2000. Its focus is on improving services on a user-pays basis. For example, it articu-
and standardising perioperative nursing care, which lates nursing practices for surgical patients by
16
researching and distributing scientifically based professional practice standards define periopera-
recommendations. This activity is not dissimilar to tive nurses as a community and function as a
that achieved by other PNAs; however, political reminder for professional practice, assisting peri-
activism is one area where AORN succeeds more operative nurses when advocating for consistency
than most. This is because it has a well-structured, in quality patient care (Osborne, 2013). Standards
planned and successful approach to influencing are often used to ensure the quality of professional
health policy. This approach, led by its board and work and make principles of practice more trans-
directors, reaches all levels of the organisation parent for user groups, consumers and other stake-
and actively fosters grassroots political activism. holders (Evetts, 2011). Standards provide minimum
Working for the enactment of legislation in all requirements for practice and are regarded as gen-
states to ensure that every OR has an RN circulator erally accepted principles of patient care and peri-
is one example of AORN successfully engaging operative management. In Australia, their standing
its members to achieve an organisational goal has been clearly demonstrated in the law courts;
(Hamlin, 2012). this is further explored in Chapter 4. In healthcare,
A number of international PNAs whose members standards provide a common language and set of
are national organisations within (largely) geo- expectations that enable healthcare professionals,
graphical regions have emerged over the past two systems and organisations to work together for the
decades. These include the European Operating best patient outcomes (Osborne, 2013). Standards
Room Nurses Association (EORNA), established in and guidelines for practice are also dynamic because
1992; the Nordic Operating Room Nurses Associa- there is an imperative for continual, rigorous review
tion (NORNA), founded in 1993; and the Asian Peri- and updating in response to changes in healthcare
operative Nurses Association (ASIORNA), formed in practice, policy and legislation, and the emergence
2009 (Hamlin, 2012). The International Federation of new research, technologies and trends in surgery
of Perioperative Nurses (IFPN), launched in 1999, (Osborne, 2013).
represents 13 national organisations worldwide and
more than 80,000 perioperative nurses. It supports
perioperative nurses by working on a global scale RESEARCH AND EVIDENCE-BASED
to improve patient care, promote safe surgery and PRACTICE
develop evidence-based practice standards (IFPN,
Perioperative nurses utilise research findings in a
nd). The IFPN aims to promote education and
variety of ways in practice and on a daily basis. For
research for nurses in perioperative settings in col-
example, the World Health Organization Surgical
laboration with member organisations and other
Safety Checklist (WHO SSC) was developed in
relevant collaborators. Past and present members
response to research that examined ways to reduce
include national perioperative organisations from
surgical mortality and morbidity (Weiser et al.,
Australia, Brazil, Canada, Europe, Japan, Kenya,
2010). Where possible, evidence-based research
Korea, New Zealand, Papua New Guinea, South
findings underpin the ACORN Standards and
Africa, Thailand, the United Kingdom and the
AORN’s Guidelines for Practice (ACORN, 2016;
United States of America. The IFPN is particularly
AORN, 2015). Perioperative nurse clinicians also
committed to improving standards of patient care
conduct research into their own practice, often in
in developing countries and its activities are focused
collaboration with others. Research box 1-1 lists
on providing universally applicable guidelines for
some examples of their research activities, while
practice, which IFPN board members develop. This
Research box 1-2 presents the findings of a system-
is one of its most commendable activities. The IFPN
atic review that should be of interest to periopera-
is also an affiliate of the ICN.
tive nurses.
PROFESSIONAL PRACTICE STANDARDS AN EVIDENCE-BASED APPROACH TO PRACTICE

Both the NMBA and the NCNZ provide competency As well as applying to the perioperative nurse’s
standards and codes of conduct and ethics for decisions, competency and scope of practice,
NPs, RNs and ENs in their respective countries. accountability can also apply to the nurse’s engage-
These professional standards and codes inform ment with the latest evidence-based practice
and underpin specialty nursing practice. Specialty (EBP) and whether she or he is able to critically
17
RESEARCH BOX 1-1: Perioperative Practice Areas of Interest to Researchers
~ Evidence-based practice (Duff, Butler, Davies, Williams & Carlile, 2014a)

~ Patient skin preparation (Hadiati, Hakimi, Nurdiati & Ota, 2014)
~ Inadvertent perioperative hypothermia (IPH) (Duff, Walker, Edward, Williams & Sutherland-Fraser,
2014b)
~ Preoperative oral carbohydrate to reduce hospital length of stay (Webster et al., 2014)
~ Retained surgical items (Moffatt-Bruce, Cook, Steinberg & Stawicki, 2014)
~ Surgical safety checklists (Gillespie, Chaboyer, Thalib, Fairweather & Slater, 2014)
~ Wearing of rings and nail polish (Arrowsmith & Taylor, 2014)
~ Wrong site surgery (Algie et al., 2015)
RESEARCH BOX 1-2: Preoperative Bathing or Showering with Skin Antiseptics to Prevent Surgical
Site Infection
The human skin harbours thousands of bacteria known as ‘residential flora’. For many years, it has been
common practice to instruct surgical patients to shower or bathe using a skin antiseptic before the day
of admission to hospital. While there is evidence to support this practice as a means of reducing this
residential flora, it is unclear whether this practice can also lower the rate of surgical site infections (SSIs).
A Cochrane Systematic Review from 2004 assessed evidence from seven randomised-controlled trials
(RCTs) involving more than 10,000 patients. These trials compared the use of skin antiseptics (4% chlo-
rhexidine gluconate) with normal bar-soap or without preoperative wash. No new trials were identified
during the fifth review in 2014, which found no clear evidence to support the use of these skin antiseptics
as a means of reducing SSIs.
SOURCE: WEBSTER & OSBORNE (2015).
appraise the evidence and determine its application patients’ surgical site infections (SSIs) and staff
to practice (Spruce, 2015). Duff and colleagues must minimise the dispersal of such microorgan-
(2014a) identify the commitment to EBP as a defin- isms by wearing hats or scarves that completely
ing difference between the nursing profession cover and contain their hair (Spruce, 2015).
and technicians, or non-nurses. The perioperative
nurse’s ability to justify department policies or The perioperative nurse can seek rationales for
aspects of patient care is demonstrated most effec- practice from organisations that promote and
tively when the nurse can articulate the rationales support the synthesis, transfer and utilisation of
for her or his practice. While there will always be a evidence. In 2104, AORN began publishing the
requirement to follow departmental policies, this evidence-appraisal tools that had been used in the
does not equate with a rationale for practice. If told AORN Journal’s series of research review articles
that ‘the policy says we should do it this way’, the (Spruce et al., 2014). These tools can be accessed
new perioperative nurse should enquire about the from the journal or digital versions can be down-
rationale beyond this explanation. For example, loaded from the website by AORN members. The
perioperative staff completely cover their hair not Cochrane Collaboration is a global independent
because it is a policy requirement but because of network of researchers, professionals, patients and
the rationale that human hair harbours bacteria carers that publishes systematic reviews of the
and other microorganisms that may contribute to effects of healthcare interventions and summaries
18
of the latest research findings. These are accessible

resources for nurses seeking to support and justify
THE FUTURE OF PERIOPERATIVE
changes to practice. The Joanna Briggs Institute is NURSING PRACTICE
an international research and development agency, Several reviews have been commissioned over the
collaborating internationally with more than 70 past two decades to explore the health workforce in
entities worldwide and incorporating nursing, mid- Australia, including the 2006 Australian Health
wifery and allied health research findings. Exam- Workforce Advisory Committee (AHWAC) report
ples of systematic reviews that inform perioperative and the 2012 Health Workforce Australia (HWA)
nursing practice include the following: report, which provided Australia’s first major long-
• Cochrane Reviews term, national projection to understand the current
– preoperative bathing or showering with workforce and project future workforce demand
skin antiseptics to prevent surgical site and supply. More recently, the Grattan Institute
infection (Webster & Osborne, 2015) (see report (Duckett, Breadon & Farmer, 2014) recom-
Research Box 1-2) mended extending the boundaries of specialist
nurses and explored the benefits of endoscopy
– disposable surgical face masks for
nurses and nurses providing sedation and anaes-
preventing surgical wound infection in
thesia. At least one commonality shared by all
clean surgery (Lipp & Edwards, 2014)
workforce reports is their dependence on projec-
• JBI Systematic Reviews tions not only in future trends, increasing demands
– nurses’ experiences of advocacy in the and rising costs, but also on implications for
perioperative department: a systematic improving health service delivery.
review protocol (Munday, Kynoch &
Hines, 2014) CREATING OPPORTUNITIES FOR NURSING
– effectiveness of nurse-led preoperative SPECIALISATION
assessment services for elective surgery: a For undergraduate nurses in Australia and New
systematic review update protocol (Hines, Zealand, entry to the perioperative environment
Munday & Kynoch, 2013). may be possible as a specialist clinical placement
Some authors argue that EBP competencies of several days or weeks, or as a single visit to com-
should be set as an expectation of performance in plement a ward-based clinical placement. Such
organisations (Melnyk et al., 2014) to foster and placements can enhance the student’s understand-
maintain a culture that values EBP. Although chal- ing of the patient’s surgical experience (ACORN,
lenging, perioperative nurses have a responsibility 2016). While specialist clinical placements are
to seek ways to implement evidence-based prac- desirable for all nursing students, even a short visit
tices that have been demonstrated to improve accompanying the surgical patient on their periop-
patient outcomes (Spruce, 2015). Skills developed erative journey can have benefits for the student.
in EBP not only enable perioperative nurses to These include the opportunity for direct observa-
justify department policies, but also enhance their tion of the specialist activities provided by each of
ability to explain the care they are providing for the nursing care roles as they interact with the
their patients (Spruce, 2015). For example, a peri- patient and with each other during clinical hand
operative nurse can advise simply that she is placing over. The student nurse will also be able to observe
a blanket filled with warmed air over the patient’s the ways in which members of the multidisciplinary
body for comfort and because the anaesthetic and team care for the perioperative patient and can
surgery may be delayed if the patient’s temperature enquire about anaesthetic and surgical techniques,
remains lower than 36°C. If the patient asks why his communication and teamwork.
temperature is so important to the theatre sched- Clinical placements can influence the student’s
ule, the nurse will be able to explain that hypother- future career choice in perioperative nursing
mia may increase the patient’s recovery time as (ACORN, 2016). In 2012, HWA commissioned a
well as increasing the risk of PO wound infection national report on clinical placements to identify
(Duff et al, 2014b). When explaining care activities, the elements required for quality clinical place-
the perioperative nurse must consider how much ment (Siggins Miller Consultants, 2012). The
information is appropriate for each patient. report suggested that a quality clinical placement
19
BOX 1-14 » SAMPLE CONTENT OF AN ORIENTATION PROGRAM

1. Perioperative nursing roles and the multidisciplinary team
2. Medico-legal principles and policy
Negligence and examples of case law
Consent for surgery
Correct patient protocols (i.e. Surgical Safety Checklist)
Management of the surgical count
Documentation
3. Patient and environmental safety
4. Principles of asepsis and infection prevention
5. Care and handling of instrumentation, sterilisation and sterile supplies
6. Patient care during anaesthesia
Airway management
Induction and emergence from general and regional anaesthesia
Pharmacology and preparation of equipment for anaesthesia
7. Intraoperative patient care and surgical technology
Risk management, manual handling and patient positioning
Aseptic techniques, skin preparation and draping
Electrosurgery and other equipment
8. Postanaesthesia patient care
Patient assessment and PO complications
Pain management
Preparation for discharge
SOURCE: SUTHERLAND (2006).
depends on a combination of many things, Box 1-14 outlines potential content for an orienta-
including: tion program for new perioperative nurses, whether
this is a one-week clinical placement or part of
• a positive workplace culture that fosters
an extended transition-to-practice program. This
supportive relationships
content can be tailored depending on the supernu-
• effective clinical supervisors who can merary time allocated, the clinical demands of the
articulate and recognise the desirable skills department and the individual’s goals and prior
and behaviours for the specialty learning.
• diverse learning opportunities tailored to
student competence levels CHANGING ANCILLARY AND UNREGULATED
WORKER ROLES
• opportunities for well-supported direct
The safe and efficient delivery of health services is
patient care.
reliant on a highly educated and flexible workforce.
Educators and staff developing orientation Workforce innovation is therefore an important
programs should have regard for these elements as consideration for the healthcare sector, particularly
they apply equally for graduate nurses and other the development of nursing roles, including emerg-
new staff entering the perioperative environment. ing roles that challenge professional boundaries.
20
RNs and midwives are expected to be flexible to latter being a recognised advanced practice role
meet the changing demands of healthcare and requiring endorsement by the NMBA. In the light
make safe decisions about when and if certain of the confusion surrounding the term advanced
aspects of patient care can be delegated to ancillary practice, the NMBA defines advanced practice
and unregulated workers (NMBA, 2013e) (see Box nursing (APN) as a level of nursing practice that
1-10). The NMBA and the NCNZ both publish uses comprehensive skills, experience and knowl-
national decision-making guidelines and frame- edge in nursing care (NMBA, 2013f). The NMBA
works to assist RNs and midwives to not only supports the view that nurses practising at this level
understand the limits of their own scope of practice are educated to Masters level, may work in a special-
but also to safely delegate consumer care to other ist or generalist capacity and have a minimum of
healthcare workers (NMBA, 2013d, NCNZ, 2010). 5000 hours (approximately 3 years) of clinical focus
Changing ancillary and unregulated worker (NMBA, 2013f). The ANMF has endorsed the criteria
roles is complex in the perioperative environment, for specialty practice identified by the National
where ancillary workers, doctors and nurses work Nursing Organisations (now known as the Coalition
effectively in many combinations and teams. Ancil- of National Nursing Organisations) (ANMF, 2013).
lary workers have varying levels of education and Criteria 8 states: ‘Specialty expertise is gained
skills sets and work as assistants in nursing, order- through various combinations of formal education
lies and healthcare assistants. In Australian ORs, programs, experience in the practice area and con-
ancillary workers represent a small but important tinuing professional development. Educational pro-
part of the workforce. ACORN’s position on ancil- grams should be framed by the practice standards
lary workers is that they must work under the of the specialty and the preparation and adminis-
supervision and management of appropriately edu- tration of the programs must include appropriate
cated and experienced RNs at all times (ACORN, nursing representation’ (NNO, 2004, p. 13).
2016), providing indirect patient care only. It is As APN becomes more established and formal-
important to note that one longstanding OR role, ised, innovative ways of teaching and assessing the
that of the anaesthetic technician, is regulated in practice of experienced clinicians beyond compe-
New Zealand (Medical Sciences Council of New tency is critical to meet the demands of a changing
Zealand, nd), but this is not the case in Australia at health services context (O’Connell, Gardner &
this time. It remains to be seen whether ACORN’s Coyer, 2014). The specialist nurse must be capable
position is sustainable. In the United Kingdom, for of effectively managing nursing care when con-
example, the RN works in a team that includes fronted with unfamiliar or complex situations.
diploma-prepared, non-nurse, operating depart- Research box 1-3 provides a summary of recent
ment practitioners who are regulated and who research, which identified years of specialty experi-
undertake activities traditionally completed by ence and specialty postgraduate educational quali-
nurses. Similarly, in the United States the non- fications as significant predictors of perceived
nursing role of the scrub technologist is one that is clinical competence and leadership in perioperative
supervised by the RN circulating nurse. In many US nurses.
states, legislation has been enacted to ensure that
there is at least one RN present in the OR, working Advanced practice nurses educated to function
as the circulating nurse (AORN, 2015) to oversee with autonomy and to undertake extended clinical
nursing care and supervise these workers. Discus- activities (Duffield et al., 2011) are well placed to
sions about professional boundaries in the periop- assist with the future demands of the health service
erative environment remain controversial, both (Baldwin et al., 2013). In New Zealand, the role
here and overseas. of nurse specialist has been identified as a key res
ponse to future health service demands (Holloway,
2012); however, the lack of clarity of the APN role
CHANGING, EVOLVING AND ADVANCED ROLES has resulted in underutilisation, poor support and
FOR PERIOPERATIVE REGISTERED NURSES workforce planning constraints (Baldwin et al.,
Already seen in the perioperative environment is 2013). The Grattan Report (Duckett, Breadon &
the emergence and establishment of advanced roles Farmer, 2014) warns that hospitals are struggling to
such as the perioperative nurse surgeon’s assistant provide enough care to meet growing needs with a
and the perioperative nurse practitioner, with the shrinking workforce and if consideration is not
21
RESEARCH BOX 1-3: The Influence of Personal Characteristics on Perioperative Nurses’ Perceived
Competence: Implications for Workforce Planning
This research highlights the results of a cross-sectional national Australian study of more than 3000
perioperative nurses, examining the influence of personal characteristics on perceived competence using
the Perceived Perioperative Competence Scale. The researchers found that nearly all demographic char-
acteristics correlated with perceived competence, with years of OR experience and postgraduate specialty
qualifications being especially strong predictors of high perceived competence. The researchers recom-
mend that strategies to retain older, experienced nurses should focus on workplace redesign and workforce
planning, such as increasing remuneration and professional recognition. Other recommended strategies
include integrating technology to promote efficiency and safety, creating academic partnerships with
universities and providing perioperative nurses with specialty education and advanced skills programs.
SOURCE: GILLESPIE, HAMLIN, POLIT & CHABOYER (2013).
given to reimagining and updating workforce roles In Australia, two models for nurse endoscopy
to reflect contemporary and future needs, these practice were explored in the Advanced Practice in
‘problems will only get worse’ (p. 3). Endoscopy Nursing (APEN) sub-project (Thompson
In the light of the projections for health service et al., 2014) in response to an increase in demand
demands, it is timely for governments, regulatory for services and a shortfall in the medical work-
bodies and professional organisations to progress force. The model at Logan Hospital in Queensland
workforce innovations in perioperative nursing. (Queensland Health, 2014) is an APN model
This will require consideration of health service whereby the nurse endoscopist undertakes protocol-
needs and an intention to develop sustainability for driven activities within a defined scope of practice
these innovations. Two innovative perioperative in a delegated role (i.e. under the direct supervision
nursing roles emerging in Australia are the nurse and delegated authority of a senior medical officer).
endoscopist and the nurse sedationist. By contrast, the model at the Austin Hospital in
Victoria is an NP model whereby the nurse practi-
NURSE ENDOSCOPIST tioner endoscopist works collaboratively within
Nurse endoscopy was first reported in the United the gastroenterology/endoscopy service. Victoria’s
States more than 35 years ago and is well established first nurse endoscopist was trained in 2009/2010 at
in the United Kingdom, with more than 300 nurse the Austin hospital (Austin Health, 2015, para. 4).
endoscopists working in acute hospitals (Duckett, In this fully integrated role, the nurse practitioner
Breadon & Farmer, 2014; NHS, 2011). Depending undertakes advanced patient assessment, inter-
on the facility, the nurse endoscopist is an RN, prets diagnostic interventions and pathology, and
trained and competent in gastrointestinal endos- establishes differential diagnoses and management
copy, who can undertake diagnostic and therapeutic plans, including selection and prescription of
flexible sigmoidoscopy and colonoscopy, and upper appropriate medication and direct referrals to
gastrointestinal endoscopy (Gastroenterological other healthcare professionals (State of Victoria,
Nurses College of Australia [GENCA], 2015). In a 2013). The first nurse endoscopist in the role after
British study, the outcomes of safety, quality and the Austin Health trial was employed in 2012
satisfaction for patients undergoing colonoscopies (Medew, 2013).
performed by nurse endoscopists compared well While the nurse endoscopist role is still in place
with those performed by surgeons and physicians at the two pilot sites, further areas for research
(Lee, Nickerson, Rees, Patnick & Rutter, 2012). A include a minimum standardised curriculum at
more recent systematic review suggested that out- Masters level, credentialling by a recognised profes-
comes and adverse events of endoscopic procedures sional association and registration or endorsement
performed by non-doctors were in line with those by regulatory authorities. The nurse endoscopist
of doctors (Day, Siao, Inadomi & Somsouk, 2014). role is not without controversy (see Box 1-15).
22
BOX 1-15 » MEDICAL COLLEGES AND HEALTH WORKFORCE INNOVATIONS

The position of the Gastroenterological Society of Australia (GESA) is that a full review of existing
nurse endoscopy services is warranted before committing further resources to establishing the role
(GESA, 2015). GESA concedes that if the role were to continue, it would be conditionally supportive only
if the nurse endoscopist was under direct medical supervision (GESA, 2015). On the other hand, the
New Zealand Society of Gastroenterology (NZSG) supports the introduction of the role within an agreed
practice framework in which training, supervision, safety, quality, competency and practice standards
have been established (NZSG, 2012).
NURSE SEDATIONIST nurse sedationists and key stakeholders perceive

The role of the nurse in anaesthetics has a wide- the role as needed, valued and making an impact
ranging scope of practice around the world, from on patient outcomes, some reported detracting
certified nurse anaesthetist in the United States issues such as limited opportunity to practice in the
to assistants to the anaesthetist in Australia and role, problems backfilling the position, only partial
New Zealand. Similar to the nurse endoscopist implementation of the role and lack of role clarity
role, the nurse sedationist role emerged in Aus- and scope (Jones, Long & Zeitz, 2011). These issues
tralia in response to increased demand for services may provide some insight into the long-term sus-
and a shortfall in the medical workforce (Jones, tainability of the role.
Long & Zeitz, 2011). The nurse sedationist has
undertaken additional training in the administra-
tion of intravenous sedation and, under the super-
CONCLUSION
vision of a medical officer, provides procedural This chapter introduced the key concepts associ-
sedation for minor procedures or investigations ated with perioperative nursing. It outlined the
and monitors the patient’s response to sedation. multiple roles that perioperative nurses undertake
Procedural sedation implies that the patient is in a and the relationship of these roles to the surgical
state of drug-induced tolerance of uncomfortable patient’s journey. The chapter also introduced the
or painful diagnostic or interventional medical, concept of cultural safety, which guides appropriate
dental or surgical procedures (Anaesthesia Peri and sensitive patient care. Importantly, it outlined
operative Care Network, 2013). The currently avail- the regulatory environment, scope of practice and
able evidence suggests that nurse-administered ongoing development specific to the perioperative
procedural sedation is safe when performed by ade- nurse, and explored current and emerging advanced
quately trained practitioners with clear protocols perioperative nursing roles. The role of profes-
for patient monitoring (Conway et al., 2014). A trial sional nursing associations, professional standards
in South Australia found positive patient satisfac- for practice and evidence-based practice were also
tion from the nurse sedation service and no adverse explored in the context of perioperative nursing
events (Jones, Long & Zeitz, 2011). However, while care.
CRITICAL THINKING EXERCISES

1. Perioperative practice
One of your student friends who is now working in the oncology ward of your hospital challenges you
with this question: ‘When are you going to take up real nursing again?’ What two examples of peri-
operative patient care would you describe as ‘real nursing’ in response to this question? Provide
rationales that explain how these two examples of your practice as a ‘real nurse’ reflect the philosophy
of perioperative nursing and patient-centred care.
Continued
23
CRITICAL THINKING EXERCISES—cont’d

2. CPD audit
You have been selected by your registering authority to undergo an audit of your continuing profes-
sional development activities for the past year. Below is a list of hypothetical CPD activities that you
might accrue over 12 months’ practice as a circulating nurse. For each activity, provide an example
you might undertake (for C, select a real conference/seminar that you have attended or plan to attend
in the coming year) and write a short reflection (100 words) on the reason you chose it (your rationale)
and the influence you expect this activity might have on your practice as a circulating nurse.
A. Self-directed learning
B. Mandatory education
C. Attendance at a conference
3. Delegation in the OR
The registered nurse (RN) has delegated the intraoperative care of a patient to the enrolled nurse (EN)
instrument nurse. During the procedure, another EN enters the theatre to relieve the RN for a meal
break.
• What aspects of delegation must the RN take into account as the delegator?
• What aspects of delegation must the EN take into account as the recipient of this
delegation?
Include rationales for your answers. You may benefit from reviewing the resources of the NMBA’s
decision-making framework (NMBA, 2013d) and the ACORN Standards (ACORN, 2016) when consider-
ing your response.
4. Patient advocate
On arrival at the holding bay, your patient Josie Chang (a young woman admitted for elective hyster-
oscopy and D&C) tells you she is unsure whether the planned surgery is still necessary. She is anxious
that she has been admitted to the OR and now it might be too late to change her mind.
• Thinking about your role as the patient’s advocate, list the actions you can take to address
Josie’s concerns. Provide rationales for your actions.
The anaesthetist is concerned about the delay in progression of the list and is preparing to take Josie
into the anaesthetic bay while you are busy receiving another patient into the holding bay.
• Explain what you would do in this situation and why you think it is important to advocate for
Josie in this way.
RESOURCES Australian Education Network

www.australianuniversities.com.au
Association of periOperative Registered Nurses (AORN) Australian Health Practitioner Regulation Agency (AHPRA)
www.aorn.org www.ahpra.gov.au
Austin Hospital Victoria, State Endoscopy Training Centre www.ahpra.gov.au/About-AHPRA/What-We-Do/
www.austin.org.au/EndoscopyTraining Legislation.aspx
Australian Association of Nurse Surgical Assistants (AANSA) Cochrane Library
www.aansa.org.au www.cochranelibrary.com
Australian College of Nursing (ACN) College of Nurses Aotearoa New Zealand
www.acn.edu.au www.nurse.org.nz
Australian College of Operating Room Nurses (ACORN) International Federation of Perioperative Nurses (IFPN)
https://www.acorn.org.au www.ifpn.org.uk
24
Joanna Briggs Institute Library RTO 91474 [Course Outline.] Sydney: Author. Retrieved from
joannabriggslibrary.org <www.acn.edu.au/rto>.
New Zealand Health Workforce Statistics Australian College of Nursing (ACN). (2015). Postgraduate
www.nzhis.govt.nz studies handbook 2016. Retrieved from <www.acn.edu.au/
New Zealand Nurses Organisation (NZNO) postgraduate>.
www.nzno.org.nz Australian College of Nursing (ACN). (nd). ACN purpose state-
Nursing and Midwifery Board of Australia (NMBA) ment. Retrieved from <www.acn.edu.au/sites/default/files/
www.nursingmidwiferyboard.gov.au governance/Purpose_statement.pdf>.
Nursing Council of New Zealand (NCNZ) Australian College of Operating Room Nurses (ACORN).
www.nursingcouncil.org.nz (2013). History of ACORN. Retrieved from <https://www
www.nursingcouncil.org.nz/Publications/ .acorn.org.au/download_file/44/191>.
Standards-and-guidelines-for-nurses Australian College of Operating Room Nurses (ACORN).
Perioperative Nurses College (PNC) of NZNO (2016). Standards for perioperative nursing 2016–2017.
www.nzno.org.nz/groups/colleges/ Adelaide: Author.
perioperative_nurses_college Australian Health Practitioner Regulation Agency (AHPRA).
Professional Development and Recognition Programmes (2015). What we do/Legislation. Canberra: Author. Retrieved
(PDRP) from <www.ahpra.gov.au/About-AHPRA/What-We-Do/
www.nzno.org.nz/support/professional_development Legislation.aspx>.
Queensland Health Australian Health Workforce Advisory Committee. (2006).

www.health.qld.gov.au/nmoq/optimisingnursing/ The perioperative workforce in Australia. AWHAC Report 2006.
endoscopy.asp Sydney: Author.
Australian Nursing & Midwifery Federation (ANMF). (2013).
Nursing specialisation. Canberra: Author. Retrieved from
REFERENCES <anmf.org.au/pages/anmf-policies>.
Algie, C. M., Mahar, R. K., Wasiak, J., Batty, L., Gruen, R. L., & Australian Nursing & Midwifery Federation (ANMF). (2014).
Mahar, P. D. (2015). Interventions for reducing wrong-site About us. Canberra: Author. Retrieved from <http://
surgery and invasive clinical procedures. Cochrane Database anmf.org.au/pages/about-the-anmf>.
of Systematic Reviews, (3), Art. No.: CD009404, doi:10.1002/ Baldwin, R., Duffield, C. M., Fry, M., Roche, M., Stasa, H., &
14651858.CD009404.pub3. Solman, A. (2013). The role and functions of clinical nurse
Anaesthesia Perioperative Care Network. (2013). Safe consultants, an Australian advanced practice role: A
procedural care project. Phase 1: Diagnostic and solution descriptive exploratory cohort study. International Journal of
design report. Retrieved from <www.aci.health.nsw.gov.au/ Nursing Studies, 50, 326–334. doi:10.1016/j.ijnurstu.2012
resources/anaesthesia-perioperative-care/sedation/safe .09.013.
-sedation-resources>. Battié, R., & Steelman, V. (2014). Accountability in nursing
Arrowsmith, V. A., & Taylor, R. (2014). Removal of nail polish practice: Why it is important for patient safety. AORN Journal,
and finger rings to prevent surgical infection. Cochrane 100(5), 537–541.
Database of Systematic Reviews, (8), Art. No.: CD003325, Blum, E. P., & Burns, S. M. (2013). Perioperative communica-
doi:10.1002/14651858.CD003325.pub3. tion and family members’ perceived level of anxiety and
Association of periOperative Registered Nurses (AORN). satisfaction. ORNAC Journal, 31(3), 14, 16–19, 34–36.
(2015). R. Connor (Ed.), AORN Guidelines for Perioperative Clayton, J., Isaacs, A. N., & Ellender, I. (2014). Perioperative
Practice. Denver: Author. nurses’ experiences of communication in a multicultural
Austin Health. (2015). State endoscopy training centre. operating theatre: A qualitative study. International Journal
Retrieved from <www.austin.org.au/EndoscopyTraining>. of Nursing Studies, epub dx.doi.org/10.1016/j.ijnur-stu.2014
Australian and New Zealand College of Anaesthetists .02.014.
(ANZCA). (2015a). PS08 BP 2015 Statement on the Assistant Conway, A., Rolley, J., Page, K., & Fullbrook, P. (2014). Trends
for the Anaesthetic [Background Paper.] Canberra: Author. in nurse-administered procedural sedation and analgesia
Retrieved from <www.anzca.edu.au/resources/professional across cardiac catheter laboratories in Australia and New
-documents>. Zealand: Results of an electronic survey. Australian Critical
Australian and New Zealand College of Anaesthetists Care, 27(2014), 4–10.
(ANZCA). (2015b). Professional documents of the Australian Cousley, A., Martin, D. S., & Hoy, L. (2014). Vulnerability in the
and New Zealand College of Anaesthetists. PS08 Statement on perioperative patient: A concept analysis. Journal of Periop-
the Assistant for the Anaesthetist (Pilot). Canberra: Author. erative Practice, 24(7–8), 164–171.
Retrieved from <www.anzca.edu.au/resources/professional Cox, L. G., & Simpson, A. (2015). Cultural safety, diversity
-documents>. and the servicer user and carer movement in mental
Australian College of Nursing (ACN). (2014). ACN HLT61107 health research. Nursing Inquiry, epub. doi:10.1111/
Advanced Diploma of Nursing (Enrolled/Division 2 nursing) nin.12096.
25
Day, L. W., Siao, D., Inadomi, J. M., & Somsouk, M. (2014). Retrieved from <www.joannabriggslibrary.org/jbilibrary/
Non-physician performance of lower and upper endoscopy: index.php/jbisrir/article/view/541/1503>.
A systematic review and meta-analysis. Endoscopy, 46(5), Holloway, K. (2012). The New Zealand nurse specialist
401–410. doi:10.1055/s-0034-1365310. framework: Clarifying the contribution of the nurse special-
Duckett, S., Breadon, P., & Farmer, J. (2014). Unlocking skills ist. Policy, Politics, & Nursing Practice, 13(3), 147–153.
in hospitals: Better jobs, more care. Carlton: Grattan Institute. International Council of Nurses (ICN). (2013). Nursing regula-
Retrieved from <grattan.edu.au/report/unlocking-skills-in tion [Position statement.] Geneva: Author. Retrieved from
-hospitals-better-jobs-more-care>. <www.icn.ch/publications/position-statements>.
Duff, J., Butler, M., Davies, M., Williams, R., & Carlile, J. International Federation of Perioperative Nurses. (nd). Wel-
(2014a). Perioperative nurses’ knowledge, practice attitude come to IFPN. Retrieved from <www.ifpn.org.uk/index.phtml>.
and perceived barriers to evidence use: A multisite, cross-
sectional survey. ACORN Journal, 27(4), 28–35. Jones, N., Long, L., & Zeitz, K. (2011). The role of the
nurse sedationist. Collegian, 18(3), 115–123. doi:10.1016/
Duff, J., Walker, K., Edward, K.-L., Williams, R., & Sutherland- j.colegn.2011.04.001.
Fraser, S. (2014b). Incidence of perioperative inadvertent
hypothermia and compliance with evidence-based recom- Lachman, V. D. (2012). Applying the ethics of care to your
mendations at four Australian hospitals: A retrospective nursing practice. Medsurg Nursing, 21(2), 112–116.
chart audit. ACORN Journal, 27(3), 16–23. Lee, T. J. W., Nickerson, C., Rees, C. J., Patnick, J., & Rutter,
Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., M. D. (2012). Comparison of colonoscopy quality indicators
King, M., et al. (2011). Nursing staffing, nursing workload, between surgeons, physicians and nurse endoscopists in the
the work environment and patient outcomes. Applied NHS bowel cancer screening programme: Analysis of the
Nursing Research, 24(4), 244–255. national database. Gut (BMJ), 61(2), A384.
Evetts, J. (2011). Sociological analysis of professionalism: Lipp, A., & Edwards, P. (2014). Disposable surgical face masks
Past, present and future. Comparative Sociology, 10, 1–37. for preventing surgical wound infection in clean surgery
[Cochrane Review.] Retrieved from <www.cochrane.org/
Gastroenterological Nurses College of Australia (GENCA). CD002929/WOUNDS_disposable-surgical-face-masks-for
(2015). Position statement: Nurse endoscopist. Beaumarice. -preventing-surgical-wound-infection-in-clean-surgery>.
Victoria: Author. doi:10.1002/14651858.CD002929.
Gastroenterological Society of Australia (GESA). (2015). Posi- Lyk-Jensen, H. T., Jepsen, R. M., Spanager, L., Dieckmann, P.,
tion statement on nurse endoscopy. Retrieved from <www & Østergaard, D. (2014). Assessing nurse anaesthetists’ non-
.gesa.org.au/news.asp?id=518>. technical skills in the operating room. Acta Anaesthesio-
Gillespie, B. M., Chaboyer, W., Thalib, L. J. M., Fairweather, N., logica Scandinavica, 58(7), 794–801.
& Slater, K. (2014). Effect of using a safety checklist on Lynn, A., & Brownie, S. (2015). The perioperative nurse sur-
patient complications after surgery: A systematic review and geon’s assistant: Issues and challenges associated with
meta-analysis. Anesthesiology, 120(6), 1380–1389. this emerging advanced practice nursing role in Australia.
Gillespie, B. M., Hamlin, L., Polit, D. F., & Chaboyer, W. (2013). Collegian, 22, 109–115. Retrieved from doi:10.1016/j.
The influence of personal characteristics on perioperative colegn.2013.12.004.
nurses’ perceived competence: Implications for workforce Matthews, J. (2012). Role of professional organizations in
planning. Australian Journal of Advanced Nursing, 30(3), advocating for the nursing profession. The Online Journal of
14–25. Issues in Nursing, 17(1), 3.
Hadiati, D. R., Hakimi, M., Nurdiati, D. S., & Ota, E. (2014). Skin McCleland, A. (2011). Culturally safe nursing research:
preparation for preventing infection following caesarean Exploring the use of an Indigenous research methodology
section. Cochrane Database of Systematic Reviews, (9), Art. No.: from an Indigenous researcher’s perspective. Journal of
CD007462, doi:10.1002/14651858.CD007462.pub3. Transcultural Nursing, 22(4), 362–367.
Hamlin, L. (2012). International perioperative organizations: Medew, J. (2013). Austin presents first nurse endoscopist.
Diversity, development, divergence. AORN Journal, 96(6), The Age, Retrieved from <www.theage.com.au/victoria/
647–651. austinpresents-first-nurse-endoscopist-20130209-2e5cq
Hamlin, L., & Anderson, L. (2011). Cultural competence and .html>; 13 February.
perioperative nursing practice in New Zealand. AORN Journal, Medical Sciences Council of New Zealand. (nd). Welcome to
93(2), 291–295. doi:10.1016/j.aorn.2010.11.025. the Medical Sciences Council of New Zealand. Retrieved from
Health Workforce Australia (HWA). (2012). Health Workforce <www.mscouncil.org.nz/home-en-AT>.
2025. Doctors, Nurses and Midwives, Volume 2. Canberra: Melnyk, B. M., Gallagher-Ford, L., Long, L. E., & Fineout-
HWA. Retrieved from <https://www.hwa.gov.au/our-work/ Overholt, E. (2014). The establishment of evidence-based
health-workforce-planning/health-workforce-2025-doctors practice competencies for practicing registered nurses and
-nurses-and-midwives>. advanced practice nurses in real-world clinical settings:
Hines, S., Munday, J., & Kynoch, K. (2013). Effectiveness of Proficiencies to improve healthcare quality, reliability,
nurse-led preoperative assessment services for elective surgery: patient outcomes, and costs. Worldviews on Evidence-based
A systematic review update protocol. Adelaide: JBI Library. Nursing, 11(1), 5–15.
26
Mitchell, L., Flin, R., Yule, S., Mitchell, J., Coutts, K., & Young- New Zealand Nurses Organisation (NZNO). (nd). Safe staffing
son, G. (2011). Thinking ahead of the surgeon. An interview in the perioperative setting. Perioperative Nurses College
study to identify scrub nurses’ non-technical skills. Interna- Guidance Statement. Wellington: Author. Retrieved from
tional Journal of Nursing Studies, 48(7), 818–828. <www.nzno.org.nz/groups/colleges_sections/colleges/
Moffatt-Bruce, S. D., Cook, C. H., Steinberg, S. M., & Stawicki, perioperative_nurses_college>.
S. P. (2014). Risk factors for retained surgical items: A New Zealand Society of Gastroenterology (NZSG). (2012).
meta-analysis and proposed risk stratification system. New Zealand Society of Gastroenterology Position Statement
Journal of Surgical Research, 190(2), 429–436. doi:10.1016/j. on Nurse Endoscopy. Retrieved from <www.nzsg.org.nz/
jss.2014.05.044. cms2/news-2/employment>.
Munday, J., Kynoch, K., & Hines, S. (2014). Nurses’ experiences Nursing and Midwifery Board of Australia (NMBA). (2011).
of advocacy in the perioperative department: A systematic Endorsement as a nurse practitioner registration standard.
review protocol [Systematic Review Protocol.] Adelaide: JBI Canberra: Author. Retrieved from <www.nursingmidwifery
Library. Retrieved from <www.joannabriggslibrary.org/ board.gov.au/Registration-and-Endorsement/Endorsements
index.php/jbisrir/article/view/1458/1966>. -Notations/Endorsement-as-a-nurse-practitioner-registration
Murphy, E. K. (2015). Patient safety and risk management. In -standard.aspx>.
J. Rothrock (Ed.) & D. McEwen (Assoc. Ed.), Alexander’s care Nursing and Midwifery Board of Australia (NMBA). (2013a).
of the patient in surgery (15th ed., pp. 16–46). St Louis: Code of professional conduct for nurses. August 2008:
Elsevier Mosby. Rebranded. Canberra: Author. Retrieved from <www.nursing
National Aboriginal Community Controlled Health Organi- midwiferyboard.gov.au/Codes-Guidelines-Statements/
sation (NACCHO). (2011). Creating the NACCHO cultural safety Codes-Guidelines.aspx>.
training standards and assessment process. A background Nursing and Midwifery Board of Australia (NMBA). (2013b).
paper. Canberra: Author. Code of ethics for nurses. August 2008: Rebranded. Canberra:
National Health Service (NHS). (2011). Evidence briefing on Author. Retrieved from <www.nursingmidwiferyboard.gov
nurse endoscopy. York: National Health Service (NHS) Centre .au/Codes-Guidelines-Statements/Codes-Guidelines.aspx>.
for Reviews and Dissemination. Retrieved from <https:// Nursing and Midwifery Board of Australia (NMBA). (2013c).
www.york.ac.uk/crd/publications/evidence-briefings>. Nurse practitioner standards for practice. Canberra: Author.
National Nursing Organisations (NNO). (2004). Glossary of Retrieved from <www.nursingmidwiferyboard.gov.au/Codes
terms. criteria for specialties in nursing. Principles of creden- -Guidelines-Statements/Professional-standards/nurse
tialling for nurses. Canberra: NNO. Retrieved from <www -practitioner-standards-of-practice.aspx>.
.conno.org.au/publications>. Nursing and Midwifery Board of Australia (NMBA). (2013d).
Nerland, M., & Karseth, B. (2015). The knowledge work of A national framework for the development of decision-making
professional associations: Approaches to standardisation tools for nursing and midwifery practice. September 2007:
and forms of legitimisation. Journal of Education and Work, Rebranded. Canberra: Author. Retrieved from <www.nursing
28(1), 1–23. doi:10.1080/13639080.2013.802833. midwiferyboard.gov.au/Codes-Guidelines-Statements/
Codes-Guidelines.aspx>.
New Zealand Nurses Organisation (NZNO). (2014a). Knowl-
edge and skills framework for registered nurse assistant to the Nursing and Midwifery Board of Australia (NMBA). (2013e).
anaesthetist for operating theatre in New Zealand. Wellington: National competency standards for the registered nurse.
Author. Retrieved from <www.nzno.org.nz/groups/colleges Canberra: Author. Retrieved from <www.nursing
_sections/colleges/perioperative_nurses_college/ midwiferyboard.gov.au/Codes-Guidelines-Statements/
resources/registered_nurse_assistant_to_the_anaesthetist>. Codes-Guidelines.aspx#competencystandards>.
New Zealand Nurses Organisation (NZNO). (2014b). Nursing and Midwifery Board of Australia (NMBA). (2013f).
Advice for aspiring nurse practitioners. Wellington: Author. Advanced practice nursing [Fact sheet.] Canberra: Author.
Retrieved from <www.nzno.org.nz/support/professional Retrieved from <www.nursingmidwiferyboard.gov.au/Codes
_development/nurse_practitioners/advice_for_aspiring -Guidelines-Statements/FAQ/fact-sheet-advanced-practice
_nurse_practitioners>. -nursing.aspx>.
New Zealand Nurses Organisation (NZNO). (2014c). Periop- Nursing and Midwifery Board of Australia (NMBA). (2014).
erative nurses college. Retrieved from <www.nzno.org.nz/ The use of health practitioner protected titles [Fact sheet.]
groups/colleges_sections/colleges/perioperative_nurses Canberra: Author. Retrieved from <www.nursingmidwifery
_college>. board.gov.au/Codes-Guidelines-Statements/FAQ/The-use
-of-health-practitioner-protected-titles.aspx>.
New Zealand Nurses Organisation (NZNO). (2014d). About
us. Retrieved from <www.nzno.org.nz/about_us>. Nursing and Midwifery Board of Australia (NMBA). (2015a).
Enrolled nurses and medicine administration [Fact sheet.]
New Zealand Nurses Organisation (NZNO). (2015). Regis-
Canberra: Author. Retrieved from <www.nursingmidwifery
tered nurse first surgical assistant for operating theatres in
board.gov.au/Codes-Guidelines-Statements/FAQ/Enrolled
New Zealand service policy guidelines. Perioperative Nurses
-nurses-and-medicine-administration.aspx>.
College Wellington: Author. Retrieved from <www.nzno.org
.nz/groups/colleges_sections/colleges/perioperative_nurses Nursing and Midwifery Board of Australia (NMBA). (2015b).
_college/resources/standards>. Continuing professional development [Fact sheet.] Melbourne:
27
Author. Retrieved from <www.nursingmidwiferyboard midwives’ use of physical assessment skills: A cross sec-
.gov.au/Codes-Guidelines-Statements/FAQ/CPD-FAQ-for tional study. International Journal of Nursing Studies, 52(2),
-nurses-and-midwives.aspx>. 951–962. doi:10.1016/j.ijnurstu.2015.01.014.
Nursing Council of New Zealand (NCNZ). (2007). Competen- Oxford Dictionaries. (2015). Retrieved from <www
cies for registered nurses. Wellington: Author. Retrieved from .oxforddictionaries.com>.
<www.nursingcouncil.org.nz/Publications/Standards-and Parliamentary Council Office. New Zealand Legislation
-guidelines-for-nurses>. (reprinted 28 August 2013). Health Practitioner Competence
Nursing Council of New Zealand (NCNZ). (2010). Decision- Assurance Act 2003. Retrieved from <www.legislation.govt
making process for expanding scope of registered nursing .nz/act/public/2003/0048/latest/DLM203312.html>.
practice. Wellington: Author. Retrieved from <www.nursing Patty, A. (2015, 28 July). Cardiac arrest during cosmetic
council.org.nz/Nurses/Scopes-of-practice/Registered surgery: Overdose of local anaesthetic likely. Sydney Morning
-nurse>. Herald. p. 3.
Nursing Council of New Zealand (NCNZ). (2011a). Guidelines Pearse, R. M., Moreno, R. P., Bauer, P., Pelosi, P., Metnitz, P.,
for cultural safety, the Treaty of Waitangi, and Maori health in Spies, C., et al. (2012). Mortality after surgery in Europe: A
nursing education and practice. Wellington: Author. Retrieved 7-day cohort study for the European Surgical Outcomes
from <www.nursingcouncil.org.nz/Publications/Standards Study (EuSOS) group for the trials groups of the European
-and-guidelines-for-nurses>. society of intensive care medicine and the European society
Nursing Council of New Zealand (NCNZ). (2011b). Profes- of anaesthesiology. Lancet, 380(9847), 1059–1065.
sional development activities template. Wellington: Author. Queensland Health. (2014). Overview of the planned intro
Retrieved from <www.nursingcouncil.org.nz/Nurses/ duction of nurse endoscopy in Queensland. Queensland
Continuing-competence>. Health. Retrieved from <www.health.qld.gov.au/nmoq/
Nursing Council of New Zealand (NCNZ). (2012a). Code of optimisingnursing/endoscopy.asp>.
conduct for nurses. Wellington: Author. Retrieved from Randmaa, M., Martensson, G., Swenne, C. L., & Engstrom, M.
<www.nursingcouncil.org.nz/Nurses/Code-of-Conduct>. (2015). An observational study of postoperative handover in
Nursing Council of New Zealand (NCNZ). (2012b). Guide- anesthetic clinics: The content of verbal information and
line: Responsibilities for direction and delegation of care to factors influencing receiver memory. Journal of Perianesthe-
enrolled nurses. Wellington: Author. Retrieved from <www sia Nursing, 30(2), 105–115.
.nursingcouncil.org.nz/Publications/Standards-and Rauta, S., Salantera, S., Nivalainen, J., & Junttila, K. (2012).
-guidelines-for-nurses>. Validation of the core elements of perioperative nursing.
Nursing Council of New Zealand (NCNZ). (2012c). Guideline: Journal of Clinical Nursing, 22(9/10), 1391–1399. doi:10.1111/
Delegation of care by a registered nurse to a health care j.1365-2702.04220.x.
assistant. Wellington: Author. Retrieved from <www Siggins Miller Consultants. (2012). Promoting quality in clini-
.nursingcouncil.org.nz/Publications/Standards-and cal placements: Literature review and national stakeholder
-guidelines-for-nurses>. consultation. Adelaide: Health Workforce Australia.
Nursing Council of New Zealand (NCNZ). (2014). Nurse prac- Spruce, L. (2015). Back to basics: Implementing evidence-
titioner scope of practice. Guidelines for applicants. Welling- based practice. AORN Journal, 101(1), 106–112. doi:10.1016/
ton: Author. Retrieved from <www.nursingcouncil.org.nz/ j.aorn.2014.08.009.
Nurses/Scopes-of-practice/Nurse-practitioner>.
Spruce, L., Van Wicklin, S. A., Hicks, R. W., Conner, R., & Dunn,
Nursing Council of New Zealand (NCNZ). (2015). Educational D. (2014). Introducing AORN’s new model for evidence
institutes offering postgraduate programs. Updated January rating. AORN Journal, 99(2), 243–255. doi:10.1016/j.
2015 [Downloadable word doc.] Wellington: Author. aorn.2013.11.014.
Retrieved from <www.nursingcouncil.org.nz/Education/
Nurse-practitioner>. State of Victoria. (2013). Nurse Endoscopy Program: Fre-
quently asked questions (FAQs). Victorian Advanced Practice
Nursing Council of New Zealand (NCNZ). (nd). Continuing Nurse Endoscopy Services. Retrieved from <www.austin.org
competence. Retrieved from <www.nursingcouncil.org.nz/ .au/EndoscopyTraining>.
Nurses/Continuing-competence>.
Sutherland, S. (2006). PIP: standardising education for the
O’Connell, J., Gardner, G., & Coyer, F. (2014). Beyond compe- perioperative nurse. Paper presented at the State Periopera-
tencies: Using a capability framework in developing prac- tive Managers’ Forum, Perioperative Nurses Association of
tice standards for advanced practice nursing. Journal of Queensland.
Advanced Nursing, 70(12), 2728–2735. epub. doi:10.1111/
jan.12475. Thompson, C., Williams, K., Morris, D., Lago, L., Quinsey, K.,
Kobel, C., et al. (2014). HWA expanded scopes of practice
Osborne, S. (2013). The ACORN standards: Our aide-memoire program evaluation: Advanced practice in endoscopy nursing
to professional practice [online.] ACORN Journal, 26(4), sub-project final report. Centre for Health Service Develop-
14–15. ment, Australian Health Services Research Institute, Univer-
Osborne, S., Douglas, C., Reid, C., Jones, L., & Gardner, G., on sity of Wollongong. Retrieved from <esoptoolkit.hwa.gov
behalf of RBWH Patient Assessment Research Council. .au/sites/default/files/Deidentified%20APEN%20Sub
(2015). The primacy of vital signs. Acute care nurses’ and -Project%20Final%20Report_HWA_4August14.pdf>.
28
van Beuzekom, M., Boer, F., Akerboom, S., & Hudson, P. Gillespie, B. M., & Hamlin, L. (2009). A synthesis of the litera-
(2012). Patient safety in the operating room: An intervention ture on ‘competence’ as it applies to perioperative nursing.
study on latent risk factors. BMC Surgery, 22(12), 10. AORN Journal, 90(2), 245–252, 254–258. doi:10.1016/j.
doi:10.1186/1471-2482-12-10. aorn.2009.07.011.
Vanlaere, L., & Gastmans, C. (2011). A personalistic approach Hilbig, J. (1999). Validation of ACORN competency research
to care ethics. Nursing Ethics, 18, 161–173. project report for the Australian Confederation of Operating
Wade, P. (2012). Historical trends influencing the future of Room Nurses Limited. Adelaide: School of Nursing, University
perioperative nursing. ORNAC Journal, 30(2), 22–25, 32, of South Australia.
34–35. New South Wales Operating Theatre Association (NSW OTA).
Webster, J., & Osborne, S. (2015). Preoperative bathing or show- (2013). Career development pathway for the registered nurse
ering with skin antiseptics to prevent surgical site infection in the perioperative environment. Sydney: Author. Retrieved
[Cochrane Review.] doi:10.1002/14651858.CD004985.pub5. from <www.ota.org.au/pages/professional-development.html>.
Webster, J., Osborne, S. R., Gill, R., Chow, C. F., Wallin, S., Jones, New Zealand Nurses Organisation (NZNO). (2015). New
L., et al. (2014). Does preoperative oral carbohydrate reduce Zealand perioperative nursing knowledge and skills frame-
hospital stay? A randomized trial. AORN Journal, 99(2), 233– work. Perioperative Nurses College Consultation Document.
242. doi:10.1016/j.aorn.2013.12.003. Wellington: Author. Retrieved from <www.nzno.org.nz/
groups/colleges/perioperative_nurses_college/resources>.
Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz,
S. R., & Gawande, A. A. (2010). Effect of a 19-item surgical Nursing and Midwifery Board of Australia (NMBA). (2013).
safety checklist during urgent operations in a global patient Registered nurse competency standards. Rebranded August
population. Annals of Surgery, 251, 976–980. 2013. Canberra: Author. Retrieved from <www.nursing
midwiferyboard.gov.au/Codes-Guidelines-Statements/
Codes-Guidelines.aspx>.
FURTHER READING
Nursing and Midwifery Board of Australia (NMBA). (2015).
Benton, D. C., González-Jurado, M. A., & Beneit-Montesinos, Scope of practice of nurse practitioners [Fact sheet.] Canberra:
J. V. (2013). Defining nurse regulation and regulatory body Author. Retrieved from <www.nursingmidwiferyboard.gov
performance: A policy Delphi study. International Nursing .au/Codes-Guidelines-Statements/Position-Statements/
Review, 60, 303–312. scope-of-practice.aspx>.
Duffield, C. M., Gardner, G., Chang, A. M., Fry, M., & Stasa, H. Stubbs, M., & Muir, J. (2015). Whilst in our care: Introducing
(2011). National regulation in Australia: A time for stand- the surgical liaison nurse. ACORN Journal, 28(2), 12–15.
ardisation in roles and titles. Collegian, 18, 45–49.
doi:10.1016/j.colegn.2011.01.002.
29
Chapter 2
THE PERIOPERATIVE TEAM AND
INTERDISCIPLINARY COLLABORATION
BRIGID M. GILLESPIE AND MENNA DAVIES
EDITOR: MENNA DAVIES
LEARNING OUTCOMES
• Explore the prominent features of perioperative culture and describe its influence on team dynamics
• Discuss the components of human factors and their importance to patient safety
• Explain the importance of clinical leadership and emotional intelligence in shaping the culture of the
perioperative department
• Apply the principles of communication and graded assertiveness to effective teamwork
KEY TERMS
communication
graded assertiveness
human factors
professional hierarchy
shared mental models
situation awareness
teamwork
INTRODUCTION umbrella term human factors. This encompasses

non-technical skills such as communication, team-
Chapter 1 provided an introduction to the framework and situation awareness, and environmental
work in which perioperative nursing is practised elements such as ergonomics, noise and task
and identified the individual nursing roles that management, all of which can have a positive or
form part of the perioperative team. Chapter 2 negative impact on patient safety.
examines perioperative team dynamics and how
team members function as effective providers of
patient care within a unique culture. The factors
THE INTERDISCIPLINARY TEAM
that underpin team dynamics and how the surgical The anaesthetic, instrument, circulating and post
team members relate to each other and interact anaesthesia care unit (PACU) nurse roles described
with their environment are discussed under the in Chapter 1 combine with the following medical
30
CHAPTER 2 | The perioperative team and interdisciplinary collaboration
team roles to create the interdisciplinary team These team members must work together effec-
responsible for the patient’s well-being: tively to provide a safe outcome for patients. For
• The consultant anaesthetist administers patients this is an anxious period of their hospitali-
anaesthesia and closely monitors the patient’s sation when they are at their most vulnerable, as
physiological status during the surgery/ they are anaesthetised or heavily sedated with no
procedure. The consultant anaesthetist is often control over their surroundings or what is happen-
assisted by a second (trainee) anaesthetist. ing to them (Mitchell et al., 2011b). The periopera-
Anaesthetic technicians may also be part of the tive team therefore has total responsibility for the
team and are responsible for the maintenance patient’s safety and well-being.
of anaesthetic equipment. In some facilities, While most teams work effectively together and
they may also act as the anaesthetic assistant produce safe outcomes for patients, sometimes
and participate in patient care. teams become dysfunctional and this can contrib-
• The consultant surgeon/proceduralist performs ute to adverse outcomes for patients or be the cause
the surgery/procedure, generally assisted by of near misses. The reasons why some surgical
other surgeons at various levels of specialty teams fail to function effectively are complex and
training. may, in part, have their origins in history. Tradi-
tionally the consultant surgeon, due to their skills
In addition, ancillary staff such as radio and perceived elevated position in society, was
graphers, orderlies, sterilising technicians, store placed at the top of the surgical team hierarchy,
keepers, cleaners and administrative staff perform with team members, including nurses, adopting
important roles, assisting the surgical team in the ‘subordinate’ roles and often fearful or reluctant to
smooth running of the perioperative environment. question the consultant’s authority. Such a ‘pecking
A successful surgical outcome for the patient order’ with its power imbalance discourages effec-
and the safe conduct of the surgical procedure are tive teamwork and communication, and evidence
the culmination of complex administrative proc- shows that poor communication and dysfunctional
esses that are managed by administration staff. teams contribute to adverse events (Bromiley, 2009;
Although these ancillary staff members are not Sydor et al., 2013). Although anecdotally remnants
involved in direct patient care, their role responsi- of this type of hierarchy still exist in some periop-
bilities involve a large component of the pre- erative environments, positive steps to improve
admission preparation of the patient, liaising with communication and teamwork by engaging in
nursing staff to structure the operating theatre human factors training is slowly changing the tra-
lists, admission and preoperative management ditional hierarchy and socialisation with the peri-
prior to the patient’s transfer to the operating suite. operative environment.
Operating suite nursing managers undertake a Exploring how professional hierarchy and
coordinating role within the wider hospital envi- socialisation are negotiated between nurses and
ronment, being closely involved with administra- other disciplines in the perioperative setting often
tive processes related to issues such as patient flow, highlights differing perceptions of professional
waiting lists and availability of postoperative (PO) roles, abilities and responsibilities. Status differen-
beds. They are responsible for ensuring the avail- tials between nurses, other health professionals
ability of operating rooms for both elective and and doctors and their effect on social relations have
emergency surgery and rostering appropriately been studied in many different clinical contexts.
skilled staff in each operating room (ACORN, 2016). Stein’s (1978) influential paper on the ‘doctor–
nurse game’ identified the pressures exerted on
THE PERIOPERATIVE TEAM AND medical and nursing students and demonstrated
PROFESSIONAL HIERARCHY the differences in their role socialisation and occu-
pational orientations. Tanner and Timmons (2000),
The operating suite is a fast-paced, busy and diverse in their early work on perioperative team dynamics,
environment and the perioperative team is likewise labelled the perioperative environment, with its
diverse, made up of an interdisciplinary group of restricted access away from public gaze, as the sur-
highly skilled medical and nursing professionals geon’s ‘backstage’ where relaxed behaviours are
with differing clinical backgrounds and expertise. evident. Practices still seen today include a level of
31
familiarity towards other staff not normally seen an important part of both providing a successful
outside the perioperative environment, as well as one and coexisting within one. Workplace culture
colleagues engaging in conversations that would be is influenced by the norms and expectations that
viewed as unprofessional if they occurred in full guide the thinking and behaviours of employees.
view of the public. Examples include joking, teasing, Furthermore, workplace stability depends on the
gossiping and discussing social events, activities extent to which individuals are accepted as team
undertaken freely without fear of being heard by members and the socialisation practices within the
the anaesthetised patients. For nurses, however, particular workplace and specialty (Chen et al.,
the perioperative environment is their ‘front stage’ 2015).
where they work each day and their professional Every workplace has its own culture and the
behaviour is in direct contrast to the relaxed behav- perioperative environment is no different, with
iours of their medical colleagues, blurring pro its necessary separation from other departments
fessional boundaries and sometimes leading to and restricted access contributing to a unique
tensions between the two groups. culture. The defining features of the perioperative
In addition, staff identities, and therefore the culture are born out of being an intense, time-
status of members, are often concealed because of pressured environment where the organisational
the uniformity of dress (i.e. wearing of scrubs), arrangement of reward systems, social ranking, and
resulting in suspension of the visual hierarchy; specialty knowledge and judgement are highly
the professional hierarchy, however, is still strong valued. ‘Survival’ in the perioperative setting
enough to be exerted when required (Tanner & depends on how well individuals are socialised
Timmons, 2000). Staff in the perioperative environ- into this secluded and often geographically isolated
ment often adopt an informal code of dress, such as environment.
wearing brightly coloured socks or a coloured head- Novices need to learn about the culture in which
scarf, or carrying a pager in order to inject a sense they work, as well as mastering an array of highly
of individuality. technical skills. Technology is evident in nearly
every facet of the patient’s journey (e.g. automatic
THE CULTURE AND CONTEXT blood pressure machine, monitoring devices, anaes-
OF THE PERIOPERATIVE thetic machine, microscopes). However, the techni-
ENVIRONMENT cal expertise that the perioperative team must
possess will not always be enough to guarantee a
It can be confusing for a novice nurse entering the good patient outcome. There are also a number of
complex perioperative environment to learn the non-technical factors the team must master in
subtleties of the work culture, yet these ‘social order to ensure patient safety and these are dis-
mores’ are frequently influential in forming the cussed under the term human factors.
novice’s developing sense of work and role identity
(Chen, Fu & Zhao, 2015). As part of the socialisa-
tion process, individuals are not only expected to
HUMAN FACTORS
master particular skills and adapt to a specific Human factors are the interrelationships between
group climate, they must also learn to work within people and their environment and each other that
the existing hierarchal structures of the subculture need to be considered to optimise performance and
of which they are nominal members (Chen et al., ensure safety. In healthcare these range from the
2015). design of tools such as medical devices to services
‘Culture’ symbolises the ‘glue’ that binds a and systems, as well as the working environment
workplace together through shared meanings, and working practices such as tasks, roles and team
expressed through language, and the effects of behaviours. Failure to apply the principles of human
culture pervade all workplaces and impact on all factors in healthcare settings has the potential to
types of employees (Chen et al., 2015). A good lead to errors (Clinical Human Factors Group, 2013).
workplace culture enables its employees to thrive, Human factors can be divided into two distinct
whereas a negative workplace culture can cause streams: individual non-technical skills and envi-
disharmony, uncertainty and unrest—leading to ronmental considerations (see the discussion below
staff attrition. Understanding workplace culture is and Fig. 2-1).
32
HUMAN
FACTORS
Environmental Non-technical
skills
Leadership and
Task Noise and Teamwork and Situational
Ergonomics decision
management distraction communication awareness
making
FIGURE 2-1: Components of human factors

Source: Adapted from Flin & Patey (2011).
NON-TECHNICAL SKILLS skills in promoting good communication and team-

Non-technical skills are defined as the social and work as being essential in the safety of passengers.
cognitive skills that complement technical skills In examining the circumstances surrounding a
and contribute to patient safety (Flin & Mitchell, series of air disasters in the 1970s, investigators
2011). The early work of Flin, O’Connor and Crich- found that in many cases the cause was not mechan-
ton (2008) identified the specific intraoperative ical failure or pilot error, but poor communication
non-technical skills for scrub practitioners as com- and dysfunctional team dynamics between the
munication, teamwork, situation awareness and cockpit crew. A hierarchical structure existed that
task management. More recent research by Flin discouraged questioning of the captain’s decisions
and Patey (2011) with anaesthetists and by Yule and in critical situations, even when the crew knew that
Paterson-Brown (2012) with surgeons identified these decisions were incorrect and would contrib-
the additional non-technical skills of leadership ute to the subsequent disaster (Alander, Brooks,
and decision making to these medical specialists. Carmack & Legan, 2011).
Mitchell, Chung, Williamson and Molesworth Following the 1978 Portland air crash (see
(2011a) found that a lack of non-technical skills Feature box 2-1) and in attempt to avert further
were the main contributing factors in 48 unex- disasters, the US aviation industry instigated a
pected health-related patient deaths that were the new training program known as Crew Resource
subject of coronial inquests in Australia. Management (CRM) incorporating human factors
During orientation to the perioperative envi- (teamwork, communication, situation awareness,
ronment a great deal of time is spent teaching new leadership, decision making). CRM was designed to
staff technical skills such as how to operate the promote team cohesiveness and reduce the effects
many pieces of equipment found in the operating of the hierarchal structure within the flight-deck
room. While knowledge of equipment is important crew. This successful strategy has been universally
for patient safety, technical knowledge alone does adopted by the aviation industry with pilots and
not guarantee patient safety. In the complex and flight-deck crews undergoing mandatory annual
often stressful perioperative environment it is CRM training. Similar training programs are used
essential that the surgical team combine their indi- across other high-risk industries including nuclear
vidual technical skills with these non-technical power plants, shipping and the military (Alander
skills to provide safe and effective care of the et al., 2011).
patient (Braaf, Manias & Riley, 2011). Parallels can be drawn between the captain and
cockpit crew and the surgeon and surgical team in
LESSONS LEARNT FROM AVIATION relation to the previous discussion on hierarchical
The aviation industry has provided valuable infor- structures and the reluctance to challenge the
mation about the effectiveness of non-technical captain/surgeon’s authority. Recognition of the
33
FEATURE BOX 2-1 » THE CRASH OF UNITED AIRLINES FLIGHT 173
In December 1978, United Airlines Flight 173 crashed into a wooded, populated area of suburban
Portland, Oregon, during an approach to Portland International Airport. The aircraft had delayed
landing for about one hour while the flight crew coped with a landing gear malfunction and
prepared the passengers for a possible emergency landing. The plane crashed about 10 km south-
east of the airport, destroying the aircraft and killing 10 passengers and crew from the total of
189 passengers and crew on board.
The National Transportation Safety Board determined that the probable cause of the accident
was the failure of the captain to properly monitor and respond to the aircraft’s low fuel supply
despite a crew member’s advice that fuel was running low. The captain’s inattention resulted from
his preoccupation with a landing gear malfunction and preparations for a possible landing
emergency.
Contributing to the accident was the failure of the other two flight crew to either fully comprehend
the critical state of the fuel supply or successfully communicate their concern to the captain.
ADAPTED FROM WWW.AIRDISASTER.COM/INVESTIGATIONS/UA173.SHTML, ACCESSED 12 JANUARY 2015.
RESEARCH BOX 2-1: Surgical Safety Checklist
Australian researchers performed a systematic review of seven independent, previously published studies
testing the effectiveness of surgical safety checklists on postoperative (PO) complications. In all of the
studies, WHO’s Surgical Safety Checklist or a modified version was used. A meta-analysis was performed
in which the results of the studies, representing 37,339 patients, were integrated. All patients had either
elective surgery or emergency surgery.
Pooled results of the meta-analysis suggested that using a checklist in surgery significantly reduced
overall PO complications, wound infections and blood loss. According to the review, there were 3.7% fewer
PO complications overall, 2.9% fewer wound infections and a 3.8% reduction in patients who had blood
loss greater than 500 mL. The use of a checklist, however, did not significantly reduce mortality rates,
pneumonia or unplanned return to surgery.
SOURCE: GILLESPIE, CHABOYER, THALIB, FAIRWEATHER & SLATER (2014).
importance of non-technical skills has seen the adapted in many countries including Australia and
adoption within surgery of many of the tools used New Zealand (Royal Australasian College of Sur-
in CRM training (Salas & Rosen, 2013). These tools geons [RACS], 2009). Practical application of the
include the use of Surgical Safety Checklists for checklist is discussed in Chapter 9 on intraopera-
correct patient identification (‘Time Out’) and tive patient care, but its relevance to human factors
patient handover, interdisciplinary simulation comes from the information in the checklist that
training and greater contributions from the surgi- communicates key facts about the patient and
cal team to intraoperative patient planning and anticipated critical events; it also identifies key
care through preoperative briefings (Alander et al., personnel involved in the patient’s care. The check-
2011; Salas & Rosen 2013). list focuses team members’ attention on key aspects
In 2004, the World Health Organization (WHO) of the patient’s care and standardising team com-
developed the Surgical Safety Checklist (see munications using the checklist is one way to
Research box 2-1) as a global initiative to promote ensure that everyone is on the same page or sharing
safer surgery. The checklist has been adopted and the same mental model (see later in chapter).
34
Possessing the same knowledge of the patient’s there is a strict hierarchical order and where a high
status assists each member of the surgical team to value is placed on the skills required to perform
prepare for events that may occur during surgery. work roles competently (Marshall, 2012). It could
Use of a checklist also provides an opportunity for be argued that the perioperative environment is
all team members, regardless of professional expe- one such workplace. Workplace bullying has been
rience or discipline, to raise any concerns they may described in relation to decreased job satisfaction,
have about the procedure (Walker, Reshamwalla & diminished work performance, burnout and nurse
Wilson, 2012). While the Surgical Safety Checklist attrition (ANF, 2011), although in many cases it still
cannot be directly linked to improved patient out- goes unreported. Examples of workplace bullying
comes, its use emphasises the need for discussion include:
and therefore enhances teamwork and communica- • behaving aggressively
tion between members of the surgical team.
• pressuring someone to act inappropriately
TEAMWORK • making belittling comments
Teamwork is defined as a group of individuals who • practising social exclusion
work together to achieve a common goal, working
• making unreasonable work demands
interdependently to perform tasks and managing
(Australian Government, 2014).
their relationships and clinical roles across profes-
sional boundaries (Salas et al., 2014). Effective The prevalence of workplace bullying com-
teamwork relies on commitment, collaboration, pounds the existing difficulties experienced by
competence, a supportive culture and commu nursing specialties in terms of their ability not only
nication (Salas & Frush, 2012). Teamwork and to retain nurses, but also to recruit nurses in the
communication are fundamental interrelated non- future. As a result, emphasis is placed on prevent-
technical skills that contribute to the delivery of ing workplace bullying and, in many healthcare
safe surgical care and are enshrined in periopera- institutions, primary prevention is underpinned by
tive culture (Braaf et al., 2011). Statistics from the education and training of staff. The Australian
US Joint Commission for Health and Safety identi- College of Operating Room Nurses (ACORN) has
fied communication and teamwork as the number published a position statement that details the
one root cause (65%) of reported sentinel events obligations of individuals and organisations in
between 1995 and 2004 (ElBardissi & Sundt, 2012). relation to the prevention and management of
workplace bullying and the imperative to promote
As members of an interdisciplinary team, indi-
‘a culture of zero tolerance’ in perioperative envi-
viduals do not work in ‘splendid isolation’ of others.
ronments (ACORN, 2016).
An important feature that distinguishes periopera-
tive teams is that each member brings different Highlighted in Feature box 2-2 are examples of
levels of expertise and knowledge to the task, workplace harassment. These cases highlight the
termed distributed expertise. Surgical teams work difficulties faced by health professionals in speak-
together interdependently; that is, members are ing out against senior colleagues who have acted
mutually dependent on each other in relation to inappropriately and unprofessionally. Courage is
performing a specified task and must adapt to one required to report inappropriate and bullying
another to achieve team goals (Gillespie, Gwinner, behaviours and staff should seek out colleagues
Chaboyer & Fairweather, 2013). who can be supportive and advise on the appropri-
ate reporting process. The second incident high-
The interdependency of the surgical team
lights a possible confusion and misunderstanding
required to function effectively can be adversely
over ‘backstage’ boundaries as new staff attempt to
affected by workplace bullying and harassment.
fit into the unique culture of the perioperative
Despite the zero-tolerance reflected in the policies
environment.
of many Australian and New Zealand healthcare
organisations, horizontal violence in the form
of workplace bullying and harassment remains COMMUNICATION
an unfortunate reality (Australian Nursing Federa- Communication between the multidisciplinary
tion [ANF], 2011; Worksafe NZ, 2014). Workplace team may be based on previous professional and
bullying appears to flourish in environments where social relationships and may have the potential to
35
FEATURE BOX 2-2 » SURGEON RESIGNS OVER SEXUAL HARASSMENT COMPLAINTS
A leading Victorian surgeon has resigned from a large teaching hospital following serious com-
plaints of sexual harassment and poor surgical decision making made by a number of junior
surgeons and other medical staff. The hospital CEO stated that although the hospital had a robust
system for managing complaints and auditing surgical performance, he had ‘significant’ concerns
that a culture existed in smaller medical departments that discouraged junior doctors from com-
plaining about their superiors.
The complaints came amid a furore around harassment in the health system prompted by a senior
female Sydney surgeon, who recently said that the careers of trainees who reported sexual harass-
ment could be ruined.
In another case, a young doctor was reduced to tears after she was told, in what appeared to have
been an attempt at humour, to take her clothes off. In this case, the surgeon’s supporters say his
behaviour was inappropriate, but was the product of his misguided efforts to be jocular.
SOURCE: ADAPTED FROM McKENZIE & BAKER (2015).
hinder team effectiveness. This is particularly true confirming the completion of a task. The term is
when team members are transitory and there is a taken from aviation when pilots are deliberately
significant reliance on casual or agency staff. Teams taught to vocalise routine actions as a double-check
who consistently work together develop an under- of tasks completed. In the perioperative environ-
standing of each other’s work capabilities and comment examples might include team members com-
municate more effectively, which reduces the risk municating to the rest of the team that they have
of adverse events occurring. It is often easy to spot completed certain tasks; for example, ‘diathermy is
a team that regularly works together and has a deep on coagulation 30’, ‘penicillin administered’, ‘aortic
understanding of the practical steps of the pro clamp applied at 1430’.
cedure. The instrument nurse anticipates the sur- While the benefits of teamwork in enhancing
geon’s move, so that verbal communication related patient care have been emphasised in a number of
to the procedure is minimal. Similarly, the circulat- studies, there are a growing number of retrospective
ing nurse anticipates the team’s need for additional and observational studies that highlight the nega-
supplies and equipment so that the procedure is tive consequences of communication breakdown in
smooth and coordinated. In contrast, surgeons who surgery (Gillespie, Chaboyer & Fairweather, 2012).
work with a different instrument nurse for each Retained sponges, wrong-site surgery, incomplete
procedure have more difficulty in establishing a clinical handover and mismatched blood transfu-
coordinated team (ElBardissi & Sundt, 2012). sions can be the result of interpersonal dynamics,
In addition, nurses and doctors are socialised where communication breakdowns occur between
into different communities of practice and there- team members. The hierarchical structure can also
fore have different foci and communication styles. contribute to such communication breakdowns
For example, doctors tend to approach a clinical when junior team members are afraid to speak up,
situation using a diagnosis-and-treatment model, even if they note an adverse event is about to
whereas nurses operate using a provision-of-care happen. Similar to the human factors training
model (Gessler, Rosenstein & Ferron, 2012). Thus, undertaken by pilots, the development of ‘hori
there is a danger that miscommunication may occur zontal communication’, which empowers junior
between team members. members of the team to speak up, is becoming
Miscommunication impacts on team effective- incorporated into medical and nursing training
ness and may also contribute to adverse patient (Brindley & Reynolds, 2011).
outcomes. Brindley and Reynolds (2011) support The provision of high-quality and safe patient
the use of ‘fly-by-voice’ commands as a method of care linked to effective communication and the
36
ability to work in a multidisciplinary team can be

enhanced via informal ‘team briefings’ or ‘huddles’.
This involves the surgical team meeting just prior
to commencement of the surgical list each day to
discuss the procedures, possible complications,
equipment and supplies required. This briefing is
over and above the requirement to complete the
Surgical Safety Checklist. Bandari and colleagues
(2012) found that briefings and debriefings by sur-
gical teams not only improved communication, but
also brought to light defects in equipment and lack
of availability of supplies. Identifying these issues
prior to surgery allows time for them to be rectified,
reducing delays and thereby contributing to patient Anaesthetist
safety.
Team training and the use of interdisciplinary
simulation exercises have also been shown to be
beneficial in improving teamwork. Simulation exer-
Surgeon Nurse
cises may involve, for example, an emergency case
scenario where the team members must work
together to identify and manage the emergency.
Debriefing following the exercise provides opportu-
nities for the team members to discuss and evaluate FIGURE 2-2: Depiction of a shared mental model between the anaesthetist, the
their performance (Wacker & Kolbe, 2014). nurse and the surgeon
Source: Adapted from Department of Defense (2006).
SHARED MENTAL MODELS

all team members critical or unexpected events
Considering the patient holistically within the con- (RACS, 2009). Consequently, team members are
tinuum of care, as opposed to being task oriented, then able to strategise their actions and behaviours
is essential. The more effective teamwork and com- should the unexpected event occur.
munication are between individuals in the surgical
team, the more likely they are to build an accurate SITUATION AWARENESS
shared mental model of the situation. A mental
model is the term applied to understanding a par- Situation awareness is a non-technical skill that
ticular situation and all of the factors that influence refers to an ability to identify and process many
the situation. The concept of a shared mental model pieces of information from within the operating
is defined by McComb and Simpson (2014) as ‘indi- room environment and act accordingly. Situation
vidually held knowledge structures’ that enable awareness requires the ability to watch, listen and
team members to function collaboratively within understand cues, anticipating what might happen
their environment and assist them in predicting next (Mitchell et al., 2011b). Team members need
what each team member is going to do and what to be aware of the big picture rather than focusing
they are going to need in order to do it. In its simon a particular task. To achieve this, an individual
plest form, a shared mental model is all the team takes in data from their senses, interprets the data
members thinking as one or colloquially, ‘being on and finally makes predictions of what will happen
the same page’, as can be seen in Figure 2-2 where in the future. Situation awareness relies on good
the anaesthetist, the surgeon and the nurse have a teamwork and communication.
shared mental model in relation to monitoring Good situation awareness alerts staff to a sudden
being required. As mentioned previously, the Surgi- change in the surgeon’s tone of voice, a comment
cal Safety Checklist provides an opportunity to about blood loss or an intraoperative complication
share information consistent with the concept of for which urgent action may be required. Recognis-
a shared mental model; for example, the section ing these vital cues can initiate immediate and pos-
on the checklist in which the surgeon shares with sibly lifesaving actions, whereas a lack of situation
37
RESEARCH BOX 2-2: Research Findings about Situation Awareness
In a recent qualitative study using observations and interviews, Gillespie and colleagues (2013) found
that instrument nurses used strategies such as ‘overhearing’ and ‘thinking ahead’ to increase their situa-
tion awareness during surgical procedures. The deliberate act of listening at the operating table during
surgery enables instrument nurses to coordinate their activities, anticipate unexpected events and plan
contingency responses. Consequently, nurses use situation awareness to build a mental model by gather-
ing cues presented in the environment and integrate information from different sources, much of which
is based on their familiarity and experience with the surgeon and the procedure.
SOURCE: GILLESPIE ET AL. (2013).
FEATURE BOX 2-3 » SITUATION AWARENESS IN CLINICAL PRACTICE
It was a routine laparoscopic cholecystectomy on a fit, healthy 45-year-old woman and Mary, the
Clinical Nurse Educator, Anaesthetics, was working with a newly graduated nurse, Josh, who had
just commenced a three-month rotation into anaesthetics. They had assisted the anaesthetist in
the patient’s induction of anaesthesia and all seemed to be progressing well with the surgery. The
doors from the operating room into the anaesthetic bay were open and Mary was showing Josh
how to set up for the next patient.
Suddenly, the surgeon commented: ‘I’ve got a bit of bleeding here.’ Mary immediately returned to
the operating room to see whether the anaesthetist required any additional fluids or equipment.
She noticed that Josh was still focusing on priming an intravenous line in the anaesthetic bay,
seemingly oblivious of what was happening in the operating room. On returning to the anaesthetic
bay, Mary asked Josh whether he had heard the surgeon’s comment. He had not and Mary made
a joke about having ‘to grow your third ear’; in other words, the ability to ‘overhear’ other conver-
sations between team members and act on them appropriately.
awareness may mean delays in obtaining equip- and Baby Boomers (Hamlin & Gillespie, 2011). Each
ment, causing the patient’s condition to be compro- generation brings vastly different core values,
mised. It can be easy as a novice perioperative nurse beliefs and expectations to the workplace. They
to become focused on one task or element of care also have different priorities, attitudes, communi-
and oblivious to what else is happening within the cation styles and ways to engage with peers and
operating room (Flin & Mitchell, 2011). Research work design that influence organisational culture
box 2-2 highlights research findings about situation and performance. Therefore, having an understand-
awareness. Feature box 2-3 is a real-life clinical ing of these underlying core values and beliefs has
example demonstrating the aspect of ‘overhearing’ important implications for those who are tasked
described by Gillespie and colleagues (2013) and with leading intergenerational teams. Leaders who
illustrates how novice nurses may need prompting capitalise on the inherent differences between gen-
and guidance in developing their non-technical erations can create a dynamic and engaged work-
skills. force, giving them a competitive edge in attracting
and retaining staff. Having a multigenerational
LEADERSHIP AND A MULTIGENERATIONAL workforce is not new, though traditionally the age
WORKFORCE groups were separated by a clear chain of command:
In the perioperative setting, there are at least three the older workers were generally the managers,
diverse generations: Generation X, Generation Y while the younger workers were junior staff. The
38
• Emotional self-awareness
• Knowing limitations and • Empathy
strengths • Appreciating alternative
Self- Social perspectives
• Accepting constructive
criticism
awareness awareness • Organisational awareness
• Emotional self-control • Inspiring leadership

Self- Relationship
• Adaptability • Influence
• Achievement management management • Conflict management
• Positive outlook • Teamwork and
collaboration
FIGURE 2-3: Domains of emotional intelligence

Source: Adapted from Goleman (2011).
new reality is a much more flattened organisational awareness when communicating with others (Kaye
structure in which nurses of different ages and gen- et al., 2012). Leaders with good emotional intelli-
erations work more closely together and junior gence understand the importance of workplace
staff are less afraid to provide opinions and voice relationships and realise that positive outcomes
demands (American Hospital Association, 2014). can be achieved only as a result of a team effort.
Leadership is the ability to motivate and direct Goleman (2011) identifies four domains of emo-
others to achieve shared goals to attain the best tional intelligence: social awareness, relationship
outcomes for perioperative patients. Leadership management, self-management and self-awareness.
skills are developed through experience, role mod- Figure 2-3 illustrates the interrelationships between
elling and critical reflection (Kaye, Fox & Urman, these domains.
2012). Enabling people to connect and collaborate,
and finding the appropriate style and content of ENVIRONMENTAL FACTORS
communication, are challenging but essential tasks The environmental elements of human factors
for perioperative leaders. Just because a person comprise task management, ergonomics and noise
holds a leadership role does not necessarily mean and distractions. Each of these has the potential to
that he or she is an effective leader. In fact, there impact on team performance.
are very few natural leaders. Leadership skills
need to be learned. Importantly, there is growing TASK MANAGEMENT
acknowledgement that emotional intelligence is an Task management refers to the organisation of
essential quality of effective leadership (Goleman, resources necessary to provide smooth, safe and
2011). effective patient care. It is also concerned with
Emotional intelligence is defined by the ‘ability maintaining standards of care and dealing with
to understand and manage our emotions and those stressful situations that occur in the perioperative
around us. This quality gives individuals a variety environment (Mitchell et al., 2011b). There are
of skills, such as the ability to manage relation- many physical and mental demands present when
ships, navigate social networks, influence and working in an operating room that can affect the
inspire others’ (Fletcher, 2012, para. 2). The ability safe and effective performance of the surgical team.
to lead and bring out the best in others is especially For the nursing staff there is a great deal of detail
applicable when considering how closely periop- to remember when setting up the operating room
erative nurses work with others as part of an inter- for surgery, prioritising tasks and managing the
disciplinary team. In managing relationships, environment when surgery is in progress. Manag-
individuals need to show empathy and use social ing this process effectively is important for patient
39
safety and missing a step (e.g. forgetting to set up amount of equipment used during a procedure
a piece of equipment) can result in procedural varies and can be significant. As well as correctly
delays and errors that could compromise patient setting up individual pieces of equipment (dis-
safety. Rather than relying on memory alone, the cussed under task management), positioning the
nursing team can be assisted by following stand- equipment is equally important to allow all staff
ardised policies and processes and using effective members to access and view video screens and
checklists (Mitchell et al., 2011b). Some helpful monitors. If the surgeon or anaesthetist is unable
resources may include: to view monitoring devices clearly or if nurses
• surgeons preference cards—so that all cannot quickly access equipment controls to change
equipment required by each surgeon can be settings, patient safety may be compromised
obtained ready for use (ElBardissi & Sundt, 2012).
• diagrams showing where specific equipment is Another element of ergonomics is workplace

located within the operating room health and safety; for example, manual handling
and the trip hazards involved in moving equipment
• a checklist for setting up each piece of and positioning electrical cords. Many operating
equipment rooms have overhead pendant systems into which
• tray lists to check each instrument tray prior electrical cords and suction tubing can be con-
to and following surgery nected, removing them as trip hazards. However,
pendants often add to inflexibility in the layout of
• team ‘Time Out’ checklist for correct
the operating room as they are either fixed or have
identification of the patient
limited movement. In the future, Bluetooth tech-
• algorithms for managing adverse events nology will make the environment ‘wireless’, ena-
(e.g. loss of a sponge intraoperatively or bling monitoring and audiovisual equipment to be
managing a difficult airway). positioned with greater flexibility, as well as reduc-
Task management also refers to the ability of ing trip hazards by eliminating electrical cords
staff to maintain correct standards of practice and (ElBardissi & Sundt, 2012). See Chapter 5 for further
to withstand the pressures of time or requests from information about the perioperative environment.
other staff members to cut corners in practice. This Strategies designed to enhance the ergonomics of
is not easy to manage, especially for new staff the operating room include standardising the
members (Mitchell et al., 2011b). The hierarchical placement of commonly used equipment and items
structure of the surgical team may contribute to to improve staff efficiency and reduce time wastage
the pressure to disregard established protocols. It and potentially life-threatening errors (Carayon,
requires courage and good communication skills Xie & Kianfar, 2014).
to resist such pressures. Agreeing to undertake
an inappropriate practice not only puts the patient NOISE AND DISTRACTION
at risk, but also can result in questions being
The amount of noise within the operating room can
asked about staff members’ professional practice.
contribute to adverse events and requires monitor-
Graded assertiveness, discussed later in the chapter,
ing and managing. Noise can come from music,
provides strategies to manage such challenging
mobile phones and pagers, drills, electronic equip-
situations.
ment, alerts on monitors and general conversation.
Many surgeons enjoy background music playing
ERGONOMICS while they operate and music does have soothing
Closely aligned to task management is ergonomics, qualities. However, noise can be a danger by dis-
which is defined as ‘the scientific discipline con- tracting staff, hindering effective communication
cerned with the understanding of the interactions and interfering with the surgeon’s ability to con-
between humans and other elements of a system’ centrate. If music is played, the volume should be
(Human Factors & Ergonomics Society of Australia at a level that does not affect requests for equip-
[HFESA], 2015, para. 1). In the context of the peri- ment from being heard or mask monitor alarms. In
operative environment, ergonomics is concerned addition, staff should not use personal electronic
with the positioning of equipment, room layout, devices during surgery for texting or accessing
safe access and unimpeded movement for staff. The social media, as this can affect situation awareness
40
and distract staff from critical events occurring of the many critical periods that occur during
during surgery. Such activities should take place surgery such as induction and reversal of anaesthe-
during breaks away from the clinical area. sia, counting swabs and sponges, ligating vessels
All of these distractions can compromise patient and so forth. It is imperative that during these types
safety if they are not properly managed. Some oper- of activities the team does not become distracted
ating rooms have policies on the use of mobile or interrupted by informal conversations, music or
phones and pagers indicating that they must be on mobile phones, which may erode their situation
silent mode, left in staff lockers or at reception for awareness and place the patient at risk. Periopera-
messages to be taken (Clark, 2013; Putnam, 2015). tive nurses may find themselves in the position of
See Chapter 5 for further information about noise managing noise and other distractions within the
in the perioperative environment. operating room and this requires a level of assert-
iveness, which is discussed in the next section
Most conversations between surgical team (ElBardissi & Sundt, 2012; Clark, 2013).
members are a necessary part of exchanging infor-
mation about the procedure or requesting equip- GRADED ASSERTIVENESS
ment, but at times the conversation may be informal
Assertiveness is a form of communication in which
‘chatter’ unrelated to surgery. Such chatter during
a person’s needs or wishes are stated clearly with
critical moments of surgery can distract team
respect for the individual and the other person in
members (just like the plane’s cockpit crew men-
the interaction. It differs from aggressive commu-
tioned below) and compromise patient safety. As a
nication where the needs or wishes are stated in a
result, some operating rooms follow another lesson
hostile or demanding manner (Brindley & Reynolds,
learned from aviation: the concept of the ‘sterile
2011). It can be difficult for nurses new to the peri-
cockpit’ (ElBardissi & Sundt, 2012).
operative environment to speak up when faced with
situations where patient or staff safety is compro-
THE ‘STERILE COCKPIT’ mised. The hierarchical structure within the surgi-
The ‘sterile cockpit’ has nothing to do with a clean cal team may discourage questioning or challenging
physical operating room environment, but refers to senior staff. This situation may be exacerbated if the
a clean mental environment, free from distractions staff member’s traditional cultural background dis-
that could compromise patient safety. Evidence courages questioning of any authority.
gathered from cockpit voice recorders (black boxes) Providing an environment in which staff
following air disasters in the 1970s showed that just members feel supported if the need to speak up
prior to a plane crashing, the flight crew were fre- arises is important; additionally, the use of graded
quently engaged in non-essential activities or con- assertiveness may assist in promoting effective
versations with colleagues in the cockpit or with dialogue. There are a number of different models of
flight attendants—tasks unrelated to their role of graded assertiveness that can be used and, as with
flying the plane. This distracting ‘chatter’ took their all elements of good communication, they require
focus away from essential tasks, especially during practise to feel comfortable using them. Two models
the critical periods of the flight, and resulted in a commonly used are explored in Feature boxes 2-4
number of adverse events, including plane crashes. and 2-5. Initially, neither strategy will be easy to
In an attempt to promote safety, the aviation indus- initiate, but with practice the ability to speak up
try invoked the ‘sterile cockpit’ or ‘below 10,000 and question colleagues about practice issues will
feet’ rule stating that during critical phases of flying become easier to achieve. The perioperative nurse
(e.g. landing, take off, taxiing), no members of the is an advocate for the patient and in some situa-
flight crew were to engage in any activities other tions for the safety of colleagues. Courage to act
than those duties required to fly the plane safely. and to speak up using graded assertiveness is a
This also included banning interruptions from necessary communication skill that perioperative
flight attendants unless there was a life-threatening nurses must practise and master.
event (ElBardissi & Sundt, 2012; Clark, 2013). Feature box 2-6 illustrates the significant part
A parallel may be drawn between critical activi- played by human factors in the adverse outcome for
ties in the cockpit and those in an operating room. one patient, Elaine Bromiley who underwent ‘just a
A ‘sterile cockpit’ rule could be invoked during one routine operation’. In reviewing the incident from
41
FEATURE BOX 2-4 » PACE MODEL OF GRADED ASSERTIVENESS
Probe: ‘Doctor, do you know that this patient is allergic to latex?’

Alert: ‘Can we reassess the situation before proceeding with surgery?’
Challenge: ‘Please stop what you are doing while we obtain latex-free gloves.’
Emergency: ‘STOP what you are doing!’
The final step might be confronting for nurses to undertake, but it may be necessary only to state
the ‘Probe’ and ‘Alert’ steps: these two statements may be sufficient to halt the person proceeding
any further and for remedial action to be taken (i.e. in this example obtaining the latex-free gloves).
SOURCE: BRINDLEY & REYNOLDS (2011).
FEATURE BOX 2-5 » STEP ADVOCACY APPROACH TO GRADED ASSERTIVENESS
• Attention getter: ‘Excuse me, Doctor Bob’

• State your concern: ‘I believe you have just contaminated your sterile gloves.’
• State the problem as you see it: ‘The instruments are now contaminated and the aseptic
field has been compromised.’
• State a solution: ‘You will need to change your gloves.’
• Obtain an agreement: ‘I have a pair of gloves ready for you here; is that OK with you?’
Again, by the time the concern has been stated, Dr Bob should have stopped his actions and
proceeded to change his gloves without the need to work through the other steps.
SOURCE: BRINDLEY & REYNOLDS (2011).
FEATURE BOX 2-6 » ‘JUST A ROUTINE OPERATION’
Elaine Bromiley was a fit and healthy young woman who was admitted to hospital for routine
sinus surgery. During induction of anaesthetic she experienced breathing problems and the anaes-
thetist was unable to insert a breathing tube to secure her airway. After 10 minutes it was a situ-
ation of ‘can’t intubate, can’t ventilate’—a recognised anaesthetic emergency for which guidelines
exist. For a further 15 minutes, three highly experienced consultants made numerous unsuccessful
attempts to secure Elaine’s airway and she suffered prolonged periods with dangerously low levels
of oxygen in her bloodstream.
Early on, the nurses informed the team that they had brought emergency equipment to the room
(instrumentation to perform a tracheostomy) and booked a bed in intensive care, but neither
option was utilised.
Thirty-five minutes after starting the anaesthetic it was decided that Elaine should be allowed to
wake up naturally and she was transferred to the recovery unit. When she failed to wake up she
was transferred to ICU. Elaine never regained consciousness and after 13 days the decision was
made to withdraw life support.
SOURCE: BROMILEY (2009).
42
a human factors perspective, it is clear that the the hierarchy of the three consultants present
team caring for Elaine failed in a number of areas: affected the nurses’ ability to intervene and
• Situation awareness. The stress of the effectively communicate their concerns and
situation caused the medical team to become suggestions with the team.
fixated on repeated attempts to secure the Following Elaine Bromiley’s death, her husband,
airway and lose sight of the bigger picture, Martin, an airline pilot, dedicated himself to pro-
that of Elaine’s overall condition. They had no moting greater understanding about human factors
sense of the time that was passing and the within healthcare, particularly for surgical teams.
increasing severity of the situation. He founded the Clinical Human Factors Group in
• Decision making. There was no clear leader the United Kingdom, which has produced some
who could step back from the situation, review excellent resources—these are included in the
actions and make appropriate decisions. Resources section at the end of the chapter.
Although very experienced, the three
consultants were not communicating with CONCLUSION
each other.
Patients are at their most vulnerable when they
• Teamwork. With no clear team leader, there enter the confines of the perioperative environ-
was no shared mental model communicated ment for surgery. There is little doubt that human
between the team members. Each team factors play a pivotal role in promoting patient
member provided his or her own strategies for safety. This chapter has examined a number of
managing Elaine’s airway. This resulted in ways in which effective interdisciplinary teamwork
uncoordinated actions that were not in line and communication, including assertiveness, can
with ‘can’t intubate, can’t ventilate’ emergency contribute to safe patient outcomes in the periop-
protocol. erative environment. As patient advocates, it is
• Culture. The nurses present recognised the important that perioperative nurses develop their
seriousness of the situation very early and skills in human factors to enable them to effectively
tried to make suggestions and bring in the advocate for patients and contribute to the team
appropriate emergency equipment. However, and patient safety.

1. Communication
Reflect on a recent communication you have had with another member of the perioperative team
(i.e. anaesthetist, surgeon, technician, radiographer, nurse) where you perceived the goals of the
exchange were not achieved.
• Why weren’t the goals achieved? How did you know?
• Were there any negative consequences for the team or the patient? If there were, what were
they? How were they dealt with?
• What steps would you take in future to ensure that this did not occur again?
Give rationales for your answers.
2. Teamwork
The operating room represents the epitome of teamwork. When members become part of the periop-
erative team, many aspects of group dynamics come into play and members’ behaviours are often
influenced by the situation and the ways in which information is exchanged. Reflect on a team you
have worked with.
• What are some of the qualities you noted?
• How did these contribute to or sabotage the effectiveness of the team?
Continued
43

• What strategies could you could use to enhance teamwork and communication between team
members? Why do you believe these would be effective?
3. Graded assertiveness
You are caring for Mr Grey in the PACU; he has undergone a transurethral resection of the prostate.
He is bleeding more than usual for this type of procedure and you are concerned. When you contact
the surgeon, Dr Michaels, and outline the details of Mr Grey’s condition, she does not offer to come
and review him. Using the STEP advocacy model, how will you respond to Dr Michaels?
4. Leadership
Identify a colleague whom you consider to be a clinical leader or role model. This person does not
have to hold a position of designated authority (e.g. nurse unit manager), but she or he should dem-
onstrate leadership qualities.
• What are the qualities that you especially admire and why?
• What is her/his leadership style?
• What strategies does she/he use to motivate or ‘get the best’ out of others in the team?
• What strategies does she/he use to ensure that team members are included in the decision-
making process?
• What strategies does she/he use to build team trust?
• What strategies does she/he use in dealing with team conflict?
REFERENCES
RESOURCES Alander, D., Brooks, R., Carmack, D., & Legan, J. (2011).
Airdisaster.com Improve surgical safety by using CRM. Journal of American
www.airdisaster.com/investigations/ua173.shtml Academy/American Association of Orthopaedic Surgeons, 5(7),
1–5. Retrieved from <www6.aaos.org/news/PDFopen/
Below Ten Thousand Medical PDFopen.cfm?page_url=www.aaos.org/news/aaosnow/
www.belowtenthousand.com jul11/clinical9.asp>.
Clinical Human Factors Group American Hospital Association, Committee on Performance
www.chfg.org.uk Improvement. (2014). Managing an intergenerational work-
Human Factors & Ergonomics Society of Australia force: Strategies for health care transformation. Chicago:
(HFESA) Health Research & Educational Trust.
www.ergonomics.org.au/resource_library/definitions Australian College of Operating Room Nurses (ACORN).
www.ergonomics.org.au (2016). Standards for perioperative nurses. Adelaide: ACORN.
‘Just a routine operation’ Australian Government. (2014). Fairwork Commission anti
www.institute.nhs.uk/safer_care/general/human_factors bullying guide. Australian Government, Canberra.
.html
Australian Nursing Federation (ANF). (2011). Bullying in
New Zealand Nurses Organisation the workplace: ANF policy. Retrieved from <anmf.org.au/
www.nzno.org.nz/support/workplace_rights/workplace documents/policies/P_Bullying.pdf>.
_bullying
Bandari, J., Schumacher, K., Simon, M., Cameron, D., Goeschel,
The Council on Surgical and Perioperative Safety C., Holzmueller, C., et al. (2012). Surfacing safety hazards
www.cspsteam.org using standardized operating room briefings and debrief-
The Human Factor: Learning from Gina’s Story ings at a large regional medical center. Joint Commission
https://www.youtube.com/watch?v=IJfoLvLLoFo&app Journal on Quality and Patient Safety, 38(4), 154–160.
=desktop Braaf, S., Manias, E., & Riley, R. (2011). The role of documents
The Patient Safety Initiative and documentation in communication failure across the
www.thepatientsafetyinitiative.com/sterile-cockpits-and perioperative pathway. A literature review. International
-sterile-operating-rooms Journal of Nursing Studies, 48, 1024–1038.
44
Brindley, P. G., & Reynolds, S. F. (2011). Improving verbal Hamlin, L., & Gillespie, B. (2011). Beam me up Scotty, but
communication in critical care medicine. Journal of Critical not just yet: Understanding generational diversity in the
Care, 26, 155–159. perioperative milieu. ACORN Journal, 24, 36–43.
Bromiley, M. (2009). Would you speak up if the consultant Human Factors & Ergonomics Society of Australia (HFESA).
got it wrong? Journal of Perioperative Practice, 19(10), (2015). Definitions. Retrieved from <www.ergonomics.org.au/
326–329. resource_library/definitions>.
Carayon, P., Xie, A., & Kianfar, S. (2014). Human factors and Kaye, A., Fox, C., & Urman, R. (2012). Operating room leadership
ergonomics as a patient safety practice. British Medical and management. Cambridge: Cambridge University Press.
Journal Quality Safety, 23, 196–205. Marshall, J. (2012). The rising cost of workplace bullying.
Chen, X., Fu, R., & Zhao, S. (2015). Culture and socialisation. Australian Education Union (AEU) Newsletter 5. Retrieved
In J. Grusec (Ed.), Handbook of socialization: Theory and from <www.aeuvic.asn.au>.
research (2nd ed.). New York: Guilford Publications. McComb, S., & Simpson, V. (2014). The concept of shared
Clark, G. J. (2013). Strategies for preventing distractions and mental models in healthcare collaboration. Journal of
interruptions in the OR. AORN Journal, 97(6), 702–707. Advanced Nursing, 70(7), 1479–1488.
Clinical Human Factors Group. (2013). Getting to grips McKenzie, N., & Baker, R. (2015). Top surgeon quits the
with the human factor: Strategic actions for safer care. A Alfred Hospital admid sex harrassment claims. The Age, 11
learning resource for Boards. UK: Clinical Human Factors March.
Group. Mitchell, R., Chung, A., Williamson, A., & Molesworth, B.
Department of Defense. (2006). TeamSTEPPS™ Multimedia (2011a). Human factors and healthcare-related deaths:
Resource Kit. [TeamSTEPPS™: Team Strategies & Tools to Review of coronial findings using a human factors classifi-
Enhance Performance and Patient Safety. USA: Agency for cation framework. Ergonomics Australia—Human Factors &
Healthcare Research & Quality. Ergonomics Society of Australasia (HFESA) Conference Edition,
ElBardissi, A. W., & Sundt, T. M. (2012). Human factors and 11(18), 1–6.
operating room safety. Surgical Clinics of North America, 92, Mitchell, L., Flin, R., Yule, S., Mitchell, J., Coutts, K., &
21–35. Youngson, G. (2011b). Thinking ahead of the surgeon.
Fletcher, S. (2012). Five reasons why emotional intelligence An interview study to identify scrub practitioners’ non-
is critical for leaders. Retrieved from <leadchangegroup technical skills. International Journal of Nursing Studies, 48,
.com/5-reasons-why-emotional-intelligence-is-critical-for 818–828.
-leaders>. Putnam, K. (2015). Minimising electronic distractions in the
Flin, R., & Mitchell, L. (2011). Scrub practitioners’ list of intra- OR. AORN Journal, 102(1), 7–9.
operative non-technical skills (SPLINTS). Aberdeen: University Royal Australasian College of Surgeons (RACS). (2009). Sur-
of Aberdeen. gical Safety Checklist (Australia and New Zealand). Retrieved
Flin, R., O’Connor, P., & Crichton, M. (2008). Safety at the sharp from <https://www.surgeons.org/media/12661/LST_2009
end: A guide to non-technical skills. Aldershot: Ashgate. _Surgical_Safety_Check_List_(Australia_and_New_Zealand)
.pdf>.
Flin, R., & Patey, R. (2011). Non-technical skills for anaes-
thetists: developing and applying ANTS. Best Practice and Salas, E., & Frush, K. (Eds.), (2012). Improving patient safety
Research. Clinical Anaesthesiology, 25(2), 215–227. through teamwork and team training. New York: Oxford Uni-
versity Press.
Gessler, R., Rosenstein, A., & Ferron, L. (2012). How to handle
disruptive physicians behaviors. American Nurse Today, 7(11), Salas, E., & Rosen, M. (2013). Building high reliability teams:
8–12. Retrieved from <www.medscape.com/viewarticle/ Progress and some reflections on teamwork training. BMJ
775407>. Quality & Safety in Healthcare, 22, 369–373.
Gillespie, B., Chaboyer, W., & Fairweather, N. (2012). Factors Salas, E., Shuffler, M., Thayer, A., Bedwell, W., & Lazzara, E.
that influence the expected length of operation: Results of (2014). Understanding and improving teamwork in organi-
a prospective study. Quality & Safety in Healthcare, 21(1), zations: A scientifically based practical guide. Human
3–12. Resource Management, doi:10.1002/hrm.21628.
Gillespie, B. M., Chaboyer, W., Thalib, L., Fairweather, N., & Stein, L. (1978). The doctor–nurse game. Readings in the soci-
Slater, K. (2014). Effect of using a safety checklist in surgery ology of nursing. Edinburgh: Churchill-Livingstone.
on patient complications: a systematic review and meta- Sydor, D., Bould, M., Naik, V., Burjorjee, J., Arzola, C., Hayter,
analysis. Anaesthesiology, 120, 1380–1389. M., et al. (2013). Challenging authority during a life-
Gillespie, B. M., Gwinner, K., Chaboyer, W., & Fairweather, N. threatening crisis: The effect of operating theatre hierarchy.
(2013). Building situational awareness in surgery through British Journal of Anaesthesia, 110(3), 463–471.
distributed dialogue. Journal of Multidisciplinary Health Care, Tanner, J., & Timmons, S. (2000). Backstage in the theatre.
6, 109–118. Journal of Advanced Nursing, 32(4), 975–980.
Goleman, D. (2011). Leadership: The power of emotional intel- Wacker, J., & Kolbe, M. (2014). Leadership and teamwork in
ligence. Selected writings. USA: More Than Sound. anesthesia: Making use of human factors to improve clinical
45
performance. Trends in Anaesthesia and Critical Care, 4, Ford, D. (2015). Speaking up to reduce noise in the OR. AORN
200–205. Journal, 102(1), 85–89.
Walker, I., Reshamwalla, S., & Wilson, I. (2012). Surgical Kang, E., Gillespie, B. M., & Massey, D. (2014). What are the
Safety Checklists: Do they improve outcomes? British Journal non-technical skills used by scrub nurses? An integrated
of Anaesthesia, 109(1), 47–54. doi:10.1093/bja/aes175. review. ACORN Journal, 27(4), 16–25.
Worksafe New Zealand. (2014). Bullying prevention tools. Kang, E., Massey, D., & Gillespie, B. M. (2015). Factors that
Retrieved from <www.business.govt.nz/worksafe/tools- influence the non-technical skills performance of scrub
resources/bullying-prevention-tools>. nurses: A prospective study. Journal of Advanced Nursing, (in
Yule, S., & Paterson-Brown, S. (2012). Surgeon’s non- press).
technical skills. The Surgical Clinics of North America, 92(1), Maran, N., Edgar, S., & May, A. (2013). Non-technical skills.
37–50. In K. Forrest, J. McKimm, & S. Edgar (Eds.), Essentials in clini-
cal simulation (pp. 131–145). London: John Wiley & Sons.
FURTHER READING Sevdalis, N., Hull, L., & Birnbach, D. (2012). Improving patient
Broom, M., Capek, A., Carachi, P., Akeroyd, M., & Hilditch, G. safety in the operating theatre and perioperative care:
(2011). Critical phase distractions in anaesthesia and the obstacles, interventions and priorities of accelerating
sterile cockpit concept. Anaesthesia, The Association of progress. British Journal of Anaesthesia, 109(51), i3–i16.
Anaesthetists of Great Britain and Ireland, 66(3), 175–179. State Government of Victoria. (2011). Bullying resources direc-
Flin, R. (2013). Non-technical skills for anaesthetists, surgeons tory for creating a positive work environment. Retrieved from
and scrub practitioners. (ANTS, NOTSS and SPLINTS). Aber- <www.health.vic.gov.au/nursing/promoting/noviolence/
deen: The Health Foundation. bullying>.
46
Chapter 3
PERIOPERATIVE PATIENT SAFETY
BEN LOCKWOOD, VICKY WARWICK AND SALLY SUTHERLAND-FRASER

LEARNING OUTCOMES
• Identify the nature and incidence of surgical adverse events
• Examine patient safety, risk management and quality activities as they relate to the perioperative
environment
• Explore a systems approach to managing risk and patient safety
• Examine core nursing interventions aimed at ensuring patient safety
KEY TERMS
adverse event
checklists
clinical audit
incident management systems
medication management
National Standards
open disclosure
patient safety
quality
sentinel event
surgical count
WHO Surgical Safety Checklist
47
INTRODUCTION CLINICAL GOVERNANCE

Every patient has the right to experience healthcare Clinical governance provides a framework through
free from harm and adverse events. Patient safety which healthcare services demonstrate accounta-
is a paramount consideration within healthcare bility for the delivery of safe, high-quality patient
services and this is particularly so in the periopera- care. It is underpinned by the concepts of continu-
tive environment due to the vulnerability of the ous quality improvement and clinical excellence,
surgical patient and the risks associated with which assist healthcare services to comply with the
anaesthesia and surgery. Providing patients with regulatory systems and professional standards of
safe care throughout their perioperative journey practice (Australian Commission on Safety and
requires collaboration between nurses and other Quality in Health Care [ACSQHC/the Commission],
members of the multidisciplinary team. In addition 2012a). Clinical governance is also underpinned by
to safe care, patients have a right to receive high- the concept of risk management, which ensures
quality, evidence-based and effective treatment, that potential risks (preventable harm) to patients,
which lead to optimal outcomes and a timely return visitors and healthcare workers can be identified,
to a state of health. controlled or removed. In the perioperative setting,
clinical governance is achieved by embedding
This chapter explores national policy frame- quality and safety into everyday activity and ensur-
works, regulatory systems, clinical governance ing practice guidelines, such as the Australian
mechanisms and professional practice standards College of Operating Room Nurses (ACORN) Stand-
that are used to deliver safe, high-quality patient ards, underpin clinical practice (ACORN, 2016).
care; it also describes how nurses work to achieve Within this framework are quality mechanisms
this within the perioperative setting. Described such as risk management, clinical auditing, inci-
in detail are mechanisms such as the use of dent reporting with open disclosure and quality
checklists to improve or make practice safe; improvement projects that enable perioperative
clinical audits to identify and measure care activi- nurses to identify service excellence as well target
ties or compliance with procedures; and various areas for improvement. Education and training,
approaches to managing situations when things another facet of clinical governance, are used to
go wrong, such as reporting systems and incident rectify gaps in practice in an ongoing cycle of evalu-
investigation. ation and improvement (see Fig. 3-1a).
Clinical governance
Policy
frameworks Safety and quality systems
e.g. National
Standards
Risk Positive
management Clinical
patient
effectiveness
outcomes
Practice Clinical audit
standards Education Research and
e.g. ACORN Open and training development
Standards disclosure
FIGURE 3-1a: Components of clinical governance

Source: Adapted from Gottwald & Lansdown (2014).
48
CHAPTER 3 | Perioperative patient safety
AS/
ISO Standards
NZS
Safety and
ACHS quality and ACSQHC HQSCNZ
accreditation
PERIOP PNC Professional

ACORN NZNO
SERVICES organisations
RACS ANZCA
FIGURE 3-1b: National framework of clinical governance affecting perioperative services
A national framework of clinical governance Surgical Safety Checklist (SSC) as well as the
arises from bodies such as the Australian Council National Safety and Quality Health Service (NSQHS)
on Healthcare Standards (ACHS) and government Standards (which apply more broadly) (WHO, 2008;
agencies such as the Commission and the Health the Commission, 2015a). Despite this focus on
Quality and Safety Commission New Zealand patient safety and the availability of practice stand-
(HQSCNZ). Similarly, quality and safety policies are ards for the perioperative environment, clinical
driven by industry standards such as those devel- incidents and adverse events continue to occur.
oped by the International Organization for Stand-
ardization (ISO) and Standards Australia and ADVERSE EVENTS AND SENTINEL EVENTS
Standards New Zealand (AS/NZS). Such policies are The Australian Institute of Health and Welfare
also embedded within professional practice stand- (AIHW) defines an adverse event as an incident
ards and guidelines and disseminated by organisa- that results in harm to a person receiving care
tions such as ACORN, the Perioperative Nurses (AIHW, 2014a, p. 239). In New Zealand, an adverse
College of the New Zealand Nurses Organisation event does not have to threaten the patient’s life,
(PNC NZNO), the Australian and New Zealand although it may result in the patient needing sig-
College of Anaesthetists (ANZCA) and the Royal nificant additional treatment (New Zealand Nurses
Australasian College of Surgeons (RACS). Figure Organisation [NZNO], 2011). Sentinel events have
3-1b depicts this national framework. been defined as ‘rare adverse events leading to
serious patient harm or death, that are specifically
PATIENT SAFETY AND RISK caused by healthcare rather than the patient’s
underlying condition or illness’ (Western Australia
MANAGEMENT IN THE Department of Health, 2011, p. 3). It should be
PERIOPERATIVE ENVIRONMENT noted that the term never events is used in the
The World Health Organization (WHO) and the United States and the United Kingdom when refer-
Commission have identified patient safety as a key ring to these rare events.
priority for healthcare services and, in the case of Over the past two decades there has been signifi-
surgical patients, have facilitated processes that cant research demonstrating how errors and serious
support this through the introduction of the WHO mishaps occur in healthcare settings—they:
49
• frequently have their roots in system 2015). Australian hospitals are required to report
failures on rates of HAIs including MRSA and Staphylococ-
• are attributed to human factors cus aureus bacteraemia (SAB). Most people carry
S. aureus with only minor ill effect; however, when
• occur as a result of complications of the microorganism enters the bloodstream it causes
treatment (ACSQHC, 2003; Gawande, 2010; serious infections (SAB), with mortality rates
Karl & Karl, 2012; Reason, 2000; Watters & reported to be 15–35% (the Commission, 2014a).
Truskett, 2013). Between 2010 and 2014, the national rate of SAB
For example, a seminal study in 2008 on the global declined from 1.10 cases to 0.87 cases per 10,000
volume of surgery noted that more than 230 million days of patient care (AIHW, 2014a). However, the
surgical procedures were performed annually, with combined incidence of all adverse events increased
a reported incidence of avoidable deaths or serious from 5.3% to 5.5% (AIHW, 2014b) (see Fig. 3-2,
morbidity of 1.5% and 11%, respectively (Haynes where the term separations refers to hospitalised
et al., 2009). Surgical complication rates have been patients discharged home or transferred to another
estimated by WHO to be somewhere between 3% service).
and 16% (Fowler, 2013), while Watters and Truskett
(2013) report an incidence of 10% for surgical
REPORTING ON SENTINEL EVENTS
adverse events. Studies from the United States, the
IN AUSTRALASIA
United Kingdom and Australia report that one in
10 hospital in patients is likely to suffer an error Reporting on sentinel events was first proposed in
during their hospital stay (Sevdalis, Hull & Birn- 2004 by the Australian health ministers, following
bach, 2012). Half of all adverse events occurring an historic agreement by the states and territories
in hospitals are mostly likely related to complica- to standardise terminology and report their inci-
tions from surgical procedures (Fowler, 2013), with dence annually (the Commission, 2011a). Sentinel
venous thromboembolism (VTE) identified as a events are categorised as follows:
common cause of preventable harm for hospitalised • procedures involving the wrong patient or
patients (Duff, Omari, Middleton, McInnes, & body part (referred to as ‘wrong site surgery’
Walker, 2013; Lau & Haut, 2014). It is no surprise from here)
then to find that the global healthcare sector has
• suicide of a patient in an inpatient unit
sharpened its focus on patient safety and has been
developing systems to improve surgical patient • retained instrument or other material
outcomes (WHO, 2012a). after surgery requiring reoperation or further
surgical procedure (referred to as ‘retained
surgical items’ from here)
REPORTING ON ADVERSE EVENTS • intravascular gas embolism resulting in death
IN AUSTRALASIA or neurological damage
The AIHW publishes national data on adverse
• haemolytic blood transfusion reaction
events from public and private hospitals (AIHW,
resulting from blood type ABO
2014a). These data are based on the International
incompatibility
Classification of Diseases (ICD) version 10 Austral-
ian Modification (ICD-10-AM) discharge codes, • medication error leading to the death of a
which indicate when an adverse event has occurred patient reasonably believed to be due to
during a patient’s hospital stay. Many of these incorrect administration of drugs
adverse events are thought to be preventable, • maternal death or serious morbidity associated
including incidents such as patient falls, medica- with labour or delivery
tion errors, pressure injuries (PI), VTE and health-
care-associated infections (HAIs). International • infant discharged to the wrong family.
data indicate that the majority of HAIs are caused Between 2007 and 2011, the Commission pub-
by antimicrobial-resistant bacteria such as methi- lished data on all sentinel events, annually. The
cillin-resistant Staphylococcus aureus (MRSA) or most recent of these national reports identified 10
multidrug-resistant gram-negative bacteria (WHO, wrong site surgery events (5 each in public and
50
Adverse events are defined as incidents in which The number of separations that reported an
harm resulted to a person receiving healthcare. adverse event per 100 separations was generally
They include infections, falls resulting in injuries, higher for:
and problems with medication and medical devices.
Some of these adverse events may be preventable. • overnight separations—11.2% in public hospitals
and 9.6% in private hospitals
In 2012–2013:
• 5.5% of separations reported a diagnosis (or other • subacute and non-acute care (for which lengths of
clinical description) that indicated an adverse stay are typically longer)—10.7% compared with
event had been treated and/or occurred during 5.2% for acute care separations
the hospitalisation.
• emergency admissions—9.7% compared with
• The rate of adverse events was higher in public 3.9% for non-emergency admissions.
hospitals than in private hospitals—6.5% and
4.0%, respectively.
Separations with an adverse event per 100 separations, public and private hospitals, 2012–2013
Public Private
hospitals hospitals Total
Separations with an adverse event 359,390 153,178 512,568
Separations with an adverse event per 100 separations
Same-day separations 1.9 1.5 1.7
Overnight separations 11.2 9.6 10.7
Acute care separations 6.2 3.7 5.2
Subacute and non-acute care separations 14.9 7.6 10.7
Emergency admission 9.5 12.0 9.7
Non-emergency admission 4.4 3.5 3.9
Total 6.5 4.0 5.5
FIGURE 3-2: Australian hospital performance: Adverse events, 2012–2013

Source: AIHW (2014b, p. 21).
private hospitals) and 44 retained surgical item retained surgical items, while five were retained
events (35 in public sector and 9 in private hospi- swabs in obstetric patients (outside the periopera-
tals) (the Commission, 2011a). tive practice setting).
New Zealand health services report on serious Although healthcare facilities are required to
adverse events in the HQSCNZ annual reports, with report and investigate sentinel events when they
data available between 2006 and 2014 (HQSCNZ, occur, comparisons between reports are unhelpful
2014a). Figure 3-3a depicts the most recent New due to variations in the reporting practices between
Zealand data from 2013–2014, during which time these two national jurisdictions. Despite this lack
454 serious adverse events were reported. Of these of a standardised reporting process, there are con-
events, 16 were incorrect processes, including five sistencies in approach across jurisdictions. For
unnecessary procedures, three wrong site surgeries, example, healthcare workers in Australia and New
four wrong patients and two wrong procedures. Zealand are required to:
Figure 3-3a also depicts two instances that were • report patient-safety incidents
near misses, where the mistake was identified
before any harm came to the patient. While these • classify the severity of the incident using
data show an upward trend in events from previous standardised Severity Assessment Code
reporting periods, the authors suggest that this (SAC) tools
trend reflects improvements in adverse event • collect incident data and report on incident
reporting systems. Figure 3-3b shows that six of management using electronic reporting
the 454 events reported in the same period were systems
51
Fourteen cases were reported involving a patient undergoing an incorrect process. There were also
two further cases where no harm was caused, as the error was identified before further action was
taken.
While rare, an error is occasionally made whereby a patient undergoes a procedure intended for
someone else, or the wrong procedure is performed. Included in reported events are those where an
unnecessary procedure was performed, for example, a patient received a repeat of an investigation
performed a few weeks earlier, or an unnecessary biopsy was performed. While these cases may
not have resulted in identifiable ‘harm’ compared to, for example, a serious medication administration
error, there was a breakdown in patient identification processes. These cases reach the threshold for
being reviewed as serious adverse events.
Incorrect process events in 2013–2014
Unnecessary procedure
5
Wrong site
3
Incorrect process events total: Wrong patient

16 4
Wrong procedure
2
Wrong patient (near miss)

2
FIGURE 3-3a: Wrong site surgeries reported in New Zealand, 2013–2014

Source: HQSCNZ (2014a, p. 20).
• investigate high-severity patient-safety sector is developing techniques to identify risks,

incidents using root cause analysis (RCA) investigate and analyse incidents, and use the
processes (the Commission, 2009). knowledge gained to improve practice. In 2010,
Healthcare workers in New Zealand facilities also Australian health ministers endorsed a safety and
use the significant incident review process (SIRP) quality framework articulating the actions that cli-
to investigate sentinel events (NZNO, 2011). nicians should take to improve the quality of
healthcare for all Australians over the next decade
It is beyond the scope of this text to further (the Commission, 2010). The framework indicates
explore the use of SAC tools and RCA processes that safe, high-quality healthcare must always
generally. More information from state and terri- be consumer-centred, driven by information and
tory health departments and safety and quality organised for safety (the Commission, 2010).
entities can be found in the Resources section at Further to this framework, the Commission pro-
the end of this chapter. duced the NSQHS Standards (the National Stand-
ards), which provide statements about the level of
healthcare patients can expect and how hospitals
SAFETY AND QUALITY are to deliver safe and quality care for their con-
By using techniques from other high-risk industries sumers (the Commission, 2011a, 2011b). Hospitals
where safety is paramount, such as the nuclear and are audited against these National Standards to
aviation industries (Fowler, 2013), the healthcare ensure quality and safety practices meet the
52
The most frequently reported retained item events were swabs being left inside patients during a
procedure; five cases related specifically to swabs being retained after a normal birth. In response
to this, DHBs have introduced measures to prevent event recurrence, including:
• the use of different swabs which are less likely to be left behind after birth
• using a swab count process similar to that used in operating theatres
• having a checklist to ensure swabs are not retained.
Retained item during process events in 2013–2014
Clip
2
Needle
1
Operating theatre Swab

6 1
Stapler anvil
1
Retained item during
process events total:
11 Laparoscopic surgery
equipment
1
Obstetric care Swab

5 5
FIGURE 3-3b: Retained surgical items reported in New Zealand, 2013–2014

Source: HQSCNZ (2014a, p. 21).
requirements. Similarly, in 2010 New Zealand achieving safe, high-quality patient care in these
established the HQSCNZ which works to ensure two important areas (see Feature box 3-1 later in
healthcare consumers receive high-quality, best the chapter).
value and equitable care (HQSCNZ, 2015).
In 2013, Australian health ministers approved NATIONAL SAFETY AND QUALITY IN
the Commission’s work plan for 2013–2016, which HEALTHCARE STANDARDS
established the Clinical Care Standards program The National Standards (see Fig. 3-4) are a set of 10
(the Commission, 2013a). Clinical Care Standards mandatory standards that aim to protect patients
are quality statements that support clinical experts from adverse events by establishing a nationally
and consumers with managing conditions that consistent framework for the delivery of safe,
would benefit from a nationally coordinated quality care and best practice (the Commission,
approach (the Commission, 2013a). Of relevance to 2015a). The key objective of the National Standards
the perioperative setting, the Commission has is to ensure that hospitals have systems to manage
developed Clinical Care Standards for Antimicro- risk by identifying and controlling potentially
bial Stewardship and Hip Fracture Care. These Clin- hazardous or unsafe activities (the Commission,
ical Care Standards provide perioperative health 2011b). Furthermore, by establishing systems to
workers nationwide with best practice guidelines to acknowledge, report and analyse adverse events in
53
S1: Governance for Safety and Quality in Health Service Organisations

describes the quality framework required for health service organisations to implement safe systems.
S2: Partnering with Consumers

describes the systems and strategies to create a consumer-centred health system by including consumers
in the development and design of quality health care.
S3: Preventing and Controlling Healthcare Associated Infections

describes the systems and strategies to prevent infection of patients within the healthcare system and to
manage infections effectively when they occur to minimise the consequences.
S4: Medication Safety

describes the systems and strategies to ensure clinicians safely prescribe, dispense and administer
appropriate medicines to informed patients.
S5: Patient Identification and Procedure Matching

describes the systems and strategies to identify patients and correctly match their identity with the
correct treatment.
S6: Clinical Handover

describes the systems and strategies for effective clinical communication whenever accountability and
responsibility for a patient’s care is transferred.
S7: Blood and Blood Products

describes the systems and strategies for the safe, effective and appropriate management of blood and blood
products so the patients receiving blood are safe.
S8: Preventing and Managing Pressure Injuries

describes the systems and strategies to prevent patients developing pressure injuries and best practice
management when pressure injuries occur.
S9: Recognising and Responding to Clinical Deterioration in Acute Health Care

describes the systems and processes to be implemented by health service organisations to respond
effectively to patients when their clinical condition deteriorates.
S10: Preventing Falls and Harm from Falls

describes the systems and strategies to reduce the incidence of patient falls in health service organisations
and best practice management when falls do occur.
FIGURE 3-4: The National Safety and Quality Health Service Standards
Source: Queensland Department of Health (2015). © State of Queensland (Queensland Health) 2012.
a transparent fashion, opportunity is created to informed and an examination of the event can
change systems (and cultures) and subsequently to take place, thus militating against future occur-
develop and implement policies to reduce or prevent rences. The Commission defines open disclosure
adverse events. Within the National Standards as follows:
framework, quality comes from the ability to iden-
tify risks to patient safety and act upon them to An open discussion with a patient about an
reduce the likelihood that they will occur. Moreo- incident(s) that resulted in harm to that patient
ver, if adverse events do occur, a quality system while they were receiving health care. The ele-
allows for open disclosure so patients are fully ments of open disclosure are an apology or
54
expression of regret (including the word An example of partnering with patients is via
‘sorry’), a factual explanation of what hap- patient satisfaction surveys. These can be paper-
pened, an opportunity for the patient to relate based or online questionnaires or, in the case of day
their experience, and an explanation of the surgery patients, may involve perioperative nurses
steps being taken to manage the event and making follow-up phone calls to check on patients’
prevent recurrence. Open disclosure is a dis- progress, when there is also an opportunity to deter-
cussion and an exchange of information that mine their level of satisfaction with the care they
may take place over several meetings (the received by using a pre-determined set of questions.
Commission, 2013b, p. 4). Measuring patient satisfaction provides valuable
The 10 National Standards are broad and information about the quality of healthcare serv-
designed to cover all aspects of healthcare (the ices; however, the information given is often subjec-
Commission, 2015a). That said, each Standard has tive and requires structured and validated tools to
relevance for perioperative practice, though this is provide meaningful and useful information (Thurai-
more overt in some compared to others. ratnam, Mathew, Montgomery & Stocker, 2014).
STANDARD 1: GOVERNANCE FOR SAFETY AND STANDARD 3: PREVENTING AND CONTROLLING

QUALITY IN HEALTH SERVICE ORGANISATIONS HEALTHCARE-ASSOCIATION INFECTIONS
This Standard describes how organisations are This Standard focuses on infection control, which
required to implement and govern quality and is at the core of many activities in perioperative
safety systems. This is demonstrated by a range of nursing. It covers the concepts of aseptic technique,
systems and practices in the perioperative setting, standard and transmission-based precautions,
including: antimicrobial stewardship, environmental cleaning
and the reprocessing and sterilisation of surgical
• compliance with policies and protocols
instruments, which is also directed by AS/NZS
that guide appropriate care, such as the
4187: Reprocessing of reusable medical devices in
sterilisation standard AS/NZS 4187 (Standards
health service organisations (Standards Australia,
Australia, 2014) and ACORN Standards (2016)
2014). The infection prevention concepts and prac-
• implementation of an effective incident tices at the core of this AS/NZS Standard are
management system to ensure that adverse explored in more detail in Chapter 6. Other exam-
events are reported, analysed and used to ples of how Standard 3 relates to the perioperative
improve patient safety setting include:
• monitoring the percentage of patients who • using the WHO SSC (2008) to determine the
receive antibiotics that have been prescribed need for antibiotic prophylaxis and to ascertain
in accordance with surgical prophylactic whether antibiotics have been administered
antibiotics guidelines (see Feature box 3-1 appropriately (timing and duration of
later in the chapter). administration) (see Feature box 3-1)
STANDARD 2: PARTNERING WITH CONSUMERS • ensuring perioperative nurses maintain

vigilance when using aseptic techniques
This standard describes how organisations and during invasive procedures such as the
healthcare professionals engage their patients. In insertion of an arterial line for blood pressure
the perioperative field this engagement may monitoring, or the set-up of an aseptic field
include: for a surgical procedure, in order to reduce the
• patient representation on operating theatre likelihood of contamination leading to surgical
governance committees where decisions are site infection (SSI)
made about service delivery • auditing and reporting of perioperative staff
• patient input and review of perioperative hand hygiene compliance in accordance with
patient information resources Hand Hygiene Australia’s 5 Moments for Hand
• consultation with patients in the design Hygiene (see Chapter 6 for further information)
and redevelopment of operating theatre • assessing perioperative nurses’ compliance
suites. with correct practices for validating, opening
55
FEATURE BOX 3-1 » ANTIMICROBIAL STEWARDSHIP CLINICAL CARE STANDARD
Antibiotic resistance poses a threat to public health and places an economic burden on society
(WHO, 2012b; the Commission, 2014b). High rates of inappropriate antibiotic usage have been
reported in the perioperative setting, with incidents such as poor timing of antibiotic prophylaxis
and/or inappropriate duration of antibiotic administration reported to occur on between 30% and
90% of occasions (the Commission, 2014b). The Clinical Care Standard is designed as part of a
systems approach to ensure that antibiotics are used appropriately by all healthcare services, to
improve patient outcomes and to reduce the risk of adverse events and antibiotic resistance in
the community (the Commission, 2014b). The Antimicrobial Stewardship Clinical Care Standard
comprises nine quality statements, with Quality Statement 9: Surgical Prophylaxis of particular
relevance to the perioperative setting:
If a patient having surgery requires prophylactic antibiotics, the prescription is made in accord-
ance with the current Therapeutic Guidelines (or local antibiotic formulary), and takes into
consideration the patient’s clinical condition (the Commission, 2014b, p. 13).
The practice of antimicrobial stewardship articulates with the Commission’s National Standards,
in particular Standard 1. For example, healthcare services are required to monitor and report on
compliance with the Standard regarding:
• percentage of patients meeting criteria for surgical prophylaxis who receive antibiotics
within 2 hours prior to surgery
• percentage of patients whose prophylactic antibiotics have been ceased within 24 hours of
surgery (within 48 hours of vascular surgery).
All members of the perioperative team support the Commission’s goal of antimicrobial steward-
ship during the Time Out stage of the SSC by asking about antibiotic prophylaxis (ACORN, 2016).
The anaesthetic nurse should anticipate this requirement and ensure the range of antibiotics
available for use reflects the prescribers’ preferences and the patient’s need.
SOURCE: ACORN (2016); THE COMMISSION (2014B ).
and dispensing sterile items to prevent in 2013 when alcoholic skin antiseptic was injected
contamination of aseptic fields into a patient instead of contrast medium (Doncas-
• identifying patients known to harbour multi- ter and Bassetlaw Hospitals NHS Foundation Trust,
resistant organisms, such as MRSA, in order to 2014). This Standard is explored in detail in the
minimise the risk for surgical site infection section on medication management.
and environmental contamination.
STANDARD 5: PATIENT IDENTIFICATION AND
PROCEDURE MATCHING
STANDARD 4: MEDICATION SAFETY This Standard focuses on correct patient identifica-
This Standard is about implementing systems to tion and procedure matching processes. Patient
reduce the incidence of medication errors. In the identification in medical records and on patient
perioperative setting it directs the handling and wristbands requires at least three nationally recog-
administration of medications, as well as the secure nised identifiers, such as the patient’s full name,
management of opioids, narcotics and sedatives, to date of birth and hospital/medical record number.
prevent misuse. Of note for perioperative nurses is In the perioperative setting, patient identification
the labelling of medications (including those on the is crucial in order to avoid performing the wrong
aseptic field) to reduce the likelihood of errors, such procedure on the wrong site or the wrong patient
as the events that occurred in the United Kingdom (see Feature box 3-2). This Standard is explored in
56
FEATURE BOX 3-2 » A CASE OF MISTAKEN IDENTITY
A report from the Health Quality and Safety Commission New Zealand in 2014 describes an inci-
dent where the wrong patient was taken for a chest X-ray. Two patients with the same first name
(Bill Adams and Bill Smith) were sharing a hospital room. An orderly arrived to pick up Bill Adams
for his chest X-ray, but when the orderly asked simply for ‘Bill’, Bill Smith replied, as Bill Adams
was out of the room. Thus, the wrong Bill accompanied the orderly to the radiology department
where the radiographer also identified the patient by his first name only. The X-ray was taken and
the error was picked up 3 days later when a subsequent CT scan was ordered for Bill Adams. The
report noted that errors in correct patient identification procedures led to the incident and as a
result formal patient identification systems were put in place at the facility.
Patients A & B with Wrong patient

identical first names Orderly used first identified and
located in same name only transported for
ward investigation
Patient B did not

Patient A underwent
receive appropriate Radiographer used
unnecessary
or timely first name only
investigation
investigation
SOURCE: HQSCNZ (2014b).
more detail in the section on the use of checklists. admitted to the operating suite and when they are
See also Chapter 9 for further information. transferred from the operating room (OR) to the
postanaesthesia care unit (PACU) (ACORN, 2016).
STANDARD 6: CLINICAL HANDOVER Clinical handover is further discussed in Chapters
This Standard describes how healthcare services 7 and 12. Nurses should conduct a structured clini-
must ensure that structured approaches are used cal handover when acting in relief roles because the
for information exchange and clinical handover. relieving nurse may not have participated in a
Unstructured clinical handovers can pose signifi- patient identification process such as Time Out.
cant risk to patients because critical information When information is provided in a structured
may be omitted, responsibility and accountability manner, there is less likelihood of miscommunica-
may not be recognised, and adverse patient events tion or omissions.
can ensue. Often in the perioperative setting patient
information is communicated via a variety of STANDARD 7: BLOOD AND BLOOD PRODUCTS
methods. These include face-to-face clinical hand This Standard is concerned with the safe adminis-
overs using frameworks such as Identification, tration, patient monitoring, documentation and
Situation, Background, Assessment, Recommenda- disposal of blood products. Transfusion-related
tion (ISBAR) or Identification, Situation, Observa- adverse events and acute haemolytic reactions can
tion, Background, Assessment, Recommendation occur if stringent cross-matching and positive
(ISOBAR) (with the latter being recommended by patient identification processes are not observed
ANZCA [2013]), as well as the use of checklists in (Australian Red Cross Blood Service, 2014). Blood
perioperative documentation. Clinical handover in products require stringent processes for correct
the perioperative setting occurs when patients are handling and storage to reduce contamination,
57
staff exposure and wastage. In Australia, blood tissue damage caused by pressure, friction or shear-
supply services are coordinated and managed by ing forces. This is due to a combination of intrinsic
the National Blood Authority (NBA), a statutory (I) patient-related risk factors and extrinsic (E)
agency established under the National Blood environment or practice-related risk factors.
Authority Act 2003 (NBA, nd: Overview and role of Perioperative clinicians must be able to assess
the NBA). The NBA has developed six patient blood a patient’s potential risk of sustaining tissue
management guidelines and a national education damage or a pressure injury and put in place strate-
program. The latter includes the BloodSafe program, gies to mitigate these risks (see Chapter 9 for
comprising several e-learning modules, which all further information). Targeted education on pres-
Australian healthcare workers involved in blood sure injury assessment and risk mitigation strate-
transfusions must complete (NBA, nd: Education gies may improve perioperative nurses’ knowledge
and training). For example, this mandatory program and practice (Sutherland-Fraser, McInnes, Maher &
is applicable to: Middleton, 2012). Nonetheless, if a pressure injury
• orderlies and patient care assistants who does occur, clinicians must report this as an adverse
are required to correctly identify and event and take measures to support restoration of
transport blood products within the tissue integrity.
healthcare facility
• doctors and nurses who are required to check STANDARD 9: RECOGNISING AND RESPONDING
and administer blood products or manage the TO CLINICAL DETERIORATION IN ACUTE
storage of blood products in the perioperative HEALTHCARE
setting. This Standard is another area that is paramount to
A common occurrence in many perioperative safe and high-quality patient care in the periopera-
settings is the administration of large volumes tive setting. Systems, such as criterion-based
of blood via a mass transfusion pack for critical patient monitoring tools, can help nurses (and
bleeding. In these instances perioperative nurses other healthcare workers) to identify and respond
must apply stringent processes for accurate cross- to a deteriorating patient in a structured, consist-
checking and documentation, and ensure that ent and timely manner. These tools are especially
blood products are stored appropriately to reduce relevant for nurses caring for patients in the post-
wastage caused by temperature variations or pack- operative phase where adverse events are more
aging contamination. ANZCA has endorsed five of likely to occur and where clinical deterioration can
the NBA’s evidence-based patient blood manage- occur rapidly. Furthermore, perioperative nurses
ment guidelines, including Module 1: Critical need educating to recognise and respond appropri-
Bleeding/Massive Transfusion and Module 2: Peri- ately to situations that are unique to acute care
operative (ANZCA, nd). settings, including airway emergencies such as
‘can’t ventilate, can’t intubate’ and crises such as
STANDARD 8: PREVENTING AND MANAGING malignant hyperthermia (see Feature box 3-3). See
PRESSURE INJURIES Chapter 8 for further information.
This Standard requires healthcare services to
implement systems to identify risks and to manage STANDARD 10: PREVENTING FALLS AND HARM
adverse pressure injury-related patient outcomes, FROM FALLS
many of which have their genesis in the OR (the This Standard describes how healthcare services
Commission, 2012b). Perioperative services should must work to prevent or minimise harm from these
have regard to international guidelines for the pre- events. Falls can occur when patients are ambula-
vention of pressure injuries, which make specific tory, often during transfer and admission to the
recommendations for patients in the OR. The perioperative service. Moreover, if intraoperative
National Pressure Ulcer Advisory Panel, in associa- patient positioning is not well-planned and closely
tion with the European Pressure Ulcer Advisory monitored, the patient’s limbs may fall over the
Panel and Pan Pacific Pressure Injury Alliance, rec- edge of the OR table with potential to cause tissue,
ognises perioperative patients as a special needs nerve or musculoskeletal injury (see Chapter 9 for
population (NPUAP-EPUAP-PPPIA, 2015). All sur- further information). Healthcare workers are also
gical patients face increased risk of sustaining at risk of falls. For example, the perioperative
58
FEATURE BOX 3-3 » THE HIDDEN DANGERS OF MALIGNANT HYPERTHERMIA
A 35-year-old woman with no significant medical history was admitted to hospital for a routine
hernia repair. Her only previous surgery was a caesarean section under spinal anaesthesia. Upon
induction, the anaesthetist noticed some unusual cardiac arrhythmias followed by a dramatic rise
in expired CO2 levels. The symptoms continued to escalate, with muscle rigidity and an increase
in body temperature occurring. Recognising the symptoms, the anaesthetist declared a malignant
hyperthermia (MH) emergency.
Due to the rarity of such a crisis, the perioperative team was unprepared. There was delay in
obtaining the supply of dantrolene (the muscle relaxant required to treat the symptoms) and
staff were inexperienced in the correct process for its reconstitution and administration. Lack of
clinical leadership on the part of the anaesthetist contributed to poor team cohesiveness; conse-
quently, the team did not commence cooling strategies in a timely fashion and the patient’s
temperature continued to rise. The patient’s condition deteriorated further, until this metabolic
crisis precipitated a cardiac arrest. Fortuitously, the patient was successfully resuscitated, her
condition stabilised and she was admitted to the intensive care unit where she spent a further 7
days recovering.
Although rare, MH represents a significant risk to surgical patients (Royal Melbourne Hospital,
2012). This example demonstrates the importance of early recognition and appropriate response
to clinical deterioration in the perioperative setting. It further highlights that perioperative staff
require periodic training to deal with unexpected crises and need clear action plans for managing
them. A guide to the appropriate management of malignant hyperthermia can be found at www.
anaesthesia.mh.org.au/mh-resource-kit/w1/i1002692.
SOURCE: B. LOCKWOOD, PERSONAL COMMUNICATION, 23 JULY 2015.
environment presents potentially dangerous clini- • the Incident Information Management System
cal situations such as: (IIMS) used by NSW Health
• when staff rush to prepare the OR between • the significant incident review process (SIRP)
patients, particularly if the OR floor has not in New Zealand and the electronic incident
dried completely after cleaning management system (RL6Risk) used by South
• the potential for slipping on wet floors around Island District Health Boards (see the
scrub bays Resources section at the end of the chapter).
• the impact of large fluid spills during

procedures such as those undertaken during NATIONAL STANDARDS: VERSION 2
closed urology surgery In 2014, the Commission began its review of the
• the presence of trip hazards from power cords National Standards. The review was conducted over
or leads in cramped physical spaces such as six stages with drafting and national consultation
the anaesthetic bay. undertaken during the second half of 2015. The
final draft National Standards: Version 2 is sched-
Perioperative nurses should comply with facil- uled to be tabled for approval by health ministers
ity policies to assess individual patient risks for at their first meeting in 2016. At the time of writing
falls (as well as for pressure injuries) and should be this draft was still in the consultation stage, and
familiar with the use of incident management Box 3-1 outlines some of the proposed changes.
systems. There are a variety of systems in use, Assessment against Version 2 is expected to begin
including: in the 2017/2018 financial year, allowing a ‘period
• the Clinical Incident Management System of grace’ as healthcare facilities transition from the
(Datix CIMS) used by WA Health former Standards to the new version.
59
BOX 3-1 » NATIONAL STANDARDS: VERSION 2

It is evident that safe and high-quality healthcare depends on positive consumer experiences and in
response the Commission forecasts that there will be a stronger focus on partnerships with consumers
in the new Standards. A notable change is the use of letters to abbreviate the name of each Standard,
thereby encouraging the use of initials rather than numbers when referring to the Standards. For
example, ‘Standard 1: Governance for safety and quality in health service organisations’ will retain its
place as the first standard, but is proposed to become ‘Standard GS: Governance for safety and quality’.
Other proposed changes include:
• a reduction from 10 to nine Standards, as follows:
– Standard GS: Governance for safety and quality
– Standard PC: Partnering with consumers
– Standard CC: Comprehensive care
– Standard RH: Reducing harm
– Standard CS: Communicating for safety
– Standard IP: Healthcare-associated infection prevention
– Standard MS: Medication safety
– Standard RR: Recognising and responding to acute deterioration
– Standard BP: Blood product safety
• fewer actions within each Standard
• clearer identification of who is responsible for the implementation of actions
• a new column to map the actions from Version 1 to Version 2.
The Commission achieved the reduction from 10 to nine Standards and the consolidation of actions by:
• removing three Standards to consolidate overlapping principles (Standard 5: Patient identification
and procedure matching; Standard 8: Preventing and managing pressure injuries; and Standard 10:
Preventing falls and harm from falls)
• replacing them with two new Standards (Standard CC: Comprehensive care; and Standard RH:
Reducing harm)
• expanding the former Standard 6: Clinical handover to focus on clinical communication in general.
SOURCE: ACSQHC/THE COMMISSION (2015b).
AUSTRALIAN COUNCIL ON cyclical accreditation process ensures that health-

HEALTHCARE STANDARDS care services can demonstrate adherence to rele-
Healthcare facility accreditation occurs in a four- vant regulatory frameworks. Safety and quality
year cycle by means of evaluation audits and organ- activities in healthcare services are shaped not only
isation-wide surveys (ACHS, 2015). The ACHS is by the 10 National Standards but also by a further
an independent council and accreditation agency five standards under EQuIP National:
representing governments, peak health bodies • Standard 11: Service delivery (e.g. equitable
and healthcare consumers in Australia. In tandem access and admission to services, as well as
with the Commission and the National Standards, patient consent)
ACHS is tasked with the process of accrediting • Standard 12: Provision of care (e.g. assessment
healthcare organisations using the Evaluation and care planning, ongoing care, and discharge
and Quality Improvement Program (EQuIP). This or transfer)
60
• Standard 13: Workforce planning and other professional documents of the

management (e.g. ongoing employment and College (ANZCA, 2012)
staff development) • Australasian College for Infection Prevention
• Standard 14: Information management and Control (ACIPC), which is the peak
(e.g. collection, use and storage of Australasian body for infection prevention and
information) control professionals, consulting with key
stakeholders such as the Commission, the
• Standard 15: Corporate systems and safety
ACHS and the Australian Society for Infectious
(e.g. safety management systems, waste and
Diseases (ASID). ACIPC’s website provides
environmental management) (ACHS, 2013).
open access to position statements such as
As part of the accreditation cycle, perioperative ‘Single-use devices’ (ACIPC, 2012) and ‘Role
services are expected to implement, audit and of the infection control practitioner in
improve patient safety and quality systems con- antimicrobial stewardship’ (ACIPC, 2013);
tinuously, culminating in the accreditation survey, there are also many downloadable resources
when all evidence of the service’s compliance is relevant to perioperative settings, in particular
assessed. In New Zealand, the certification of the practice of aseptic technique, including
healthcare services is provided by HealthCERT, risk assessment and practice audit tools, as
under the Health and Disability Service (Safety) Act well as clinician competency assessment tools,
2001 (Ministry of Health, New Zealand, 2014). policies and procedures
• Australian Day Surgery Nurses Association
PROFESSIONAL PRACTICE STANDARDS AND (ADSNA), which consults with government and
PATIENT SAFETY other relevant bodies and develops the ‘Day
The development of practice standards is the surgery best practice guidelines’
core activity of many professional associations. • Gastroenterological Nurses College of
Chapter 1 introduced the concept that standards Australia (GENCA), which promotes excellence
provide the minimum requirements for practice in gastroenterology nursing practice through
and outlined the key professional associations the development of national standards and
established for perioperative nurses including guidelines, and by dissemination of education
ACORN, the PNC NZNO, the Association of periOp- and credentialling programs; GENCA members
erative Registered Nurses (AORN) and the Interna- have access to discussion forums via its
tional Federation of Perioperative Nurses (IFPN). website and there is open access to GENCA
There are other multidisciplinary associations position statements including:
whose professional standards are also relevant to – ‘Educational requirements for personnel
perioperative settings and patient safety. These reprocessing flexible endoscopic
include, but are not limited to, the following profes- equipment’, which recommends annual
sional associations: education for all personnel responsible
• Australian and New Zealand College of for reprocessing flexible endoscope
Anaesthetists (ANZCA), which produces (GENCA, 2012)
position statements and practice guidelines • Royal Australasian College of Surgeons
such as: (RACS), which supports and informs the
– ‘Statement on roles in anaesthesia and practice of surgical trainees, members and
perioperative care’, which proposes that College Fellows with a range of guidelines and
the composition of the anaesthetic and position papers including:
perioperative teams must support safe, – ‘Bullying and harassment: Recognition,
high-quality patient care (ANZCA, 2015) avoidance and management’, which
– ‘Guidelines on quality assurance in identifies the negative impact of workplace
anaesthesia’, which recommends bullying on the quality of patient care
evaluation of clinical care by quality (RACS, 2014)
assurance programs to ensure practice – ‘Indigenous health’, in which the RACS
consistently reflects the standards and identifies the disadvantage of many
61
Aboriginal, Torres Strait Islander and Māori stop and check that specific activities have occurred.
populations and expresses its commitment These are:
to addressing the health discrepancies of • the period before induction of anaesthesia
these Indigenous groups (RACS, 2013) (Sign In)
– ‘Outreach surgery in regional, rural and • the period after induction and before surgical
remote areas of Australia and New incision (Time Out)
Zealand’, which outlines RACS’ minimum
requirements for the delivery of outreach • the period during or immediately after wound
surgical care to ensure that it is safe, closure before the patient leaves the OR (Sign
effective and appropriate for the needs of Out) (WHO, 2008, p. 6).
those remote communities (RACS, 2015). Initial research showed that implementation
It is evident that perioperative nursing practice of the SSC resulted in a one-third reduction in
in Australasia is well supported by a diverse range complications among surgical patient populations
of professional practice standards and resources. globally and fewer deaths (Weiser et al., 2010).
These resources complement the standards and The RACS adopted the SSC in early 2009, following
resources developed for perioperative nurses by consultation with the ANZCA, the Royal Australian
ACORN and the PNC NZNO and provide guidance and New Zealand College of Obstetricians and
more broadly on the safe delivery of patient care Gynaecologists (RANZCOG), ACORN and the Com-
by healthcare teams in a range of perioperative mission (Gough, 2010). The Australian and New
settings. Zealand edition of the SSC was developed and
endorsed in late 2009 by health ministers in both
countries and its use is now standard perioperative
USE OF CHECKLISTS practice (Gough, 2010). Subsequent studies have
demonstrated that effective implementation of,
Checklists provide a mechanism to safeguard
and compliance with, the SSC significantly reduces
against human failure and have been used success-
pre-, intra- and postoperative (PO) complications
fully in many industries including healthcare to
including infections and blood loss, and mortality
reduce adverse events, complications and mortality
(Gillespie et al., 2014; Haugen et al., 2015; Tang,
(Gawande, 2010). Checklists work by ensuring that
Ranmuthugala & Cunningham, 2013; van Klei
essential task components are undertaken in a spe-
et al., 2012).
cific order, before the next activity can occur, thus
reducing the likelihood of error occurring due to Checklists are used in the PACU to assess a
omission of process or activity. Preoperative check- patient’s readiness for discharge back to the ward
lists guide healthcare workers in the preparation or to a stage two (step-down) recovery unit prior
of patients for surgery. They can be as simple as to discharge home in day-surgery cases (see
tools that confirm a patient’s readiness for surgery Research box 3-1) (ACORN, 2016; ANZCA, 2006).
through to comprehensive documents that follow Such checklists enable the PACU nurse to use
the entire surgical patient journey from preadmis- clinical judgement in combination with the objec-
sion clinic to entry into the operating suite. Check- tive scoring of physiological parameters to deter-
lists also include tools used intraoperatively and mine patient readiness for discharge (Phillips
during the patient’s stay in the PACU. See Chapters et al., 2011). The concept of a postanaesthesia dis-
8, 9, 12 and 13 for further information. charge scoring system was first introduced as the
Aldrete Score by Aldrete and Kroulik in 1970. The
WHO SURGICAL SAFETY CHECKLIST use of criterion-based discharge tools helps avoid
WHO introduced the Safe Surgery Saves Lives ini- the potentially dangerous case of discharging PO
tiative in 2008, promoting the use of the SSC (WHO, patients prematurely.
2008). Auckland City Hospital was one of the foun-
dational sites that participated in this WHO initia- MANAGEMENT OF ACCOUNTABLE ITEMS
tive (Vogts, Hannam, Merry & Mitchell, 2011). Another example of a checklist is one used to
Other sites were chosen from across the globe. ensure that all surgical items are accounted for on
Once a patient has entered the OR, the SSC identi- completion of a surgical intervention. An integral
fies three occasions when clinicians are required to aspect of patient safety in perioperative settings is
62
RESEARCH BOX 3-1: Perioperative Checklist Methodologies
This article reviewed some of the mechanisms of checklist methodologies and their use in perioperative
practice. The authors reported on a growing body of evidence to support the use of perioperative check-
lists and highlighted the importance of their use in team-based clinical environments where there is
significant risk for adverse patient events. For example, checklist design falls into two categories—either
READ-DO or CHALLENGE-CONFIRM—with the authors claiming that the latter is better suited to periop-
erative environments where multiple teams may be involved in the patient’s care.
The lead author was a member of the Safe Surgery Saves Lives Investigators and Study Group, which
conducted an early study of the SSC and reported a drop in complications greater than 30% in patients
undergoing urgent surgery (Weiser et al., 2010). The review noted that adoption of the SSC internationally
has contributed to a 40% reduction in perioperative deaths, a 40% reduction in patient complications
and a 30% reduction in PO mortality. The authors commented that while checklists help to prompt and
promote communication, there are cultural attitudes and systemic barriers that influence acceptance or
inhibit use. For example, the culture of medicine sees the surgeon as a highly intelligent and competent
professional for whom the use of a checklist as aid memoire may be demeaning. The authors suggest
this culture is changing in the face of compelling evidence that checklists can save lives.
SOURCE: WEISER & BERRY (2012).
the performance of the surgical count. The instru- morbidity (Consultative Council on Anaesthetic
ments, sponges, swabs and so forth used during Mortality and Morbidity, 2011). Understanding the
surgery are at risk of being retained in patients’ unique risks to surgical patients will help periop-
body cavities and/or wounds (ACORN, 2016). The erative nurses recognise threats to patient safety
presence of all items on the aseptic field and and may assist strategies to mitigate adverse medi-
their use within the patient require the careful cation events (Hicks, Wanzer & Denholm, 2012).
attention of all team members and the use of a Preoperatively, there is scope for medication
risk management tool. Conducting a count of all errors; for example, the nurse may inadvertently
surgical items before the commencement of surgery withhold oral medications from a fasting patient,
and on its completion, and documenting the out- with unfortunate consequences (Symons & McMur-
comes, enable the perioperative nurse to account ray, 2014). Alternatively, medications that should
for and manage this risk (ACORN, 2016; AORN, have been withheld, such as anticoagulants, may
2012). Despite this activity, the inadvertent reten- instead be given to the preoperative patient result-
tion of surgical items still occurs. See Chapter 9 for ing in the potential for excessive intraoperative
further information on the conduct of the surgical bleeding (Lai, Davidson, Galloway & Thachil, 2014;
count. Queensland Department of Health, 2014). Drugs of
dependence such as opioids, narcotics and seda-
tives are routinely administered to patients in the
MEDICATION MANAGEMENT perioperative setting. There is state and national
Medications pose a risk to patients, and medica- legislation describing the controlled access to these
tion management (the safe handling and admin- medications, and perioperative nurses should
istration of pharmacological preparations) is both always ensure that medication dispensing and
regulated and widely researched in healthcare administration practices are within relevant medi-
(ACORN, 2016; Roughhead, Semple & Rosenfeld, cation legislation (ACORN, 2016). The periopera-
2013; the Commission, 2011a). Errors in medica- tive setting provides unique medication situations
tion administration occur, and they are largely pre- where, due to the flow of activities during anaes-
ventable (Roughhead et al., 2013). The same is true thetic or surgical procedures, the circulating,
in the perioperative setting where medications are instrument or anaesthetic nurse may be required to
often managed in unique ways, and administration prepare medications for subsequent administration
errors have contributed to patient mortality and by a medical officer (ACORN, 2016; NSW Health,
63
2014). This practice comes with considerable risk— Injectable Medicines, Fluids and Lines. The docu-
for example: ment, revised in 2012, outlines the minimum
• the circulating nurse may supply the wrong requirements for the safe handling, identification
medication onto the aseptic field and administration of injectable medicines both
on and in the aseptic field (the Commission,
• the instrument nurse may prepare an 2012c). Box 3-2 outlines the core principles of the
incorrect dose/concentration for the recommendations.
surgeon
The Commission’s national labelling recom-
• the instrument nurse may fail to label the mendations also reflect AORN’s Recommended
medication or the medication becomes Practices for Medication Safety (Hicks et al., 2012)
unidentifiable and is easily confused with and continue to provide guidance to perioperative
another on the aseptic field. nurses in New Zealand. On the aseptic field, periop-
Within Australia and New Zealand there are erative nurses must be able to identify medicines
no national policies for the preparation of medica- and fluids within containers and syringes, as medi-
tions in the perioperative setting. However, new cation mix-ups resulting in the administration of
procedures in some states such as New South Wales the wrong drugs have been reported with fatal con-
provide a safety framework for the perioperative sequences (the Commission, 2012c). Pre-printed
setting (NSW Health, 2014). Professional organisa- sterile medication labels provide a standardised
tions such as ACORN (2016) and AORN (Hicks et al., methodology for identifying medications on an
2012) have developed best-practice standards that aseptic setup. The Commission notes several require-
also guide perioperative nurses in this regard. ments for the safe usage of sterile medication labels:
• Labels should be pre-printed with commonly
LABELLING OF INJECTABLE MEDICINES, used medication names.
FLUIDS AND LINES • A sterile marking pen should be included to
In 2010, the Commission produced the National write on abbreviated container labels when
Recommendations for User-applied Labelling of pre-printed labels are not available.
BOX 3-2 » PRACTICE POINTS FOR USER-APPLIED LABELLING OF INJECTABLE MEDICINES, FLUIDS
AND LINES
• Medicines or fluids removed from the original packaging must be identifiable.
• All containers (e.g. bags and syringes) containing medicines must be labelled on leaving the hands
of the person preparing the medicine.
• Prepare and label one medicine at a time.
• Discard medicines or fluids in unlabelled containers, or where there is doubt about the contents.
• Labelling of syringes containing drugs used during anaesthesia must comply with ISO 26825: 2008
User-applied labels for syringes containing drugs used during anaesthesia.
• In closed-practice environments, use abbreviated container labels or pre-printed labels (patient and
user identification details ARE NOT REQUIRED). The operating room is considered a closed-practice
environment because only one patient is present and identified by the team.
• In open-practice environments use container labels with full identification (patient and user
identification ARE REQUIRED). The PACU is considered an open-practice environment because there
may be more than one patient in the same area.
• Preparation and bolus administration of a SINGLE medicine in one uninterrupted process does not
require a label, provided the syringe DOES NOT leave the hands of the person who prepared it, and
that same person administers the medicine IMMEDIATELY.
SOURCE: THE COMMISSION (2015c).
64
Sodium Chloride Water

Hydrogen Peroxide for Irrigation for Irrigation
3% 0.9%
Sodium Chloride Water

Hydrogen Peroxide for Irrigation for Irrigation
6% 0.9%
Chlorhexidine Chlorhexidine Povidone-lodine Methylene Blue

Gluconate 0.1% Alcoholic 2% Aqueous 10%
Chlorhexidine lodine Aqueous Povidone-lodine Sodium Chloride

Acetate 1% (Lugol’s) 5% Alcoholic 10% for Irrigation 0.9%
Chlorhexidine Povidone-lodine Sodium Chloride

Paraffin Liquid
Alcoholic 0.5% Aqueous 5% for Irrigation 0.9%
Sodium Chloride Medicine Medicine

for Injection
9% Conc (units/mL) Conc (units/mL)
Sodium Chloride Betamethasone

for Injection 0.9% Soldium Phosphate
Clonidine Verapamil
Sodium Chloride Adrenaline

for Injection 0.9%
Bupivacaine Heparin
10 units/mL 1 in 1,000
Adrenaline
cephaZOLin Lignocaine Heparin
25 units/mL 1 in 10,000
Adrenaline
Gentamicin Ropivacaine Heparin
1,000 units/mL 1 in 400,000
Lignocine
Vancomycin Ropivacaine Heparin
1,000 units/mL Adrenaline
Ropivacaine
Contrast Morphine Heparin
25,000 units/mL Adrenaline
FIGURE 3-5: Examples of pre-printed abbreviated container labels for user-applied identification in the closed-practice environment
Source: The Commission (2012c).
• Labels should be able to be removed from such as the PACU or postoperative ward. Periopera-
re-usable containers without leaving a residue. tive nurses also need to recognise the additional
• Labels must be durable when wet so they do risks described in Feature box 3-4 when managing
not peel off throughout the surgical procedure. medications for special populations.
• Colour coding must comply with ISO 26825:

2008 User-applied labels for syringes CLINICAL AUDIT
containing drugs used during anaesthesia (the
Commission, 2012d). Clinical audits have a long-established history in
healthcare with early clinicians such as Nightingale
Figure 3-5 shows examples of pre-printed sterile and Codman monitoring mortality and morbidity
medication labels and sterile abbreviated container by means of epidemiological or patient record
labels that may be used on the aseptic field. review (Travaglia & Debono, 2009). Today, clinical
Despite systems such as medication labelling auditing is a component of a quality and safety
and double-checking protocols, medication errors framework and is vital to ensure health systems and
still occur (Roughhead et al., 2013). Perioperative practices are safe. Figure 3-1a illustrates how clini-
nurses need to be cognisant of this fact, whether cal auditing is a central component of clinical gov-
they are caring for patients in the OR, procedure ernance. Audits are cyclical processes that involve
room, catheter laboratory or endoscopy suite, which a systematic gathering of information by observa-
the Commission (2012c) defines as ‘closed practice tion or data analysis. The information is used
environments’, or in ‘open practice environments’ to review performance, assess compliance with
65
FEATURE BOX 3-4 » MEDICATION MANAGEMENT AND SPECIAL POPULATIONS
The Association of periOperative Registered Nurses recommends that perioperative nurses estab-
lish distraction-free zones in the perioperative environment when managing medications for
special populations such as pregnant patients, the elderly or paediatric patients. This is due to
the narrow therapeutic ranges for medications and the presence of high-risk medications. The
additional vulnerability of these special populations may at times be a distraction for members
of the perioperative team preparing and handling medications.
SOURCE: HICKS ET AL. (2012).
standards or procedures, or compare outcomes Perioperative nurses engage in auditing proc-

against previous results or benchmarked standards esses in a wide variety of ways. These auditing
(the Commission, 2011a). Perioperative nursing is activities may be part of a clinical portfolio that a
shaped and directed by many standards, policies nurse holds, for example a perioperative infection
and clinical procedures and it is important to control portfolio, or they may be completed as part
understand whether clinicians are complying with of the regular practice audits required of hospital
these standards, procedures and legislative require- departments, such as hand hygiene compliance or
ments. It is equally important for patient safety and review of medication documentation. Research box
practice improvement to understand why clinicians 3-2 describes how practice may be improved by
fail to comply with these requirements. clinical audits.
RESEARCH BOX 3-2: Auditing Clinical Practice: Ensuring High Reliability at an Australian Hospital
This article outlines the development of a series of clinical audits in the perioperative setting of a tertiary
hospital in Brisbane. The audits, which aligned to the National Standards, collected evidence of staff
compliance with best practice and gave insights into strategies used to minimise risks to patient safety.
The audits were aimed at four key areas of perioperative practice:
~ Surgical Safety Checklist: The observational audit tool captured information that previous audits had
missed, including the name of the person initiating the Time Out, which helped to identify occasions
when key staff did not participate in the conduct of the checklist.
~ Intraoperative medication labelling: Real-time observational audits were conducted of staff compli-
ance with pre-populated sterile labels.
~ Surgical aseptic technique: Nurses’ practice and techniques were observed for compliance with stand-
ards on gowning, gloving, and establishing and maintaining surgical aseptic practices. Facilitators
suspended the audit to address breaches in practice when required.
~ Clinical handover from the OR to the PACU: Each month, facilitators conduct 20 audits of the informa-
tion and efficacy of clinical handover between OR and PACU nurses.
The article describes the aims of each clinical audit as well as the methodology for data collection. The
article discusses the insights gained from each audit and describes how the results were used to improve
clinical practice. Of importance, the article notes that the audits were used as tools to create positive
change in the perioperative setting, rather than as a punitive measure, thus empowering staff to engage
in quality improvement activities.
SOURCE: STEEL (2015).
66
For audits to be meaningful they must be rele- may choose to engage in informal audit processes
vant to clinical practice, and patient and staff safety, by means of self-evaluation or practice reflection
or guide the improvement of patient outcomes (the by asking questions such as: ‘Did I complete that
Commission, 2011b). Audits are accompanied by procedure correctly?’, ‘What went well/wrong?’ or
reports that detail their purpose and scope, and ‘How can I improve?’ Figure 3-6 details the clinical
discuss the outcomes and findings. Audit reports audit cycle.
also contain action plans that detail specific tasks Research box 3-3 describes a retrospective doc-
to be completed based on audit findings. Peri umentation audit of health records in two UK hos-
operative nurses are often engaged in the imple- pitals. This research demonstrates that clinical
mentation phase of the clinical audit cycle, by audits, combined with feedback to clinicians, can be
enacting recommendations, strategies or activities effective tools for practice improvement.
to improve practice. Indeed, perioperative nurses
Preparing to
6. How do I know audit 1. What do I want
I was successful? to know/assess?
Topic
Scope
Objectives
Defining
Implement
5. How will I standards
changes 2. How
make and ACORN should it be
sustain any Improvements NSQHSS done in
changes? Sustaining new Policy, practice?
practice procedure
4. To whom Data
will I report Audit report collection
my findings and Results 3. How will I
and analysis collect and analyse
recommendations? Action plans
Feedback Observation my evidence?
Case review
FIGURE 3-6: Clinical audit cycle
RESEARCH BOX 3-3: Clinical Audit of Perioperative Practice
A retrospective documentation audit of health records was conducted in two UK hospitals to determine
surgeon compliance with the Royal College of Surgeons (RCS) Best Surgical Practice Guidelines. The health
records of 91 patients undergoing orthopaedic surgical procedures were reviewed for legibility, efficacy
to inform PO care and adherence to RCS guidelines including documentation of:
~ consultant’s name
~ name of operation
~ date and time of operation
~ closure type.
Continued
67
RESEARCH BOX 3-3: Clinical Audit of Perioperative Practice—cont’d
The authors provided feedback of audit results at monthly meetings and reminded surgeons of the RCS
guidelines. The same methods were used to conduct a follow-up audit of 103 patients’ health records
2 months later. The authors concluded that ‘before intervention, adherence to “best surgical practice” was
unacceptably poor’ (p. 110). At follow up, the authors reported that all parameters including legibility had
improved, although it was not clear whether this was a result of education and prompts to senior surgeons
or the uptake of electronic health records.
SOURCE: WHITEHEAD- CLARKE ET AL. (2015).
At a time of intense public scrutiny and profes-

CONCLUSION sional interest in safety and quality in healthcare,
Patients admitted to hospital should feel safe and ways to ensure patient safety in the high-risk
not have concerns that something may go wrong setting of the operating suite remain paramount.
while they are receiving treatment. The evidence, Indeed, this chapter has shown that perioperative
however, demonstrates that patients do experience patient safety is of concern globally, with particular
adverse events, many of which are preventable. attention focused on reducing sentinel events such
This chapter has explored the concepts of clinical as wrong site surgery and retained surgical items.
governance and national safety and quality frame- The implementation of the National Standards, as
works for healthcare workers, as well as the strat part of a wider clinical governance framework, is
egies commonly used to prevent adverse events and crucial to ensure positive patient outcomes. Patient
ensure perioperative patients are provided with the safety is the ultimate aim of every healthcare pro-
safest possible care. fessional and will continue to be a primary focus of
perioperative practice in the future.

1. Review of a sentinel event
You have been asked to participate in a Root Cause Analysis of a recent sentinel event in which a
wrong site surgery occurred at another facility in your region. The investigation reveals that team
communication and distractions contributed to this event. In particular, it was noted that the surgeon
was called to the telephone during the team Time Out.
• What actions would you take if a disruption occurred during team Time Out? Provide rationales
to explain why you believe your actions are important.
• Name two protocols or standards that guide the practice requirements for team Time Out and
will assist you to manage this situation.
• List at least two other factors reported in the literature that can contribute to wrong site
surgeries.
2. Checklists
You are allocated to the role of circulating nurse for a left hip hemi-arthroplasty on a 75-year-old
female. During the Surgical Safety Checklist it becomes apparent that incorrect prostheses have been
ordered and no other alternatives are available. The patient is already anaesthetised and now needs
to be woken as the surgery cannot go ahead as planned.
• What preoperative checks do you think should have occurred? Give rationales to explain why
you think these checks are important.
• Identify at least three types of reporting that should accompany this kind of adverse event.
68
3. Medication management
You have ‘scrubbed-in’ to take over the instrument nurse role for a patient undergoing a complex
breast reconstruction involving a latissimus dorsi free flap. The procedure is at the mid-way point
when you scrub in. The instrumentation set-up has multiple receivers (i.e. gallipots) and syringes
containing a variety of fluids, which your colleague identifies as local anaesthetic, heparinised saline
and adrenaline solutions. None of the containers or syringes is labelled.
• Describe the potential adverse events that might occur in this circumstance.
• How could you safely identify the medications on the set-up? Provide rationales to explain why
you believe your actions are important.
4. Clinical audits
You have been assigned by your manager to investigate whether nurses in your operating suite are
performing adequate hand hygiene before and after patient contact in the PACU in an effort to improve
compliance and patient outcomes. You decide to conduct a practice audit.
• Describe the objectives of your audit in relation to the 5 Moments of Hand Hygiene and identify
at least two other standards that might inform your practice audit.
• Describe how you would collect your evidence. Provide rationales to explain why you believe
your collection methods are necessary.
• How would you report your findings and recommendations to your manager?
• If changes were implemented as a result of your audit, how would you know whether they were
sustained into the future?
Health Quality and Safety Commission New Zealand

RESOURCES (HQSCNZ)
Australasian College for Infection Prevention and Control www.hqsc.govt.nz
Ltd (ACIPC) Incident management and reporting systems
www.acipc.org.au NSW Health
Australian Commission on Safety and Quality in Health www.cec.health.nsw.gov.au/clinical-incident
Care (ACSQHC/the Commission) -management
www.safetyandquality.gov.au WA Health
Implementation Toolkit for Clinical Handover www.safetyandquality.health.wa.gov.au/clinical_incid
Improvement _man/aims.cfm
www.safetyandquality.gov.au/implementation-toolkit New Zealand
-resource-portal www.hqsc.govt.nz/our-programmes/reportable-events
Labelling recommendations Malignant Hyperthermia Resource Kit, Royal Melbourne
www.safetyandquality.gov.au/acsqhc_program/labelling Hospital, Department of Anaesthesia and Pain
On the Radar Management
www.safetyandquality.gov.au/publications-resources/ www.anaesthesia.mh.org.au/mh-resource-kit/w1/
on-the-radar i1002692/
Resources to implement the NSQHS Standards Patient safety reports and sentinel event reporting
www.safetyandquality.gov.au/our-work/accreditation New Zealand
-and-the-nsqhs-standards/resources-to-implement www.hqsc.govt.nz/our-programmes/reportable-events/
-the-nsqhs-standards serious-adverse-events-reports/
Australian Day Surgery Nurses Association (ADSNA) South Australia
adsna.info www.sahealth.sa.gov.au/wps/wcm/connect/public
Australian Institute of Health and Welfare (AIHW) +content/sa+health+internet/clinical+resources/
www.aihw.gov.au/online-reports safety+and+quality/patient+safety+reports
Gastroenterological Nurses College of Australia (GENCA) Victoria
www.genca.org www.health.vic.gov.au/clinrisk/sentinel/index.htm
69
Western Australia Australian College of Operating Room Nurses (ACORN).

www.safetyandquality.health.wa.gov.au/clinical_incid (2016). ACORN Standards for perioperative nursing 2016–17.
_man/sentinel_events.cfm Adelaide, South Australia: Author.
Safe surgery Australian Commission on Safety and Quality in Health Care
ACSQHC/the Commission (ACSQHC/the Commission). (2009). Windows into safety and
www.safetyandquality.gov.au/our-work/patient quality in health care, 2009. Retrieved from <www.safety
-identification/patient-procedure-matching-protocols/ andquality.gov.au/publications/windows-into-safety-and
surgical-safety-checklist -quality-in-health-care-national-report-2009>.
Reducing Perioperative Harm (HQSCNZ) Australian Commission on Safety and Quality in Health Care
www.hqsc.govt.nz/our-programmes/reducing (ACSQHC/the Commission). (2010). Australian safety and
-perioperative-harm quality framework for health care. Retrieved from <www.safe
tyandquality.gov.au/national-priorities/australian-safety
Safe Surgery -and-quality-framework-for-health-care>.
www.safesurg.org
Australian Commission on Safety and Quality in Health Care
Safe Surgery 2015 (ACSQHC/the Commission). (2011a). Windows into safety and
www.safesurgery2015.org quality in health care, 2011. Retrieved from <www.safety
World Health Organization (WHO) Safe Surgery andquality.gov.au/publications/windows-into-safety-and
www.who.int/patientsafety/safesurgery/en -quality-in-health-care-2011>.
Australian Commission on Safety and Quality in Health Care
REFERENCES (ACSQHC/the Commission). (2011b). National Safety and
Quality Health Service Standards. Sydney: Author.
Association of periOperative Registered Nurses (AORN).
(2012). Recommended practices summary: Recommended Australian Commission on Safety and Quality in Health Care
practices for prevention of retained surgical items. AORN (ACSQHC/the Commission). (2012a). National Safety and
Journal, 95(2), 220–221. doi:10.1016/j.aorn.2011.11.005. Quality Health Service Standards: Standard 1: Governance for
Safety and Quality in Health Service Organisations. Retrieved
Australasian College for Infection Prevention and Control from <www.safetyandquality.gov.au>.
(ACIPC). (2012). Single-use devices [Position statement.] Bris-
bane: Author. Retrieved from <www.acipc.org.au/Resources/ Australian Commission on Safety and Quality in Health Care
Position-Statements>. (ACSQHC/the Commission). (2012b). National Safety and
Quality Health Service Standards: Standard 8: Preventing and
Australasian College for Infection Prevention and Control managing pressure injuries. Retrieved from <www.safetyand
(ACIPC). (2013). The role of the infection control practitioner quality.gov.au>.
in antimicrobial stewardship [Position statement.] Brisbane:
Author. Retrieved from <www.acipc.org.au/Resources/ Australian Commission on Safety and Quality in Health Care
Position-Statements>. (ACSQHC/the Commission). (2012c). National recommenda-
tions for user-applied labelling of injectable medicines, fluids
Australian and New Zealand College of Anaesthetists and lines. Sydney: Author.
(ANZCA). (2006). PS04 Recommendations for the post-
anaesthesia recovery room. Melbourne: Author. Retrieved Australian Commission on Safety and Quality in Health Care
from <www.anzca.edu.au/resources/professional-documents/ (ACSQHC/the Commission). (2012d). National recommenda-
pdfs/ps04-2006-recommendations-for-the-post-anaesthesia tions for user-applied labelling of injectable medicines, fluids
-recovery-room.pdf>. and lines: Evaluation of pre-printed labels for identification of
medicines and fluids on the perioperative sterile field. Sydney:
Australian and New Zealand College of Anaesthetists Author.
(ANZCA). (2012). PS58 Guidelines on quality assurance in
anaesthesia. Melbourne: Author. Retrieved from <www Australian Commission on Safety and Quality in Health Care
.anzca.edu.au/resources/professional-documents>. (ACSQHC/the Commission). (2013a). Clinical Care Standards.
Retrieved from <www.safetyandquality.gov.au/our-work/
Australian and New Zealand College of Anaesthetists clinical-care-standards>.
(ANZCA). (2013). PS53 Background paper: Statement on the
handover responsibilities of the anaesthetist. Melbourne: Australian Commission on Safety and Quality in Health Care
Author. Retrieved from <www.anzca.edu.au/search?Searcha (ACSQHC/the Commission). (2013b). Australian Open Disclo-
bleText=ISOBAR>. sure Framework. Retrieved from <www.safetyandquality.gov
.au/publications/australian-open-disclosure-framework>.
Australian and New Zealand College of Anaesthetists
(ANZCA). (2015). PS59 Statement on roles in anaesthesia and Australian Commission on Safety and Quality in Health Care
perioperative care. Melbourne: Author. Retrieved from <www (ACSQHC/the Commission). (2014a). Report on healthcare
.anzca.edu.au/resources/professional-documents>. associated Staphylococcus aureus bacteraemia workshop.
Retrieved from <www.safetyandquality.gov.au/our-work/
Australian and New Zealand College of Anaesthetists healthcare-associated-infection/national-hai-surveillance
(ANZCA). (nd). Patient blood management guidelines. Mel- -initiative/healthcare-associated-staphylococcus-aureus
bourne: Author. Retrieved from <www.anzca.edu.au/ -bacteraemia-workshop>.
resources/endorsed-guidelines>.
70
Australian Commission on Safety and Quality in Health Care thromboembolism prevention in hospitalised medical
(ACSQHC/the Commission). (2014b). Antimicrobial Steward- patients: A prospective before-and-after intervention study.
ship Clinical Care Standard. Retrieved from <www.safetyand BMC Health Services Research, 13, 398. Retrieved from <www
quality.gov.au/wp-content/uploads/2014/11/Antimicrobial .biomedcentral.com/1472-6963/13/398>.
-Stewardship-Clinical-Care-Standard-web.pdf>. Fowler, A. J. (2013). A review of recent advances in periopera-
Australian Commission on Safety and Quality in Health Care tive patient safety. Annals of Medicine and Surgery, 2(1),
(ACSQHC/the Commission). (2015a). National Standards and 10–14.
Accreditation. Retrieved from <www.safetyandquality.gov Gastroenterological Nurses College of Australia (GENCA).
.au/our-work/national-standards-and-accreditation>. (2012). Educational requirements for personnel reprocessing
Australian Commission on Safety and Quality in Health Care flexible endoscopic equipment [Position statement.] Beau-
(ACSQHC/the Commission). (2015b). National Safety and maris, Victoria: Author. Retrieved from <www.genca.org/
Quality Health Service Standards Version 2: Consultation draft. standards-positions/position-statements/www.genca.org/
Sydney: Author. Retrieved from <www.safetyandquality.gov standards-positions/guidelines>.
.au/our-work/accreditation-and-the-nsqhs-standards/ Gawande, A. (2010). The checklist manifesto: How to get
c u r r e n t- co n s u l t a t i o n s / # Ve r s i o n - 2 - of - t h e - N S Q H S things right. New York: Metropolitan Books.
-Standards>.
Gillespie, B. M., Chaboyer, W., Thalib, L., John, M., Fairweather,
Australian Commission on Safety and Quality in Health Care N., & Slater, K. (2014). Effect of using a safety checklist on
(ACSQHC/the Commission). (2015c). National Standard for patient complications after surgery: A systematic review and
User-applied Labelling of Injectable Medicines, Fluids and meta-analysis. Anesthesiology, 120, 1380–1389.
Lines. Sydney: Author.
Gottwald, M., & Lansdown, G. E. (2014). Clinical governance:
Australian Council for Safety and Quality in Healthcare Improving the quality of healthcare for patients and service
(ACSQHC). (2003). Setting the human factor standards for users. Maidenhead, UK: McGraw-Hill Education.
health care: Do lessons from aviation apply? A report on the
human factors in health care workshop held as part of the Gough, I. (2010). A surgical safety checklist for Australia and
sixth international Australian aviation psychology sympo- New Zealand. ANZ Journal of Surgery, 80, 1–2.
sium, Sydney, 6 December 2003. Haugen, A. S., Søfteland, E., Almeland, S. K., Sevdalis, N.,
Australian Council on Healthcare Standards (ACHS). (2013). Vonen, B., Eide, G. E., et al. (2015). Effect of the World Health
EQuIP national brochure. Retrieved from <www.achs.org.au/ Organization checklist on patient outcomes: A stepped
publications-resources/equipnational>. wedge cluster randomized controlled trial. Annals of Surgery,
261(5), 821–828.
Australian Council on Healthcare Standards (ACHS). (2015).
Overview of accreditation programs and services. Retrieved Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R.,
from <www.achs.org.au/programs-services/overview>. Breizat, A. H., Dellinger, E. P., et al. (2009). A surgical safety
checklist to reduce morbidity and mortality in a global
Australian Institute of Health and Welfare (AIHW). (2014a). population. Safe Surgery Saves Lives Study Group. New
Staphylococcus aureus bacteraemia in Australian public hos- England Journal of Medicine, 360(5), 491–499. doi:10.1056/
pitals 2013–14: Australian hospital statistics. Health services NEJMsa0810119.
series no. 59. Cat. no. HSE 155. Retrieved from <www.aihw
.gov.au/publication-detail/?id=60129550044>. Health Quality and Safety Commission New Zealand
(HQSCNZ). (2014a). Making health and disability services safer:
Australian Institute of Health and Welfare (AIHW). (2014b). Serious adverse events reported to the Health Quality & Safety
Australian hospital statistics 2012–13. Health services series Commission 1 July 2013 to 30 June 2014. Wellington: HQSCNZ.
no. 54. Cat. no. HSE 145. Retrieved from <www.aihw.gov.au/ Retrieved from <www.hqsc.govt.nz/our-programmes/
publication-detail/?id=60129546922>. reportable-events/serious-adverse-events-reports>.
Australian Red Cross Blood Service. (2014). Factors contri Health Quality and Safety Commission New Zealand
buting to transfusion-related adverse events [Web page.] (HQSCNZ). (2014b). Open book: Accurate patient identification,
Retrieved from <www.transfusion.com.au/adverse_events/ December 2014. Wellington: Author. Retrieved from <www
risks>. .hqsc.govt.nz/assets/Reportable-Events/Publications/Open
Consultative Council on Anaesthetic Mortality and Morbid- -book/OB-accurate-patient-identification-Dec-2014.pdf>.
ity. (2011). Tenth report of the Victorian consultative council Health Quality and Safety Commission New Zealand
on anaesthetic mortality and morbidity. Melbourne, 2011. (HQSCNZ). (2015). Health Quality and Safety Commission New
Retrieved from <www.health.vic.gov.au/vccamm/vccamm Zealand webpage. Retrieved from <www.hqsc.govt.nz>.
-reports.htm>.
Hicks, R. W., Wanzer, L. J., & Denholm, B. (2012). Implement-
Doncaster and Bassetlaw Hospitals NHS Foundation Trust. ing AORN recommended practices for medication safety.
(2014). The human factor: Learning from Gina’s story [Video AORN Journal, 96(6), 606–619.
file.] Retrieved from <https://www.youtube.com/watch
?feature=youtu.be&v=IJfoLvLLoFo&app=desktop>. Karl, R., & Karl, M. C. (2012). Adverse events: Root causes
and latent factors. Surgical Clinics of North America, 92(1),
Duff, J., Omari, A., Middleton, S., McInnes, E., & Walker, K. 89–100.
(2013). Educational outreach visits to improve venous
71
Lai, A., Davidson, N., Galloway, S. W., & Thachil, J. (2014). Melbourne: Author. Retrieved from <www.surgeons.org/
Perioperative management of patients on new oral policies-publications/publications/position-papers/#b>.
anticoagulants. The British Journal of Surgery, 101(7), Royal Melbourne Hospital, Department of Anaesthesia and
742–749. Pain Management. (2012). Malignant hyperthermia resource
Lau, B. D., & Haut, E. R. (2014). Practices to prevent venous kit. Retrieved from <www.anaesthesia.mh.org.au/mh
thromboembolism: A brief review. BMJ Quality & Safety, 23, -resource-kit/w1/i1002692>.
187–195. doi:10.1136/bmjqs-2012-001782. Sevdalis, N., Hull, L., & Birnbach, D. J. (2012). Improving
Ministry of Health, New Zealand. (2014). Certification of patient safety in the operating theatre and perioperative
health care services [Web page.] Retrieved from <www care: Obstacles, interventions, and priorities for accelerating
.health.govt.nz/our-work/regulation-health-and-disability progress. British Journal of Anaesthesia, 109(S1), i3–i16.
-system/certification-health-care-services>. Standards Australia. (2014). AS/NZS 4187 Reprocessing of
National Blood Authority Australia (NBA). (nd). Retrieved reusable medical devices in health service organisations.
from <www.blood.gov.au>. Sydney: Author.
National Pressure Ulcer Advisory Panel, European Pressure Steel, C. (2015). Auditing clinical practice: Ensuring high
Ulcer Advisory Panel and Pan Pacific Pressure Injury Alli- reliability at an Australian hospital. AORN Journal, 102, 81–
ance. (NPUAP-EPUAP-PPPIA). (2015). Prevention and treat- 84. doi:10.1016/j.aorn.2015.05.013.
ment of pressure ulcers: Quick reference guide. E. Haesler (Ed.). Sutherland-Fraser, S., McInnes, E., Maher, E., & Middleton, S.
Perth, Australia: Cambridge Media. (2012). Perioperative nurses’ knowledge and reported prac-
New Zealand Nurses Organisation (NZNO). (2011). Serious tice of pressure injury risk assessment and prevention: A
and sentinel events [Fact sheet.] Retrieved from <www.nzno before-after intervention study. BMC Nursing, 11, 25.
.org.nz/support/workplace_rights/serious_and_sentinel doi:10.1186/1472-6955-11-25.
_events>. Symons, V. C., & McMurray, A. (2014). Factors influencing
NSW Department of Health. (2014). South Eastern Sydney nurses to withhold surgical patients’ oral medications pre-
Local Health District (SESLHD) procedure: Medicine. Managing and postoperatively. Collegian: Journal of the Royal College of
intraoperative medications. SESLHDPR/209. Retrieved from Nursing, Australia, 21(4), 267–274.
<www.seslhd.health.nsw.gov.au/Policies_Procedures_ Tang, R., Ranmuthugala, R., & Cunningham, F. (2013). Surgi-
Guidelines/Clinical/Medicine/documents/SESLHDPR209 cal safety checklists: A review. ANZ Journal of Surgery, 84,
-MedicineManagingIntraoperativeMedications.pdf>. 148–154.
Phillips, N. M., Haesler, E., Street, M., & Kent, B. (2011). Post- Thurairatnam, R. R., Mathew, G. S., Montgomery, J., & Stocker,
anaesthetic discharge scoring criteria: A systematic review. M. (2014). The role of patient satisfaction surveys to improve
JBI Library of Systematic Reviews, 9(41), 1679–1713. patient care in day surgery [online]. Day Surgery Australia,
Queensland Department of Health. (2014). Guideline for 13(3), 6–8.
anticoagulation and prophylaxis using low molecular weight Travaglia, J., & Debono, D. (2009). Clinical audit: A compre-
heparin (lmwh) in adult inpatients. Document Number # QH- hensive review of the literature. Sydney: University of New
GDL-951:2014-2. Retrieved from <www.health.qld.gov.au/ South Wales, Centre for Clinical Governance Research in
clinical-practice/guidelines-procedures>. Health, Faculty of Medicine.
Queensland Department of Health. (2015). National Safety van Klei, W. A., Hoff, R. G., van Aarnhem, E. E. H. L., Simmer-
and Quality Health Service Standards [Poster.] Retrieved from macher, R. K. J., Regli, L. P. E., Kappen, T. H., et al. (2012).
<https://www.health.qld.gov.au/rbwh/docs/nsqhss-poster Effects of the introduction of the WHO Surgical Safety
.pdf>. Checklist on in-hospital mortality: A cohort study. Annals of
Reason, J. (2000). Human error; models and management. Surgery, 255, 44–49.
British Medical Journal, 320, 768–770. Vogts, N., Hannam, J. A., Merry, A. F., & Mitchell, S. J. (2011).
Roughhead, L., Semple, S., & Rosenfeld, E. (2013). Literature Compliance and quality in administration of a surgical
review: Medication safety in Australia. Sydney: ACSQHC. safety checklist in a tertiary New Zealand hospital. NZ
Royal Australasian College of Surgeons (RACS). (2013). Medical Journal, 124(1342), Retrieved from <https://www
Indigenous health. Ref. No. FES-FEL-001 [Position paper.] .nzma.org.nz/journal/read-the-journal/all-issues/2010
Melbourne: Author. Retrieved from <www.surgeons.org/ -2019/2011/vol-124-no-1342/article-vogts>.
policies-publications/publications/position-papers/#b>. Watters, D. A. K., & Truskett, P. G. (2013). Reducing errors in
Royal Australasian College of Surgeons (RACS). (2014). Bul- emergency surgery. ANZ Journal of Surgery, 83, 434–437.
lying and harassment: Recognition, avoidance and manage- Weiser, T. G., & Berry, W. R. (2012). Review article: Periopera-
ment [Position paper.] Melbourne: Author. Retrieved from tive checklist methodologies. Canadian Journal of Anaesthe-
<www.surgeons.org/policies-publications/publications/ sia, 60(2), 136–142.
position-papers/#b>. Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz,
Royal Australasian College of Surgeons (RACS). (2015). Out- S. R., & Gawande, A. A. (2010). Effect of a 19-item surgical
reach surgery in regional, rural and remote areas of Australia safety checklist during urgent operations in a global patient
and New Zealand, Ref. No. FES-FEL-033 [Position paper.] population. Annals of Surgery, 251, 976–980.
72
Western Australia Department of Health. (2011). WA Sentinel former-publications/adverse-event-rates-fact-sheet-pdf

Event Report 2010/2011. Perth: Author. Retrieved from <ww2 -73-kb>.
.health.wa.gov.au/Corporate/Articles/S_T/Sentinel-events>. Australian Institute of Health and Welfare (AIHW). (2014).
Whitehead-Clarke, T., Varma, N., Hadjimichael, A., Gillham, F., Australian hospital statistics. Retrieved from <www.aihw.gov
& O’Brien, K. (2015). Improving operation notes and post- .au/online-reports>.
operative care: an audit of current practice. Journal of Peri- Gordon, S., Mendenhall, P., & O’Connor, B. B. (2013). Beyond
operative Practice, 25(5), 107–111. the checklist: What else health care can learn from aviation
World Health Organization (WHO). (2008). Implementation teamwork and safety. New York: Cornell University Press.
manual surgical safety checklist. Geneva, Switzerland: Author. Health Quality and Safety Commission New Zealand
World Health Organization. (WHO). (2012a). Patient safety (HQSCNZ). (various dates). Serious sentinel events in New
research: A guide for developing training programmes. Geneva, Zealand hospitals (2006–2007, 2007–2008, 2008–2009);
Switzerland: WHO Press. Retrieved from <www.who.int/ Making our hospitals safer: Serious sentinel events (2009–
patientsafety/information_centre/documents/en>. 2010, 2010–2011, 2011–2012); and Making health and dis-
World Health Organization. (WHO). (2012b). The evolving ability services safer: Serious sentinel events (2012–2013,
threat of antimicrobial resistance: Options for action. Geneva, 2013–2014); Retrieved from <www.hqsc.govt.nz/our
Switzerland: WHO Press. Retrieved from <whqlibdoc.who -programmes/reportable-events/serious-adverse-events
.int/publications/2012/9789241503181_eng.pdf>. -reports>.
World Health Organization. (WHO). (2015). Antimicrobial Hemingway, M. W., O’Malley, C., & Silvestri, S. (2015). Safety
resistance [Fact sheet No. 194.] Geneva, Switzerland: WHO culture and care: A program to prevent surgical errors. Con-
Press. Retrieved from <www.who.int/mediacentre/ tinuing education. AORN Journal, 101(4), 404–415.
factsheets/fs194/en>. Jensen, J., & Shipp, D. (2015). Labelling in perioperative
areas: An evolving process. ACORN Journal, 28(4), 10–13.
FURTHER READING Pearse, R. M., Moreno, R. P., Bauer, P., Pelosi, P., Metnitz, P.,
Australian Commission on Safety and Quality in Health Care Spies, C., et al. (2012). Mortality after surgery in Europe: A
(ACSQHC/the Commission). (2012). Adverse event rates 7-day cohort study. Lancet, 380, 1059–1065. doi:10.1016/
[Fact sheet.] Retrieved from <www.safetyandquality.gov.au/ S0140-6736(12)61148-9.
73
Chapter 4
MEDICO-LEGAL ASPECTS OF
PERIOPERATIVE NURSING PRACTICE
MENNA DAVIES AND AMANDA ADRIAN
EDITOR: LOIS HAMLIN
LEARNING OUTCOMES
• Discuss the statutes and common law cases that guide nursing practice
• Apply statutes and common law cases in relation to negligence, consent to care and treatment, and
documentation
• Examine the management of complaints against nurses and the conduct of disciplinary hearings
• Differentiate between privacy and confidentiality
• Explore the use of social media as it relates to patient privacy and professional nursing practice
KEY TERMS
advance health directive

consent to treatment
coroners’ courts
disciplinary hearings
documentation
negligence
privacy and confidentiality
professional conduct
professional standards
social media
unprofessional conduct
74
CHAPTER 4 | Medico-legal aspects of perioperative nursing practice
• being an advocate is proactive rather than

INTRODUCTION passive
This chapter focuses on medico-legal and ethical • the nurse is prepared to speak up and act on
topics as they relate to the delivery of patient care behalf of the patient
in the perioperative setting. In addition to the regu-
latory framework, codes of conduct and profes- • some difficulty or challenge exists that
sional standards discussed in Chapter 1, nursing requires action as an advocate (Kerridge, Lowe
practice is also informed by legislation and common & Stewart, 2013).
law decisions, and by state and federal health There are few better examples of acting on
department or national ministry of health policies. behalf of the patient than doing so in the periop-
In particular, this chapter explores consent to treat- erative environment where patients are, for the
ment, negligence, patient confidentiality and indi- most part, either sedated or anaesthetised and
vidual as well as organisational privacy. It also unable to look after themselves. As patient advo-
examines pitfalls when using social media in cate, the perioperative nurse has an obligation to
healthcare settings. At a time of strong public and ensure the patient’s physical, emotional and ethical
professional scrutiny of patient safety, periopera- needs are met, and must be ready to intervene to
tive nurses require an understanding of the proc- protect the patient’s safety. This may include speak-
esses contained within the regulatory framework ing up if correct policies or procedures are not
associated with managing complaints made about being adhered to or when potential exists for injury
nursing care. without intervention.
Acting as the patient’s advocate has legal and
ACCOUNTABILITY AND ADVOCACY ethical implications that the perioperative nurse
In all of their activities, perioperative nurses remain must consider and the role is not without its chal-
accountable for their practice and, as necessary, lenges. This is especially so if acting on behalf of
advocate on behalf of their patients (see Chapter 1). the patient brings the perioperative nurse into con-
These roles are enshrined in the Nursing and Mid- flict with others, some of whom may be close col-
wifery Board of Australia (NMBA) codes of ethics leagues. If faced with this situation, the nurse may
and professional conduct (2013a, 2013b) and the need to confront the person concerned. This is best
New Zealand code of health and disability services done after seeking advice from more senior col-
consumers’ rights (code of rights) (New Zealand leagues who can advise on an appropriate course of
Health and Disability Commissioner, 1996a, 1996b). action.
Indeed, being a patient advocate is fundamental to Some situations, however, may require a more
the nurse’s role and is reflected in definitions of serious response. Turning a blind eye to incorrect
nursing (see Feature box 4-1). In its simplest form, or inappropriate behaviour may result in harm
as reflected in Virginia Henderson’s words, advo- to the patient and is in conflict with the NMBA
cacy can be defined as intervening or speaking up codes of ethics and professional conduct and the
on behalf of patients when they are unable to do so New Zealand code of rights. In addition, under
due to their physical or mental condition. The the National Law 2009, registered health practi-
concept of advocacy (addressed in Chapter 1) has tioners and employers have a legal obligation to
three basic assumptions: make a mandatory notification if they have formed
FEATURE BOX 4-1 » DEFINITION OF NURSING
The unique function of a nurse is to assist the individual, sick or well, in the performance of those
activities contributing to health, or its recovery (or to peaceful death) that he would perform
unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to
help him gain independence as rapidly as possible (Henderson, 1964, p. 66).
75
a reasonable belief that a health practitioner has COMMON LAW

behaved in a way that constitutes notifiable conduct Common law decisions also have a direct bearing
in relation to the practice of her or his profession on practice, such as those related to negligence (see
(Australian Health Practitioner Regulation Agency discussion below), which is a civil wrong (or tort),
[AHPRA], 2013). This places great responsibility on and to consent to treatment (see later in the
the nurse to act, and consulting with a senior col- chapter). Failure to gain consent from patients
league can clarify the course of action to be taken. before treating them constitutes part of the civil
Documentation of the facts of the situation is wrong of trespass to the person, specifically assault
essential when proceeding with mandatory report- and battery; it should not be confused with the civil
ing of a colleague and will be used in any subse- wrong of negligence. The underpinning legal prin-
quent investigation. ciples associated with all civil wrongs are well-
established common law principles developed by
STATUTES AND COMMON LAW the courts over several centuries (thereby establish-
ing precedents) and sometimes referred to as case
Various statutes and common law precedents
law. Some of the principles addressing the law of
impact perioperative nursing practice in Australa-
civil wrongs or torts have been extended by national,
sia. The relevant legislation is outlined in Table 4-1.
state or territory legislation, all of which vary
In addition, in New Zealand the Health and Disabil-
somewhat (Staunton & Chiarella, 2013). In each
ity Commissioner Act 1994 and the Health and
Australian state and territory, and in New Zealand,
Disability Commissioner Amendment Act 2003
legislation applies to adults who are not competent
incorporate the code of rights, which extends to any
to give consent (Medical Council of New Zealand,
person or organisation providing a health service to
2011; WA Department of Health, 2011).
the public. The code of rights covers all health pro-
fessionals, and one obligation is to take reasonable
action in the circumstances to give effect to the HEALTH POLICIES AND PROFESSIONAL
rights and comply with the duties. Furthermore, in PRACTICE STANDARDS
July 2008 Australian health ministers endorsed the Various state, territory and national health depart-
Australian charter of healthcare rights (Australian ment/ministry policies have a direct bearing on
Commission on Safety and Quality in Health Care perioperative practice; for example, NSW Health
[the Commission], 2008), which describes the rights has a policy related to the conduct of the surgical
of patients and others using the Australian health count, which is mandatory in public hospitals
system. These rights are essential to make sure (NSW Health, 2013). In addition, New Zealand, the
that, wherever and whenever care is provided, it is Commonwealth and all Australian states and ter-
of a high quality and safe. ritories have infection control policies that have a
TABLE 4-1: Statute Law
SUBJECT AREA AUSTRALIA NEW ZEALAND

Nursing regulation National Law 2009 Health Practitioners Competence Assurance
Act 2003
Privacy and confidentiality Privacy Act 1988 (Cth) Privacy Act 1993
Health Records and Information Privacy Act
2002 (NSW)
Health Records Act 2001 (Vic)
Information Act 2003 (NT)
Poisons and drugs Therapeutic Goods Act 1989 (Cth) Misuse of Drugs Act 1975
Health (Drugs and Poisons) Regulation
1996 (Qld)
Medicines, Poisons and Therapeutic Goods
Act 2008 (ACT)
76
significant impact on perioperative nursing prac- When entering the operating suite, patients are
tice; for example, Australian guidelines for the pre- at one of the most vulnerable periods of their hos-
vention and control of infection in healthcare (National pitalisation. They place their trust in the surgical
Health & Medical Research Council [NHMRC], team to ensure that no harm will come to them.
2010) and the Surgical Site Infection Improvement Unfortunately, sometimes incidents do occur that
Programme (Health Quality and Safety Commis- result in patients being injured. Patients who expe-
sion New Zealand, 2012). rience injury may decide to bring a civil case for
There are perioperative nursing practice stand- negligence against the health service and/or those
ards that are not mandatory; however, they can health professionals who they believe are responsi-
and have been influential when used in cases of ble. The plaintiff (or the person’s family, if the
negligence or hearings relating to professional patient has died) can allege that the patient was
practice and conduct. Both the Australian College injured as a result of the health professional’s care
of Operating Room Nurses (ACORN, 2016) and the falling below the required or accepted standard of
Perioperative Nurses College of the New Zealand care. That is, the acts (or omissions) were not those
Nurses Organisation (PNC NZNO) (2016) have expected of a reasonable health professional with
standards (howsoever titled) that have been devel- the necessary skills, knowledge, experience and
oped by specialty nurses to guide practice in peri- judgement. Nurses can and do become involved in
operative settings. Failing to adhere to these legal proceedings, resulting in their practice being
standards can have adverse consequences for examined. However, it should be noted that it is rare
patients. Additionally, such actions may result in for nurses to have an action brought against them
the practice of individual nurses being examined by directly (i.e. to be sued individually).
regulatory authorities.
VICARIOUS LIABILITY
NEGLIGENCE As the majority of nurses are employees in most
Negligence is the most widely known civil wrong jurisdictions, the doctrine of vicarious liability
or tort. Although there is no one accepted defini- is likely to apply. Vicarious liability means that
tion of negligence, the cardinal principle is that the an employer is deemed liable for the acts of its
party complaining (the plaintiff) is owed a duty of employees if an action arises while an employee is
care by the party complained of (the defendant), acting in good faith as part of his or her employ-
this duty of care has been breached and, as a con- ment. It is only when the employee is found to
sequence of that breach, the party complaining suf- be ‘on a frolic of their own’ (acting totally outside
fered damage (Staunton & Chiarella, 2013). the recognised policies and procedures of the
employer) that the doctrine will not apply (Staun-
The roles that perioperative nurses undertake ton & Chiarella, 2013).
while caring for surgical patients require diligence
and discipline because the incidence of periop
OPEN DISCLOSURE
erative-related adverse events (such as death or
serious injury) is greater than occurs in other If an adverse event results in patient harm, it is
settings. This is due to the vulnerability of indi- mandated under the National Safety and Quality
viduals undergoing surgical intervention and the Health Service (NSQHS) Standards that there is
nature of the surgical environment itself. Some an open discussion about this (the Commission,
examples of incidents that surgical patients may 2013a). The elements of open disclosure are:
experience and that could lead to adverse outcomes • an apology or expression of regret, which
include: should include the words ‘I am sorry’ or ‘we
• incorrect positioning are sorry
• inadvertently retained surgical items • a factual explanation of what happened
• lost tissue specimens • an opportunity for the patient, his or

her family and carers to relate their
• incorrect operation or operative site experience
• medication error • a discussion of the potential consequences of
• equipment failure. the adverse event
77
• an explanation of the steps being taken to Compensation Act 2001 as amended by the Injury
manage the adverse event and prevent Prevention, Rehabilitation and Compensation Act
recurrence (the Commission, 2013b). (No 2) 2005 continues to provide cover for unin-
As discussed in Chapter 3, in Australia the Com- tended injuries to patients caused by treatment
mission has published the Open disclosure frame- provided by health professionals (Manning, 2006).
work (2013b) and state/territory health departments If a negligence action against a nurse goes
have also published policies in relation to this; for before a court the patient, or plaintiff, has to prove
example, South Australia (Government of South a number of elements to establish that, on the
Australia, 2011). In New Zealand, the code of rights balance of probabilities, there was negligence on
supports the right of the consumer to open disclo- the part of the nurse. These elements include estab-
sure (New Zealand Health and Disability Commis- lishing that:
sioner, 1996a). • the nurse owed the patient a duty of care; this
PURSUING CASES OF NEGLIGENCE IN is usually unequivocal
CIVIL COURTS • there was a breach of the duty of care (i.e. the
Pursuing an action for negligence through the nurse failed to act according to accepted
courts in Australia can be a complex (and expen- practice standards; for example, National
sive) process. Legislation has now been enacted by competency standards for the registered nurse
each Australian state and territory (e.g. Civil Law (NMBA, 2010) or Standards for perioperative
Act 2002 [NSW]) in response to increased litigation nursing 2016–2017 (ACORN, 2016)
and the subsequent rise in the cost of public liabil- • there was damage to the patient; this can be
ity and medical indemnity insurance, which has physical or psychological
become unsustainable. The legislation seeks to
balance the costs involved with insurance premi- • there was a direct link between the breach of
ums, settling negligence claims and the rights of the duty of care and the damage suffered by
individuals to be compensated for harm resulting the patient (Staunton & Chiarella, 2013).
from health professionals’ negligence (Kerridge All of these elements are exemplified in the
et al., 2013; Staunton & Chiarella, 2013). Australian negligence case, Langley & Another v
The legal situation in relation to medical negli- Glandore Pty Ltd (in Liq) & Another (1997) outlined
gence is very different in New Zealand, where a ‘no in Feature box 4-2. The elements of negligence
fault’ accident compensation scheme was estab- from this case were as follows:
lished as early as 1974. Although this has evolved • The surgical team owed a duty of care to the
over time, the Injury Prevention, Rehabilitation and patient during surgery.
FEATURE BOX 4-2 » LANGLEY & ANOTHER V GLANDORE PTY LTD (IN LIQ) & ANOTHER (1997)
A patient underwent a hysterectomy in a Queensland hospital. After suffering adverse symptoms

over a period of months following the surgery, investigations revealed that a surgical sponge had
been inadvertently left in her abdomen. This was removed in a second operation 10 months after
the first procedure. The patient sued the surgeons and the hospital, as the latter was vicariously
responsible for the perioperative nurses. The judge found the surgeons negligent for leaving the
sponge inside the patient, but the nurses were found not to be negligent. The surgeons appealed
the judgement on the basis that the circulating and instrument nurses played a crucial role in
accounting for the sponges used in the procedure. At the appeal hearing, the judge agreed with
the surgeons and, in a significant judgement for perioperative nurses, made it clear that both of
the nurses were ‘primarily responsible’ for the count. Neither nurse could provide an explanation
as to how a counting error occurred or why the count sheet from the original operation was shown
to be complete (Staunton & Chiarella, 2013).
78
• The nurses breached their duty of care by consent form. For patient consent to treatment to
failing to follow accepted standards in relation be valid:
to counting. This was determined by reference • it must be freely and voluntarily given
to the ACORN (1996) Standards, Guidelines
and Policy Statements: Standard A6: Managing • the patient must be of the correct age, which
accountable items, which was current at the varies from state to state/territory and in
time of the incident. New Zealand
• The sponge left inside the patient caused • the patient must have the mental capacity to
damage, pain and suffering. understand the intended procedure
• The sponge inadvertently left inside the • the consent given and the information
patient’s abdomen was the direct cause of the documented in the consent form must relate
damage to the patient. to the procedure to be performed
Significant points highlighted by this case include • the patient must be provided with adequate
the use of the ACORN Standards in court in order information about the procedure, its benefits,
to establish the standard of care expected when side effects, complications and alternative
handling accountable items; and the point made by treatments, and have their questions answered
the judge in the appeal hearing placing ‘primary (Staunton & Chiarella, 2013).
responsibility’ for the count in the hands of the cir- The final point was significant in the case of
culating and instrument nurses. It should be noted Rogers v Whitaker (1992) 175 CLR 479, which is out-
that the count sheet produced in evidence in this lined in Feature box 4-3. In Australia this case
case was complete, with no indication of a counting established the standard of care required when
error evident. This case and others that have since doctors give information to patients about risks of
arisen (e.g. Elliot v Bickerstaff [1999]) highlight the proposed procedures.
need for vigilance when conducting and recording
It must be understood that the responsibility for
counts, and handling accountable items intraoper-
providing information about proposed surgery and
atively (Staunton & Chiarella, 2013).
for obtaining the patient’s consent remains with
the surgeon performing the procedure or a dele-
CONSENT TO TREATMENT gated (medical) deputy. However, as part of the
All adult patients undergoing surgery must under- checking procedure that the patient undergoes
stand the nature and risks of the surgery and give during their perioperative experience, the periop-
informed consent to the procedure. This is the same erative nurse reviews the consent form and asks the
for any healthcare treatment, which patients may patient to verify the surgery she or he is about to
accept or decline (Staunton & Chiarella, 2013). undergo and her or his understanding of it. The
Health department and local policies set out the perioperative nurse should be alert to any signs of
requirements for obtaining valid consent. In Aus- the patient lacking understanding of the procedure.
tralia, these are largely based on common law deci- In such a situation, the perioperative nurse has an
sions, which vary across the eight jurisdictions. In obligation to discuss this with the surgeon in charge
some cases they are also enshrined in legislation; of the patient’s care, so the latter can follow up with
for example, in New Zealand the code of rights the patient prior to surgery commencing. While
(New Zealand Health and Disability Commissioner, this situation clearly imposes a duty of care on the
1996a) enshrines patients’ rights related to con- perioperative nurse to take action, it is also an
sent, which must be fully informed and given freely. example of the perioperative nurse acting as an
As in Australia, the code is principally based on advocate for the patient. Finally, it is important to
common law judgements. note that patients may withdraw their consent to
treatment at any time without prejudice.
Although it is not the role of perioperative
nurses to obtain the patient’s consent for a surgical
intervention, nurses do have a responsibility to PATIENTS UNABLE TO GIVE CONSENT
check that patients have given consent to treat- Under common law there is a presumption that
ment and that this consent is informed. This is adults are competent to make decisions about
usually substantiated by the presence of a signed their medical treatment, including surgery. Some
79
FEATURE BOX 4-3 » ROGERS V WHITAKER (1992) 175 CLR 479
Mrs Whitaker, a woman in her 60s, was blind in her right eye following a penetrating eye injury
when she was 9 years old. Despite this, she had led a normal life, was married and had raised four
children. In 1983 she decided to re-join the workforce and went for a pre-employment health
check. Her general practitioner suggested that she consider investigating the possibility of a
corneal graft to her damaged right eye and referred her to Dr Rogers, an expert in this area. Over
the next few months, Mrs Whitaker and Dr Rogers had several consultations and treatment options
were discussed. Dr Rogers felt that surgery could significantly improve her sight and after inces-
sant questioning about the risk of complications, Mrs Whitaker agreed to undergo surgery. She
was not, however, warned of the possibility of damage to her ‘good’ eye.
Surgery proceeded uneventfully, but complications developed in the postoperative period. Sig
nificantly, the left eye (the eye that had vision) developed ‘sympathetic ophthalmia’, a serious,
although rare, inflammatory condition. Despite intensive treatment, Mrs Whitaker lost the sight in
her left eye and, unfortunately, had little improvement in her right eye. She was effectively left
blind. Mrs Whitaker sued Dr Rogers for negligence on the grounds that he had failed in his duty
of care by not warning her of the possibility of sympathetic ophthalmia. She won her case and
was awarded compensation. Dr Rogers appealed the decision against him in a case that went all
the way to the High Court of Australia. In a majority judgement, the High Court upheld the deci-
sion of the lower court and, in doing so, made several significant statements that have subsequently
influenced policy development in the area of informed consent (Staunton & Chiarella, 2013).
patients, however, may lack the intellectual capac- Property Rights Act 1988 (NZ) (Kerridge et al.,
ity to give consent to treatment because they are: 2013; Staunton & Chiarella, 2013). There is a hier-
• suffering from dementia archy of people able to give consent, ranging from
a formally appointed guardian to a spouse, close
• have sustained brain injury friend(s) or relative(s). If a patient has no family
• intellectually disabled. member or other suitable person to provide substi-
Other patients may be unconscious or in a physical tute consent, then under the guardianship jurisdic-
state that prevents them from being informed and tions, a public guardian is appointed to make
making decisions about the treatment and care decisions on behalf of the patient (Staunton &
options available to them. It is important to distin- Chiarella, 2013).
guish these situations. From a practical perspective, the issue of the
To assist patients and to help staff manage patient’s competence may not be clear. For example,
patients who lack the intellectual capacity to on arrival in the perioperative environment, a
consent there are guardianship statutes. Guardian- patient may be able to communicate personal
ship legislation contains mechanisms designed to information accurately, but otherwise demonstrate
ensure that patients’ rights to make decisions about a lack of capacity or understanding about the pro-
their treatment are supported and the best deci- posed surgery. Part of the handover procedure is
sions about their care made. This is known as sub- for the perioperative nurse to check the relevant
stitute consent, whereby consent to treatment is consent documentation and, if necessary, seek
made by a designated ‘person responsible’. Each advice from a senior colleague about any issues
jurisdiction in Australia and New Zealand has leg- relating to substitute consent. This should ensure
islation setting out provisions for appointing a that the patient’s rights to appropriate decision-
formal guardian and the scope of his or her deci- making processes are being upheld.
sion-making powers. Examples of legislation Patients may also make their wishes for treat-
include the Guardianship & Administration Act ment known through an advance health directive
2000 (Qld) and the Protection of Personal and (AHD), which becomes effective only when the
80
FEATURE BOX 4-4 » ADVANCE HEALTH DIRECTIVES AND

PERIOPERATIVE CONSIDERATIONS
In Australia and New Zealand advance health directives (sometimes called living wills) are avail-
able to assist patients who, in anticipation of future illness (e.g. dementia), may lose their capacity
to provide informed consent to medical or other healthcare and treatment. The person making
the AHD must have the capacity to understand the effects and implications of the AHD and comply
with formalities, which vary between states and territories in Australia and in New Zealand, in
order for the AHD to become legally binding (Copley, 2013; Ministry of Health NZ, 2011). Commonly,
AHDs spell out treatments that patients do not desire (e.g. active resuscitation measures) as well
as those they find acceptable. As long as health professionals are appraised of the existence of a
patient’s AHD, they are obliged to adhere to its provisions during a patient’s hospitalisation (Copley,
2013; Ministry of Health NZ, 2011).
individual loses the capacity to make those choices and Contract) Act 1970 (NSW). In certain situations
themselves (Copley, 2013) (see Feature box 4-4). conflict may arise between children and their
AHDs can pose a dilemma for healthcare personnel parents in relation to giving consent to a medical
when patients who have elected not to be resusci- procedure. Ideally, there should be discussion and
tated in the event of a cardiac arrest are scheduled agreement on treatment options between the child,
for a surgical procedure. For example, terminally ill the parents and the treating medical practitioner.
patients may require a palliative procedure such The NSW Law Reform Commission has stated, ‘a
as insertion of an access device for pain relief. An prudent doctor would be unlikely to continue to
AHD stating ‘not for resuscitation’ should not auto- treat a child or young person when he or she became
matically remain active in this instance; instead, aware that the medical treatment was against the
the surgical team should discuss with the patient wishes of one of the parents’ (2008, p. 142). In these
whether he or she wishes to suspend the AHD circumstances, relevant courts or authorities such
during the perioperative period, so that, if need be, as the NSW Family Court or government depart-
active resuscitation can be instigated. The result ments can be called upon for assistance to resolve
of this discussion should be clearly documented in conflict over treatment or to make a determination
the patient’s notes. Additionally, the surgical team (Staunton & Chiarella, 2013). In emergency situa-
must ensure that all perioperative staff involved in tions requiring lifesaving intervention, doctors can
the patient’s care are informed of the patient’s override any parental objections and carry out
wishes prior to the latter’s admission into the oper- treatment.
ating suite (Murphy, 2015).
CONSENT AND MENTAL ILLNESS
CONSENT AND MINORS Consent for treatment from patients who are
In Australia a person is deemed an adult at the age deemed mentally ill is managed under relevant
of 18 years and thereafter legally empowered to mental health legislation; for example, Mental
give (or withhold) consent to treatment. In the case Health Act 1996 (WA), Mental Health (Compulsory
of children (minors), the age they can give consent Assessment and Treatment) Act 1992 (NZ). Patients
to medical treatment varies by jurisdiction. For can voluntarily present themselves for treatment
example, in South Australia and New Zealand, a and they retain the same rights as others. In con-
person over the age of 16 years can consent to their trast, patients who threaten suicide or present as a
own medical treatment under the Consent to serious threat to themselves or others may be
Medical Treatment and Palliative Care Act 1995 involuntarily admitted for care and treatment. This
(SA) and the Care of Children Act 2004 (NZ), respec- may include, for example, the administration of
tively. In New South Wales, a person over the age medication, surgery or electroconvulsive therapy
14 years can consent to medical or dental pro (ECT). However, such treatments must be under-
cedures, as described under the Minors (Property taken in accordance with the requirements of the
81
relevant mental health legislation, because to that they are a Jehovah’s Witness. Such cards should
apprehend, detain and treat a person otherwise is indicate which alternative blood products they will
not legitimate (Kerridge et al., 2013). ECT is care- accept and their wishes are sacrosanct. If no notifi-
fully regulated and requires the voluntary patient cation exists, medical staff are entitled to proceed
to give informed consent. For patients admitted as they would with any other patient and provide
involuntarily, the treatment must be approved by a appropriate life saving treatment, including blood
mental health tribunal, which also determines the transfusion (Kerridge et al., 2013).
number of ECT treatments to be given. When the The care of children of Jehovah’s Witnesses who
prescribed number have been given, a further require blood transfusion is managed via statutory
review is required before any additional course of provisions, which permit blood to be administered
ECT can be administered (Kerridge et al., 2013). without parental consent if necessary. These provi-
Patients with mental illness can prove challeng- sions also allow parental non-consent to blood
ing when admitted into the perioperative environ- transfusion to be overridden; for example, section
ment. Some patients may be accompanied by 3 of the Transplantation and Anatomy Act 1979
specialist mental health nurses and possibly secu- (Qld) and the Care of Children Act 2004 (NZ).
rity personnel to ensure the safety of the patient Parents can challenge these decisions through the
and perioperative staff. They require sympathetic courts and the outcomes are based on what is
management with careful attention paid to ensur- deemed to be best for the child (Staunton & Chi-
ing a legitimate consent process has occurred and arella, 2013). The New Zealand case in Feature box
that the consent forms and other administrative 4-5 illustrates this final point.
documentation related to mental health protocols The management of patients who are Jehovah’s
are complete. Witnesses and the education of staff who care for
them has been assisted by the Jehovah’s Witness
CONSENT AND BLOOD TRANSFUSIONS governing body publishing practical guides and
Situations may arise when an adult patient refuses setting up liaison committees within many health-
a blood transfusion on religious grounds (e.g. care facilities (Kerridge et al., 2013).
Jehovah’s Witness) or for other reasons. Adult
patients have the right to refuse any treatment, CULTURE, RELIGION AND SURGERY
including blood transfusions; however, they must Australia and New Zealand are home to millions of
be given a full explanation about the risks and residents who have arrived from other countries.
alternatives should they do so. In the perioperative Respect for and sensitivity to varying religious and
environment refusal of blood products can some- cultural beliefs during hospitalisation must be
times lead to confusion and conflict among staff demonstrated by healthcare staff and, if necessary,
who do not share the same beliefs as the patient. guidance sought from relevant hospital depart-
Health professionals cannot override an adult ments. For example, both male and female patients
patient’s wishes to refuse blood transfusion, except of the Jewish, Muslim and Hindu faiths generally
by seeking legal intervention, because to do so prefer to be examined by healthcare providers of
without court sanction could expose them to actions the same sex where possible. Female patients in
in assault and battery (Kerridge et al., 2013). From particular require sensitivity in relation to modesty
a practical perspective, Jehovah’s Witnesses admit- concerns. Patients may also wear religious artefacts
ted for elective surgery have usually made their that need to be removed if they interfere with access
wishes clear preoperatively and have had the oppor- to operative site; for example, Hindu women may
tunity to discuss options for substitute intravenous wear a sacred thread, a ring or a gold chain around
products with medical staff. Advances in surgical their neck; while men may wear a sacred thread
techniques and in the development of alternative across their chest. However, before these items can
blood products have resulted in the availability of be removed, permission must be sought from either
a range of alternative measures for patients who do the patient or a relative (Queensland Health, 2011).
not want to receive blood. In Māori culture, all body parts are highly
When patients are admitted to hospital uncon- revered and are either disposed of according to
scious, their wishes may not be known unless they tikanga (traditional customs and beliefs) or returned
are carrying a ‘medical directive’ card indicating to the patient and/or the whānau (extended family).
82
FEATURE BOX 4-5 » RELIGION VS SCIENCE
A 10-month-old baby diagnosed with stage 4 cancer was placed under the care of the New Zealand
High Court after her parents refused to consent for her to have blood transfusions to treat her
cancer. In August, doctors found a large tumour in the right side of the baby’s chest. They indicated
that the tumour was cancer and told the parents the cancer was in her bones but if she was
treated with blood transfusions, it was likely she would have a 90% chance of survival. However,
if the baby did not receive the blood transfusion, life-threatening complications could occur.
Her parents would not agree to their child having a blood transfusion because they are Jehovah’s
Witnesses, but they did agree to the administration of chemotherapy and surgery for removal of
the tumour. Consequently, the New Zealand High Court granted the application of the Auckland
District Board to place the baby under its guardianship for 9 months, allowing the baby to receive
the blood transfusions she needed. The baby was given an urgent blood transfusion when doctors
performed a biopsy on her tumour.
Justice Helen Winkelman of the New Zealand High Court appointed the baby’s parents as general
agents of the court. This meant that they were still to care for the child except when it came to
the administration of blood. Justice Winkelman said it was important for the parents to continue
supporting their child. She hoped the court order would relieve them of their religious dilemma.
Doctors were appointed as the agents for the administration of blood.
SOURCE: REISSA (2013).
The code of rights and Māori concepts of health these Acts, the coroner must hold inquests into
code set out specific rights in respect to the removal deaths that occur under certain circumstances. It is
and use of an individual’s body parts and bodily beyond the scope of this text to discuss these in
substances. Perioperative nurses should observe detail; however, one circumstance that has direct
these cultural beliefs when disposing of resected implications for perioperative nurses is the death
organs or tissues (New Zealand Health and Disabil- of a patient who has ‘died during the process or as
ity Commissioner, 1996b). a result of being administered anaesthetic’ and
where the person’s death ‘was not the reasonably
CORONERS’ COURTS expected outcome of a health-related procedure
Although the outcome of the vast majority of surgi- carried out in relation to a person’. A health-related
cal cases is positive, occasionally patients die on procedure includes ‘medical, surgical and dental
the operating table. This is a devastating event for procedures including the administration of an
all concerned. As well as the emotional aftermath, anaesthetic, sedative or other drug’ (Coroners’ Act
there are specific legal requirements to be adhered 2009 [NSW]).
to and these fall within the jurisdiction of the When a patient dies while under, as a result of,
coroner. The role of the coroner and the coroners’ or within 24 hours after the administration of an
courts in Australia and New Zealand has been anaesthetic or sedative drug for a medical, surgical
inherited from English common law, where they or dental operation or procedure, the NSW Public
have existed for hundreds of years. The main role Health Act 2010 requires the health practitioner
of the coroner is to detect unlawful homicides and responsible for administering the anaesthetic or
investigate deaths that have occurred in unusual, sedative drug to attend the Special Committee
unexpected, violent or unnatural circumstances to Investigating Deaths Under Anaesthesia (SCIDUA).
ensure that there was no foul play (Staunton & This is an expert committee established under
Chiarella, 2013). Each Australian state/territory has Section 20 of the NSW Health Administration Act
a Coroners’ Act and in New Zealand there is the 1982. It has a national focus and is represented
Coroners Act 2006 (currently under review). Under by anaesthetists from a broad range of clinical
83
specialties and professional organisations (Clinical care provided. When care is delivered, but not docu-
Excellence Commission [CEC], 2015). mented, it may be inferred that it was not provided
Although responsibility for the documentation to the patient (ACORN, 2016). Documentation is
related to the death of a patient on the operating therefore an integral part of the role of the periop-
table rests with the surgeon and the anaesthetist, erative nurse, whether it is completing patients’
perioperative nurses must be aware of the require- records about care and treatment provided, docu-
ments related to the care of the patient after death. menting the facts of an incident in the workplace
Essentially, these are that the patient’s body should or providing a statement for a coronial inquiry or
be undisturbed until a post-mortem examination disciplinary hearing. The same principles of good
has been completed (i.e. it should not be washed; documentation apply regardless of the context.
and all drains, cannulae, airways, catheters and These principles are that documentation should be:
other such items should be left in place). Accesso- • accurate and factual
ries such as drip bags, bottles, feed lines and cath- • contemporaneous
eter bags should accompany the patient’s body to
the morgue. The patient’s clothing or belongings • based on evidence and observation
may also be required for forensic examination (and • descriptive of care provided and actions taken
must not be returned to the family). Local policies (Staunton & Chiarella, 2013).
provide guidance on the correct handling of these Within the perioperative environment docu-
items, as well as the patient’s body (e.g. NSW mentation includes, for example, anaesthetic
Health, 2010). records, fluid balance charts, the ‘count sheet’, the
Nurses may be called as witnesses in the coro- WHO Surgical Safety Checklist, perioperative
ners’ court if they were present at the time of the nursing care record, patient observation/assess-
patient’s death and can provide information that ment charts used in the postanaesthesia care unit,
may assist the coroner. It is important for nurses to surgeons’ notes, and radiology and pathology
be fully aware of their rights and obligations to the requests and associated reports. The majority of
court and they should be provided with legal advice perioperative nursing documentation is electronic,
by their hospital or professional organisation to with real-time data entry completed mostly by the
support them in these matters. circulating nurse. Examples of information cap-
tured electronically include:
As well as handing down findings as to the
manner and cause of death, the coroner may make • patient positioning and positional aids used
comments critical of the treatment and care the • placement of electrosurgery dispersive
patient received and make recommendations for electrode (diathermy plate or mat)
improvements. The coroner can also make com-
• solutions used for skin preparation
ments critical of the actions of the personnel
(e.g. chlorhexidine solution or povidone
involved in the patient’s care. This may give rise to
iodine solution)
disciplinary action being brought against a nurse by
the appropriate regulatory agency. Should there be • specimens taken
any doubt about the circumstances surrounding the • placement of drains and/or catheters
manner of a patient’s death and/or nurses’ actions, • patient’s skin condition (before and after
it is important that the latter are aware of their surgery)
rights. Until legal advice has been obtained, nurses
can refuse to answer questions or give a statement • pressure injury prevention measures utilised.
if approached by a police officer assisting the Even though most perioperative records are
coroner. While this may appear overcautious, it is electronic, the ‘count sheet’ and the perioperative
prudent for the nurse to obtain legal advice when nursing care record are likely to remain paper-
writing statements and preparing to appear in court based for practical reasons (see the sample periop-
(Staunton & Chiarella, 2013). erative nursing care record in Chapter 9). The
documented information gives a clear picture of the
DOCUMENTATION intraoperative nursing care the patient received,
Accurate records contribute to optimal patient care ensures continuity of care and provides handover
and provide evidence of the standard of nursing information.
84
ELECTRONIC HEALTH RECORD In addition, it is important to check that the correct

The advent of the electronic health record (EHR) medical record has been opened to avoid data being
has the potential to provide all nurses with a better entered for the wrong patient (South Eastern
medium to outline the care they deliver and its Sydney Local Health District, 2012).
effectiveness in a transparent format that can be In addition, vigilance is required by all periop-
understood by those outside nursing (Staunton & erative staff to ensure that documentation is com-
Chiarella, 2013). Many countries, including Aus- pleted, closed and/or removed from the operating
tralia and New Zealand, have adopted the EHR as a room on completion of a procedure and prior to the
means of facilitating an efficient flow of informa- next patient entering. For example, patient address
tion related to patient care across hospital depart- labels from a previous patient have the potential to
ments, at a local level, and across state and national be used on a subsequent patient’s records or speci-
boundaries (Staunton & Chiarella, 2013). This has mens, with the possibility of serious consequences.
the potential to benefit the continuity of patient (The correct handling and labelling of specimens is
care, particularly in populations where people addressed in Chapter 9.)
travel or move around for work or family reasons.
There are many advantages to maintaining an REGULATORY ACTION AND
electronic record. For example, they do not require
the reader to decipher handwriting, thus reducing
DISCIPLINARY HEARINGS
the risk of misunderstandings and thereby provid- NOTIFICATIONS AND COMPLAINTS
ing a safer method of communication. However, the All registered health practitioners have a profes-
EHR requires computer literacy to enable data sional and ethical obligation to protect and promote
entry. A number of hospitals have introduced cus- public health and safe healthcare. Protection of the
tomised software that enables the capture of spe- community means that people (including other
cific patient information by those involved in the health professionals) have a right (and in some
patient’s care. Electronic record keeping can be a instances a duty) to notify the relevant health pro-
fast and efficient method of documenting care, as fessional registration authority if they have con-
well as allowing hospitals to generate data that can cerns about:
assist with allocating resources, monitoring patient
• a health practitioner’s conduct if it appears in
care and demonstrating the attainment of key per-
some way to be putting members of the
formance indicators. However, staff do need to pri-
community at risk
oritise their workloads to ensure that patient care
is not compromised by data entry occurring at • the health of a health practitioner if it affects
times when patient care activities are required her or his ability to practise safely
(Read-Brown et al., 2013). Despite the technical • the clinical competence or performance of a
advances now seen in most operating rooms, issues health practitioner (AHPRA, 2013).
related to privacy and patient confidentiality, as
well as to the secure transmission of data, remain. MANDATORY NOTIFICATIONS
Health professionals are accountable for all In Australia under the National Law (2009) health
documentation that is completed, whether it is practitioners, employers and education providers
electronic or paper-based (Kerridge et al., 2013). also have some mandatory reporting responsibili-
Staff are assigned unique log-in details to access ties. These are outlined on the AHPRA and NMBA
the computer system and it is important that care websites. However, notifications and complaints are
providers use their own username and password managed differently in New South Wales and
when completing data entry. Electronic records can Queensland, with state legislation working along-
be erroneous if staff are not vigilant in logging out side the National Law in a co-regulatory way. In
on completion of data entry (e.g. when leaving the New South Wales, the Nursing and Midwifery
operating room for breaks or going off duty). Council (NMC) carries out its regulatory functions
Without logging off from the computer, data can be in conjunction with the Health Care Complaints
entered by other staff members and so be wrongly Commission (HCCC) established under the Health
attributed, with possible repercussions if such Care Complaints Act (NSW) 1993. The Queensland
records are used in legal or professional hearings. Nursing Council has a similar relationship with the
85
Office of the Health Ombudsman established under PERFORMANCE

the Health Ombudsman Act (Qld) 2013. A common category of complaint received in all
In New Zealand, all complaints received by the jurisdictions relates to nurses’ performance. For
Nursing Council alleging that the practice or example, in New South Wales in 2014, 45% of the
conduct of a nurse has affected a health consumer complaints received by the NMC NSW fell into the
must be referred to the Health and Disability Com- performance category. A non-disciplinary pathway
missioner (the Commissioner). The Commissioner is used to manage issues that relate to the standard
determines jurisdiction in respect of the matter of nurses’ clinical performance and whether their
and/or whether the Commission will investigate the performance has fallen significantly below the
complaint. The Health Practitioners Competence standard reasonably expected, given the individual
Assurance Act 2003 requires court registrars to send nurse’s level of training or experience. In managing
a notice of conviction to the Nursing Council for a performance issues, the nurse may be required to
nurse convicted of an offence as stated in the Act. undertake a performance assessment. This may
take place in the nurse’s own workplace or in a
ASSESSMENT OF COMPLAINTS simulated environment. Appropriately trained
AND NOTIFICATIONS assessors appointed by the NMC NSW undertake
As identified in Chapter 1, the nursing and mid- the assessment. If the assessment is unsatisfactory,
wifery councils in each state and territory of Aus- the nurse may be referred to the Performance
tralia and the Commissioner in New Zealand have Review Panel (PRP), whose procedures are addressed
specific pathways to manage complaints about per- later in the chapter. The decisions made by the
formance, conduct and health matters concerning PRP will depend on deficiencies noted during the
practising nurses (and midwives—while acknowl- performance assessment, but remediation could
edging that the information in this chapter also include ‘attending courses, undertaking supervi-
refers to midwives, only nurses are referenced to sion or engaging in additional continuing profes-
simplify the text). Table 4-2 shows the number and sional development’ (NMC NSW, 2014, p. 15).
types of decisions made by panels set up by the Conditions may also be placed on the nurse to
NMBA in Australia. protect the public while remediation is taking place
(NMC NSW, 2014).
The Nursing Council of New Zealand (NCNZ)
publishes detailed data in relation to the conduct, CONDUCT
health and competence of nurses and this is avail- Complaints related to conduct fall into two
able in the current annual report on its website categories:
(www.nursingcouncil.org.nz).
• Unprofessional conduct of a registered
health practitioner means professional
conduct that is of a lesser standard than
that which might reasonably be expected
TABLE 4-2: Panel Decisions of Nursing Boards in of the health practitioner by the public or
Australia, 2014 the practitioner’s professional peers
(AHPRA, 2009).
PANEL FINDINGS RELATING TO: NUMBER
• Professional misconduct of a registered
Professional conduct 7 health practitioner is the more serious of the
two categories and relates to unprofessional
Professional performance 6
conduct by the practitioner that amounts to
Health 2 conduct that is substantially below the
standard reasonably expected of a registered
Professional performance and health 1
health practitioner of an equivalent level of
No case to answer 2 training or experience. Complaints that are
substantiated can result in the suspension or
TOTAL 18
cancellation of the practitioner’s licence to
SOURCE: ADAPTED FROM AHPRA (2015). practise (AHPRA, 2009).
86
FEATURE BOX 4-6 » NZHPDT PROFESSIONAL MISCONDUCT CASE
The NZHPDT found a special clinical nurse in a rheumatology unit guilty of professional miscon-
duct. It was demonstrated that the nurse had compromised patient safety by failing to document
consultations with patients on 109 occasions in relation to 79 patients. It was also proven that
she compromised, or potentially compromised, the safety of a patient by failing to notify a medical
practitioner when the patient told her of symptoms consistent with adverse side effects of a medi-
cation the patient was taking. The nurse was censured and suspended for a period of 9 months. In
addition, on resumption of practice, a range of conditions were imposed on her practice, including
attending a course on legal and professional obligations of documentation. She also had to undergo
a period of supervision in relation to communication and documentation (NZHPDT, 2013).
Conduct issues are generally related to behav- Table 4-3 lists situations where the NMBA may
ioural acts or omissions. Following investigation of take immediate action. This is a serious step and is
a complaint, action may be taken by a professional not taken lightly—the threshold is necessarily high.
standards committee or tribunal, depending on To take immediate action the NMBA must reason-
the seriousness of the complaint (AHPRA, 2009). ably believe that:
Feature box 4-6 presents the outcomes of the New • because of his or her conduct, performance or
Zealand Health Practitioners Disciplinary Tribunal health, the nurse poses a ‘serious risk to
(NZHPDT) in relation to a case of professional persons’ and that it is necessary to take
misconduct. immediate action to protect public health or
safety or
HEALTH MATTERS
• the nurse’s registration was improperly
Complaints about health matters concerning
obtained or
nurses relate to physical or cognitive impairment,
substance abuse and/or mental illness. A non- • the nurse’s registration was cancelled or
disciplinary impaired registrants panel (IRP) may suspended in another jurisdiction (AHPRA,
be established to assess the physical or mental 2009).
impairment of the nurse and determine a course An example of a matter relating to a registered
of action. This may result in assisting impaired nurse where the NMBA took immediate action and
nurses to manage their condition while they remain placed conditions on the nurse’s practice while a
employed or there may be a recommendation to full assessment and investigation were conducted
make their registration conditional; for example, is outlined in Feature box 4-7.
suspension (AHPRA, 2013, p. 18).
INVESTIGATION
IMMEDIATE ACTION
In jurisdictions in Australia if the investigation of
The NMBA and the NCNZ have the power to take complaints is not conducted by an independent
immediate action to suspend or place conditions agency with co-regulatory responsibilities under
upon the practice of a nurse if they are provided the National Law (the HCCC in New South Wales
with information that the conduct, health or per- and the Office of Health Ombudsmen in Queens-
formance of the nurse is likely to pose a serious risk land), the NMBA may decide to investigate a nurse
to the community (AHPRA, 2009). (The NMBA can if it believes that:
also accept an undertaking from a nurse and the
surrender of her or his registration.) This is only an • the nurse has, or may have, an impairment
interim step while a complete investigation takes and/or
place and other action may occur after a formal • the way the nurse practises is, or may be,
hearing by a committee, panel or tribunal. unsatisfactory and/or
87
TABLE 4-3: Matters the NMBA May Consider Require Immediate Action
CATEGORY EXAMPLE
Police charges Offences relating to a health practitioner’s work or professional practice (e.g. assaulting a patient)
Patient outcome A patient dies unexpectedly or a routine operation has severe adverse outcomes
Drugs Notified by a practitioner or an independent body; includes accusations of self-administering and

inappropriate prescribing of illicit or prescription drugs
Alcohol Allegations of presenting to work under the influence of alcohol
Sexual behaviour Inappropriate touching or professional/sexual boundary violation
Theft Stealing drugs from the workplace
Health Impairments (e.g. involuntary admission to hospital under the Mental Health Act) or concerns
about memory/behaviour
Breach of A practitioner has conditions on their registration and the conduct/incident described may breach
conditions registration conditions
SOURCE: AHPRA (2013).
FEATURE BOX 4-7 » IMMEDIATE ACTION IN A PROFESSIONAL MISCONDUCT CASE
Between 2009 and 2010, RN S was working as a registered nurse in a specialist paediatric hospital.
During that time the performance of RN S was assessed on five occasions by her employer because
of serious concerns relating to the knowledge, skill, judgement possessed or care exercised in her
practice of nursing. During these assessments various failings were identified in relation to her
administration of medication, communication skills, making and recording adequate observations,
and response to emergency situations.
On 6 May 2010, the Nurses and Midwives Board (NSW) placed immediate conditions on RN S’s
practice, prohibiting her from administering or checking medications and requiring her to advise
all nursing employers of the conditions. These conditions had been modified to apply only to
administering medications to paediatric patients and advising employers accordingly.
At the Tribunal hearing, the Tribunal was satisfied that there had been repeated near-miss medica-
tion errors by RN S throughout her employment as well as actual medication errors on some
occasions. This led to findings being made against RN S of unsatisfactory professional conduct
and professional misconduct (under the National Law) on the basis of competence issues and
medication errors. The orders of the Tribunal were that the registration of RN S was to be cancelled
and she was disqualified from seeking review of the cancellation for 1 year. Costs were awarded
against RN S (HCCC v Santos [2012]).
• the nurse’s conduct is, or may be, comply with nationally consistent policies and pro-
unsatisfactory (AHPRA, 2009). cedures. It usually involves the investigator seeking
extra information to inform the NMBA’s decision.
An investigator appointed by the NMBA conducts An investigation will also consider whether a nurse
the investigation and the process depends on the has complied with the NMBA’s registration stand-
facts of the case. However, the investigation must ards, codes and guidelines (NMBA, 2013c).
88
It is usual for nurses being investigated to be identifying information about the nurse is made by
given notice of the investigation as well as informa- the tribunal (AHPRA, 2014a). The tribunal may also
tion about what is being investigated. It is also have a role in establishing a nurse’s fitness to prac-
usual for nurses under investigation to be provided tise after a period of cancellation or suspension.
with regular updates on the progress of the inves- Serious criminal matters involving the conduct
tigation. The only exceptions to this are when there of a nurse are often dealt with in two legal jurisdic-
is a reasonable belief that informing the nurse may: tions: the criminal justice system and the health
• seriously prejudice the investigation professional regulatory system.
• place someone’s health or safety at risk or
APPEALS
• place someone at risk of harassment or Nurses can appeal a decision made against them to
intimidation (AHPRA, 2013). the relevant tribunal; for example, in relation to
These processes are very similar to the require- reprimand, suspension or cancellation of registra-
ments under the New Zealand legislation (Health tion, or conditions placed upon practice (AHPRA,
Practitioners Competence Assurance Act (NZ) 2003 2014a).
and Health and Disability Commissioner Act (NZ)
1994). MONITORING AND COMPLIANCE
In Australia AHPRA monitors those nurses who
PANEL AND COMMITTEE HEARINGS have restrictions placed on their registration, to
Under the National Law, the NMBA has the power make sure that they are complying with them
to establish two types of panel: (AHPRA, 2014a). In New Zealand this monitoring
and compliance role is undertaken by the NCNZ
• health panels for health matters if it believes
(2012).
that a nurse has a physical or mental
impairment
• performance and professional standards panels
CONFIDENTIALITY AND PRIVACY
for conduct and performance matters (AHPRA, The legal obligations of privacy and confidential-
2009). ity necessarily arise when creating, managing or
Similar legislative provisions exist in New Zealand using healthcare records. However, these two areas
and various policies and procedures have been deal with matters that are broader than healthcare
established by the NCNZ (2012). records as they extend to include relationships,
trust and having adequate information to provide
safe, competent care to patients while ensuring
TRIBUNAL HEARINGS
that their dignity and integrity is maintained. Fur-
The NMBA can refer a matter to a tribunal for thermore, personal information is available only to
hearing. This happens only when the allegations those who have a legitimate right to access it.
involve professional misconduct and when the
NMBA believes that suspension or cancellation of The terms confidentiality and privacy are often
the nurse’s registration may be warranted. Under used interchangeably and, while related, each has a
the National Law, the NMBA must refer a matter distinct and distinguishable meaning. ‘Privacy
about a nurse to a tribunal if it reasonably believes refers to one’s ownership of one’s body or informa-
that the nurse has behaved in a way that constitutes tion about one’s self’, whereas ‘confidentiality
professional misconduct. Nurses referred to a tribu- refers specifically to restrictions upon private infor-
nal are urged to seek legal advice and representa- mation revealed in confidence where there is an
tion as the tribunal procedures are formal and the explicit or implicit assumption that the informa-
consequences may have long-term impacts on a tion shared will not be disclosed to others’ (Ker-
nurse’s career, life and livelihood (AHPRA, 2014a). ridge et al., 2013, p. 298).
The NMBA is responsible for implementing the In relation to privacy, the Privacy Act 1988 (Cth)
decisions of tribunals, such as removing a nurse’s regulates the handling of personal information by
name from the Register when his or her registration Australian government agencies and some private
has been cancelled. By law, tribunal proceedings are sector organisations. State and territory legislation
open to the public. Any decision made to suppress also places similar obligations on agencies and
89
organisations, including private hospitals and health professionals accessing it. However, there
health services. This applies to any sensitive infor- continues to be an obligation that this information
mation and certainly applies to patient healthcare is not accessed or shared outside the clinical team
records and health information. In New Zealand the who have a ‘need-to-know’ for the purposes of pro-
Privacy Act 1993 controls how agencies collect, use, viding safe, effective care. Patients would not tell
disclose, store and give access to personal informa- healthcare professionals their most intimate and
tion. The privacy codes of practice do the same, but private details or consent to them having access to
they apply to specific areas; namely, health, tele- it if they did not expect that information to be
communications and credit reporting (New Zealand treated in the strictest confidence. When nurses
Privacy Commissioner, 1996). need to share personal information that patients
Privacy also relates to people’s expectations and have disclosed to them in confidence—for example,
right to be treated with dignity and respect. Effec- with other healthcare professionals—they are
tive nurse–patient relationships are built on respect obliged to seek the patient’s permission to do so
and trust (NCNZ, 2012) and the provision of treat- first. Similarly, when another healthcare profes-
ment and care always involves some invasion of sional reveals information about a patient to the
privacy (Kerridge et al., 2013). In operating rooms nurse, the nurse must always treat the information
the clinical team transfer patients who are clad only as confidential unless advised otherwise.
in a gown from trolley to operating table, place These principles are distilled in the codes of
them in undignified positions and perform intimate professional conduct for nurses in Australia and
procedures such as urinary catheterisation. These New Zealand. For example, the code of professional
patients may be conscious, but often they are conduct for nurses in Australia notes that nurses
sedated or unconscious; either way, the potential have ethical and legal obligations to protect the
for loss of dignity is great. It is important for peri- privacy of patients receiving treatment and care.
operative nurses to remember that they have legal Information obtained in the course of the relation-
and ethical obligations and maintaining the dignity ship between nurses and patients must be kept
of the patients they care for is an aspect of those confidential and restricted to use for professional
obligations. purposes only (NMBA, 2013a, 2013b). In New
Providing perioperative nursing care necessar- Zealand, the code of conduct exhorts nurses to use
ily means that patients are subject to breaches of their professional judgement to ensure that con-
their privacy and confidence. Taking health and cerns about privacy do not compromise the infor-
social histories from patients to enable the provi- mation they give to health consumers or their
sion of informed care often means that health pro- involvement in care planning (NCNZ, 2012).
fessionals are in possession of information that
they may share with other health professionals; BREACHES OF CONFIDENCE AND PRIVACY
this could be information that patients may not There are some exceptions when healthcare profes-
even share with their own family. Information that sionals are required to disclose what otherwise
must remain confidential not only includes infor- might be confidential, highly sensitive information.
mation the patient shares with health profession- For example, in cases of child abuse, notifiable dis-
als, it also covers information arising from clinical eases or professional misconduct by health profes-
assessment of the patient’s physical and mental sionals, legislation requires mandatory reporting
health; imaging and other investigations; and pro- by health professionals to authorities to protect
cedures. Even the fact that the person has been a individuals or populations from harm. The protec-
patient of a health service is information that tion of authorised persons who make disclosures
nurses must not divulge unless the patient has con- under such legislation is usually dealt with as pro-
sented to share it. tection from prosecution under the general common
It is recognised that it is ‘difficult to maintain law and legislation; for example, under the Public
confidentiality in a health-care system that is Health and Wellbeing Act 2008 (Vic).
increasingly team-oriented, fragmented and Except in legitimate circumstances such as
complex’ (Kerridge et al., 2013, p. 299) and where those outlined above, nurses need to remain vigi-
information is stored both electronically and paper- lant about the potential for breaching the confiden-
based in multiple sites, often distant from the tiality of people in their care. Gossiping in the
90
FEATURE BOX 4-8 » HCCC V BURGGRAAFF [2012]
In the case of HCCC v Burggraaff [2012] heard before the tribunal in New South Wales, a complaint
was made about a registered nurse who, without authorisation, accessed medical records for
reasons other than for the provision of clinical care or carrying out his role in providing health
services to patients across a number of health services. It was alleged that this access was in
breach of the NSW Health Code of Conduct (2012), the Privacy and Personal Information Protection
Act 1998 (NSW) and the Health Records and Information Privacy Act 2002 (NSW). The tribunal
found that the complaints of unsatisfactory professional conduct and professional misconduct
were proven and went on to make protective orders against the nurse. The nurse had conditions
placed upon his practice and received a reprimand. The tribunal also made an order for costs to
be paid by the nurse.
operating suite tearoom about ‘interesting patients’ or is limited to a specific group, health profession-
or ‘amusing moments’, or sharing these on social als need to be aware of the implications of using
media, may seem reasonable, but they are explicit social media. This is because information circulated
breaches of privacy. They could lead to nurses on social media may end up in the public domain
having a complaint made about their conduct under and remain there, irrespective of the intent at the
the National Law or being dealt with in the court time of posting (AHPRA, 2014b).
system for a breach of confidentiality or privacy.
This is highlighted in the 2012 NSW tribunal MISUSE OF SOCIAL MEDIA
hearing outlined in Feature box 4-8. Examples of how social media can be misused with
possible breaches of patient confidentiality and
SOCIAL MEDIA privacy include:
Social media is defined as follows: • pursuing relationships with patients via social
networks (e.g. befriending patients on
The online and mobile tools that people use Facebook)
to share opinions, information, experiences,
images, and video or audio clips and includes • discussing patients
websites and applications used for social • posting photographs of procedures, specimens,
networking. Common sources of social media case studies, patients or other sensitive
include, but are not limited to, social network- material that may enable people to be
ing sites such as Facebook and LinkedIn, identified, without first having obtained
blogs (personal, professional and those pub- consent.
lished anonymously), Word of Mouth Online Health professionals must be aware that such
(WOMO), True Local and microblogs such actions are all possible breaches of the obligations
as Twitter, content-sharing websites such as imposed on them through specific regulatory poli-
YouTube and Instagram, and discussion cies or common law (AHPRA, 2014b). For example,
forums and message boards (AHPRA, 2014b, in the UK a nurse was dismissed from Nottingham
p. 4). University Hospitals Trust for posting a picture of
The use of social media has provided global oppor- a patient on Facebook. This was one of 29 incidents
tunities to share information, form friendships, reported whereby patient privacy was breached
locate school friends and a myriad of other positive during a three-year period from 2008 to 2011 (‘Not-
social interactions. However, with such a form of tingham nurse sacked over Facebook photo’, 2011).
communication comes the responsibility to act In another UK-based incident, in 2009 seven emer-
appropriately while using it, particularly as a gency department staff were suspended pending
member of the nursing profession. Whether an disciplinary hearings after posting images of
online activity can be viewed by the general public themselves on Facebook taking part in the ‘Lying
91
FEATURE BOX 4-9 » UNPROFESSIONAL CONDUCT AND FACEBOOK
In a 2013 decision by the NMBA, a Northern Territory nurse was found guilty of unprofessional
conduct and reprimanded. The nurse was found to have acted aggressively towards a patient with
disabilities and subsequently published details of the incident on her Facebook page. In addition
to a reprimand, conditions were placed on her practice for a period of one year, including counsel-
ling by a psychologist and attendance at an NMBA-approved program on legal and ethical nursing
practice (NMBA, 2013c).
down game’. This ‘game’ involved them lying face instances consent to take photographs should be
down on resuscitation trolleys, hospital ward floors sought from the patient, even if the patient cannot
and an air ambulance helipad. These actions were be identified in them (Burns & Belton, 2013).
deemed to constitute unprofessional conduct Similarly, the partners of patients undergoing a
(‘Lying down NHS staff suspended’, 2009). caesarean section may be eager to capture the
Publishing complaints against colleagues about moment of the baby’s birth, believing this to be a
working conditions or whistleblowing using social reasonable and accepted practice. However, if the
media also constitute inappropriate use of social photograph includes nursing or medical staff, their
media. An Australian example of the misuse of permission should be sought prior to the photo-
social media is illustrated in Feature box 4-9. graph being taken. Burns and Belton (2013) address
the need for hospitals to develop policies govern-
USE OF CAMERAS WITHIN HOSPITALS ing the consent, capture, management, copyright
Capturing photographs of the progress of a disease, and retention of medical images. Some hospitals—
a traumatic injury, an operative procedure or before- for example, St Vincent’s Hospital, Sydney—have
and-after results of plastic surgery has been a well- implemented policies to prevent the general public
recognised practice for many years. Photographs taking photos of patients without first seeking per-
were generally undertaken by a trained medical mission from the hospital (Michael & Faktor, 2015).
photographer employed by the hospital (Burns &
Belton, 2013) with the photographs kept as part of PATIENT CARE AND SOCIAL MEDIA
the patient’s medical record or for teaching pur- In contrast to previous discussion on the misuse
poses. However, lack of availability of medical pho- of social media, considerable evidence exists about
tographers along with an increase in the use of its positive applications. The use of social media
smart phones with cameras has encouraged clini- has been embraced by a number of healthcare facil-
cians to take their own photographs. In a similar ities to enhance patient care in a variety of areas
vein, a surgeon may request a medical or nursing (e.g. reminding patients about medical appoint-
colleague to take a photograph of a surgical wound ments or sharing general health information). Sim-
or part of a procedure for teaching purposes, using ilarly, health professionals are connecting with
their own camera or mobile phone. Such actions colleagues, sharing research and seeking answers
give rise to practical, legal and ethical issues. to clinical questions. Patients use social media to
Careful management of images taken on personal connect with others suffering similar medical com-
devices is necessary to avoid accidental or deliber- plaints, sharing tips on management and using
ate misuse with resultant breaches of a patient’s social media as a support mechanism (Cheretien
confidentiality and privacy. In particular, retention & Kind, 2013). Several healthcare facilities have
of images on a mobile device encourages their use Facebook pages where events and staff achieve-
beyond the original clinical purpose (e.g. viewing ments are announced and patient testimonials
in social circles) (Burns & Belton, 2013). In all published. See, for example, The Royal Hospital for
92
Women, Melbourne (https://www.facebook.com/ Patients entering the perioperative setting, like

theroyalwomenshospital?fref=ts) and Auckland other healthcare settings, have the right be treated
City Hospital, New Zealand (https://www.facebook with respect and dignity, to have their information
.com/akldhb). kept private and confidential, and to be cared for by
safe, competent healthcare professionals. Thus, it
is imperative that perioperative nurses maintain an
CONCLUSION up-to-date working knowledge of the relevant Acts,
Perioperative nurses’ practice is informed by and regulations and codes to ensure that their practice
regulated within statutory and regulatory frame- conforms to the high standards expected by the
works whose intent is the protection of the public. public.

1. Consent for surgery
You are checking a patient, Mr Papadopoulos, into the operating suite. Mr Papadopoulos is scheduled
to have a transurethral resection of the prostate gland and this is stated on his consent form, which
he has signed and the signature has been witnessed. However, when you ask Mr Papadopoulos to verify
the nature of the operation, his response indicates that he is unsure of the operation he is about to
undergo.
• What are your responsibilities as a patient advocate in this situation and what action should
you take? Provide rationales for your answer.
2. The surgical count
You are the circulating nurse for a procedure and are working with an experienced RN, who is the
instrument nurse. During the course of the initial count you note that the instrument nurse is not
counting items according to practices set out in your operating suite’s policy manual, which is based
on professional standards.
• How would you handle this situation? Provide rationale(s) for your response.
• What are your professional responsibilities in relation to conducting the count of accountable
items?
3. Photography in the postanaesthesia care unit (PACU)
A surgeon comes into the PACU where you are working. She wants to take a photograph of a patient’s
vacuum drain using her mobile phone, which she says is for teaching purposes.
• What action should you take in this situation? Provide rationale(s) for your response.
4. A colleague with a health problem
You are working with a nursing colleague who seems to be continually falling asleep while looking
after patients in the anaesthetic room prior to surgery. When you ask her if she is unwell, she tells
you she has recently been diagnosed with narcolepsy and begs you not to tell anyone.
• What are the risks to patients in this situation? Provide explanations for your response.
• What action should you take and why?
93
RESOURCES REFERENCES
Australian College of Operating Room Nurses (ACORN).
Australian College of Nursing (1996). Standards, Guidelines and Policy Statements: Standard
www.acn.edu.au A6: Managing accountable items. Adelaide: Author.
Australian College of Operating Room Nurses Australian College of Operating Room Nurses (ACORN).
www.acorn.org.au (2016). Standards for perioperative nursing 2016–2017.
Australian Commission on Safety and Quality in Adelaide: Author.
Health Care Australian Commission on Safety and Quality in Health Care
www.safetyandquality.gov.au (ACSQHC/the Commission). (2008). Australian charter of
Australian Department of Health healthcare rights. Sydney: Author.
www.health.gov.au Australian Commission on Safety and Quality in Health Care
Australian Health Practitioner Law Library (ACSQHC/the Commission). (2013a). National Safety and
www.austlii.edu.au/au/special/healthprac Quality Health Service Standards. Sydney: Author.
Australian Health Practitioners Regulation Agency Australian Commission on Safety and Quality in Health Care
(provides links to all state/territory nursing boards/ (ACSQHC/the Commission). (2013b). Australian open disclo-
councils) sure framework. Sydney: Author.
www.ahpra.gov.au Australian Health Practitioner Regulation Agency (AHPRA).
Australian Institute of Health and Welfare (2009). Health Practitioner Regulation National Law Act
www.aihw.gov.au (2009). Retrieved from <www.ahpra.gov.au/Search.aspx?q
=national%20law>.
Australian Legal Information Institute
www.austlii.edu.au Australian Health Practitioner Regulation Agency (AHPRA).
(2013). A guide for practitioners: Notifications in the national
Australian Nursing and Midwifery Accreditation
scheme. Retrieved from <www.ahpra.gov.au/Notifications/
Council
Fact-sheets.aspx>.
www.anmac.org.au
Australian Health Practitioner Regulation Agency (AHPRA).
College of Nurses Aotearoa (NZ) Inc.
(2014a). Tribunal hearings [Fact sheet.] Retrieved from
www.nurse.org.nz
<http://www.ahpra.gov.au/Notifications/Fact-sheets.aspx>.
Government of South Australia
Australian Health Practitioner Regulation Agency (AHPRA).
www.sahealth.sa.gov.au
(2014b). Social media policy. Retrieved from <www.nursing
Health Care Complaints Commission (NSW) midwiferyboard.gov.au/Codes-Guidelines-Statements/
www.hccc.nsw.gov.au Codes-Guidelines/Social-media-policy.aspx>.
Health Workforce New Zealand Australian Health Practitioner Regulation Agency (AHPRA).
www.hwac.govt.nz (2015). Panel decisions. Retrieved from <www.ahpra.gov.au/
International Council of Nurses Publications/Panel-Decisions.aspx>.
www.icn.ch Burns, K., & Belton, S. (2013). Clinicians and their cameras:
Jehovah’s Witnesses Policy, ethics and practice in an Australian tertiary hospital.
www.jw.org Australian Health Review, 37(4), 437–441.
National Health and Medical Research Council Cheretien, K. C., & Kind, T. (2013). Social media and clinical
www.nhmrc.gov.au care ethical, professional, and social implications. Circula-
tion, 127, 1413–1421.
New Zealand Health and Disability Commissioner
www.hdc.org.nz Clinical Excellence Commission (CEC). (2015). Special Com-
mittee for Investigating Deaths Under Anaesthesia. Retrieved
New Zealand Health Practitioners Disciplinary from <www.cec.health.nsw.gov.au/programs/scidua>.
Tribunal
www.hpdt.org.nz Copley, T. (2013). Advance health directives and enduring
power of attorney. The Hive, 2(Winter), 28–29.
New Zealand Ministry of Health
www.health.govt.nz Government of South Australia. (2011). Open disclosure
policy directive. Retrieved from <www.sahealth.sa.gov.au/
NSW Health wps/wcm/connect>.
www.health.nsw.gov.au
HCCC v Burggraaff [2012] NSWNMT 4. Retrieved from <www
Nursing Council of New Zealand
.austlii.edu.au/au/cases/nsw/NSWNMT/2012/4.html>.
www.nursingcouncil.org.nz
HCCC v Santos [2012] NSWNMT 8. Retrieved from <www
Perioperative Nurses College of New Zealand Nurses
.austlii.edu.au/au/cases/nsw/NSWNMT/2012/8.html>.
Organisation
www.nzno.org.nz/Site/Sections/Colleges/Perioperative/ Health Quality and Safety Commission New Zealand. (2012).
default.aspx Surgical Site Infection Improvement Programme. Retrieved
94
from <www.hqsc.govt.nz/our-programmes/infection-pre <www.parliament.nsw.gov.au/prod/la/latabdoc.nsf/0/3c33f

vention-and-control/projects/surgical-site-infection 75f821fd277ca257583007b8717/$FILE/r119.pdf>.
-improvement>. Nursing and Midwifery Board of Australia (NMBA). (2010).
Henderson, V. (1964). The nature of nursing. The American National competency standards for the registered nurse. Mel-
Journal of Nursing, 64(8), 62–68. bourne: Author.
Kerridge, I., Lowe, M., & Stewart, C. (2013). Ethics and law Nursing and Midwifery Board of Australia (NMBA). (2013a).
for the health professions (4th ed.). Sydney: The Federation Code of ethics for nurses in Australia. Melbourne: NMBA.
Press. Nursing and Midwifery Board of Australia (NMBA). (2013b).
Lying down NHS staff suspended. (2009, 9 September). Code of professional conduct for nurses in Australia. Mel-
Retrieved from <http://news.bbc.co.uk/2/hi/uk_news/ bourne: NMBA.
england/wiltshire/8246197.stm>. Nursing and Midwifery Board of Australia (NMBA). (2013c).
Manning, J. (2006). Treatment injury and medical misadven- Panel hearing summary 2013.0173. Retrieved from <www
ture. In P. Skegg & R. Paterson (Eds.), Medical law in New .ahpra.gov.au/Publications/Panel-Decisions/Panel-hearing
Zealand (pp. 269–323). Wellington: Thomson Brookers. -summary-2013-0173.aspx>.
Medical Council of New Zealand (MCNZ). (2011). Information, Nursing and Midwifery Council of NSW (NMC NSW). (2014).
choice of treatment and informed consent. Retrieved from Annual report. Sydney: Author.
<www.mcnz.org.nz>. Nursing Council of New Zealand (NCNZ)/Te Kaunihera Tapuhi
Michael, S., & Faktor, D. (2015, 15 March). Smartphones o Aotearoa. (2012). Code of conduct. Retrieved from <www
pose an inherent risk to patients’ privacy. The Sun-Herald. .adhb.govt.nz/newborn/NsgTools/CodeOfConduct.pdf>.
Retrieved from <www.smh.com.au/comment/smartphones Perioperative Nurses College of the New Zealand Nurses
-pose-inherent-risk-to-patient-privacy-20150314-1427l7 Organisation (PNC NZNO). (2016). Standards. Retrieved from
.html>. <http://www.nzno.org.nz/groups/colleges/perioperative
Ministry of Health, New Zealand. (2011). Advance care plan- _nurses_college/resources/standards>.
ning: A guide for the New Zealand health care workforce. Queensland Health. (2011). Health care providers’ handbook
Wellington: Author. on Hindu patients. Brisbane: Author.
Murphy, E. (2015). Patient safety and risk management. In J. Read-Brown, S., Sanders, D. S., Brown, A. S., Yackel, T. R., Choi,
Rothrock & D. McEwen (Eds.), Alexander’s care of the patient D., Tu, D. C., et al. (2013). Time-motion analysis of clinical
in surgery (15th ed., p. 44). St Louis: Elsevier Mosby. nursing documentation during implementation of an elec-
National Health and Medical Research Council (NHMRC). tronic operating room management system for ophthalmic
(2010). Australian guidelines for the prevention and control of surgery. Proceedings of the American Medical Informatics
infection in healthcare. Retrieved from <https://www.nhmrc Association (AMIA) Annual Symposium held in Wellington, New
.gov.au/guidelines-publications/cd33>. Zealand, 16 November (pp. 1195–1204).
New Zealand Health and Disability Commissioner. (1996a). Reissa, S. (2013, 10 September). Religion v science: Parents
The code of health and disability services consumers’ rights. denied New Zealand baby to get cancer treatment, lost
Wellington: Author. court battle. International Business Times (Australian Edition).
New Zealand Health and Disability Commissioner. (1996b). Retrieved from <www.ibtimes.com.au/religion-vs-science
The code of rights and Maori concepts of health. Wellington: -parents-denied-new-zealand-baby-get-cancer-treatment
Author. -lost-court-battle-1316900>.
New Zealand Health Practitioners Disciplinary Tribunal South Eastern Sydney Local Health District. (2012). Elec-
(NZHPDT). (2013). Nurses’ professional misconduct. Nur13/ tronic intraoperative nursing care record: Responsibility and
248P. Retrieved from <www.hpdt.org.nz/Default.aspx?tabid accountability. Sydney: Author.
=385>. Staunton, P., & Chiarella, M. (2013). Law for nurses and mid-
New Zealand Privacy Commissioner/Te Mana Matapono wives (7th ed.). Sydney: Churchill Livingstone Elsevier.
Matatapu. (1996). Codes of practice. Retrieved from <https:// WA Department of Health. (2011). Consent to treatment.
www.privacy.org.nz>. Perth: Author.
Nottingham nurse sacked over Facebook photo. (2011, 28
October). Retrieved from <www.bbc.com/news/uk-england FURTHER READING
-nottinghamshire-15492092>. Adrian, A., & Chiarella, M. (2010). Professional conduct: A
NSW Health. (2010). Coroners cases and Coroners Act 2009. casebook of disciplinary decisions relating to professional
PD 2010_054. Sydney: Author. conduct matters (2nd ed.). Sydney: Nurses and Midwives
NSW Health. (2013). Management of instruments, accountable Board of New South Wales.
items and other items used for surgery or procedures. Bickhoff, L. (2014). Smart nurses’ thoughtless posts on social
PD2013_054. Sydney: Author. media. Australian Nursing & Midwifery Journal, 22(4), 31.
NSW Law Reform Commission (NSWLRC). (2008). Report 119: Bismark, M., & Paterson, R. (2006). No-fault compensation
Young people and consent to health care. Retrieved from in New Zealand: Harmonizing injury compensation, provider
95
accountability, and patient safety. Health Affairs, 25(1), Health Care Chaplaincy. (2013). Handbook of patients’ spir-
278–283. itual and cultural values for health care professionals. Retrieved
Burns, K., & Belton, S. (2012). Click first, care second pho- from <www.healthcarechaplaincy.org>.
tography. Medical Journal of Australia, 197, 265. Johnstone, M. J. (2015). Bioethics: A nursing perspective (6th
Finlay, A., Stewart, C., & Parker, M. (2013). Open disclosure: ed.). Sydney: Churchill Livingstone Elsevier.
Ethical, professional and legal obligations, and the way White, B., Wilmott, L., & McDonald, F. (2014). Health law in
forward for regulation. Medical Journal of Australia, 198(8), Australia (2nd ed.). Sydney: Thomson Reuters.
445–448.
96
Chapter 5
THE PERIOPERATIVE ENVIRONMENT
MICHELLE LOVE AND CATHERINE STEEL

LEARNING OUTCOMES
• Examine rationales for the design, layout and traffic patterns of perioperative environments
• Identify the parameters of environmental controls including OR temperature, humidity, ventilation and
air-conditioning
• Discuss the impact of electrosurgical equipment and lasers on patient and staff safety
• Examine workplace health and safety issues such as manual handling, surgical plume, fire, latex allergy,
radiation, chemical safety and noise
• Describe the preparation, cleaning and waste management requirements of perioperative environments
KEY TERMS
electrosurgical unit
environmentally controlled unit
fire prevention
laser
latex allergy
operating suite design
radiation safety
surgical plume
ventilation systems
air-conditioning, traffic patterns to restrict entry of

INTRODUCTION contaminants from external sources in the facility,
The perioperative environment is a purpose-built easy-to-clean floor and wall surfaces, and electrical
and highly regulated environment with design safety controls, all of which are designed to reduce
features that play a significant role in patient the risk of infection for the surgical patient. Safety
and staff safety. These include positive-pressure features related to electrical equipment, radiation
97
and lasers further protect both patients and the planning and design along with other interested
perioperative team from hazards inherent in this parties such as engineers, infection control and
highly technical environment. workplace health and safety representatives (Aus-
This chapter explores the structural compo- tralian College of Operating Room Nurses [ACORN],
nents of the operating suite and the impact that 2016). Planning should incorporate human factors
design and environmental features have on the and ergonomics (HFE) in the design to eliminate
safety of the patient. Work health and safety issues hazards and performance obstacles known to
are explored, including the safe use of electrosur- impact on patient safety (Carayon, Xie & Kianfar,
gery and lasers, evacuation of surgical plume and 2014). This could include the impact of the OR
the prevention of fire and explosions. Management layout and configuration of equipment on surgical
of latex allergy is discussed, as well as the role of team members’ performance and the surgical flow
personal protective equipment to minimise occu- process (ElBardissi & Sundt, 2012). Consideration
pational exposure to radiation and chemicals. The must also be given to the flow of the patients, staff,
chapter concludes with key steps required for prep- consumables and equipment within the operating
aration of the operating room, as well as cleaning suite to minimise delays, maintain patient privacy
and waste management processes in the periopera- and allow for segregation of some patient cohorts
tive environment. (e.g. paediatric patients, infected patients and so
forth), who may require specific or individualised
flow patterns (ACORN, 2016; Assem, Ouda &
OPERATING SUITE DESIGN Wahed, 2011).
The operating suite design and layout must There are several design models for the operat-
accommodate the day-to-day workload and the ing suite layout that achieve a balance between the
corresponding fluctuations in staff and patient environmental needs of the staff, infection control,
numbers while allowing for the addition of emerg- operational flow and functional requirements
ing technology (Australasian Health Infrastructure (AHIA, 2010). Some of the planning models for the
Alliance [AHIA], 2010). The operating suite is an operating suite include the following:
environmentally controlled unit consisting of • Single corridor. This model has a central
many distinct functional areas. It may be adjacent corridor that divides the ORs and storage areas
to a preadmission area (or a perioperative unit), (see Fig. 5-1) and allows the passage of all
through which patients for day surgery and those patients, staff, supplies and equipment
requiring admission are admitted. (ACORN, 2016; AHIA, 2010). This model,
The Australian states and territories and New however, may not be appropriate if the
Zealand have their own set of building codes, infec- corridor is not wide enough to permit the
tion control guidelines and capital works guidelines passage of clean and contaminated supplies
to assist with hospital design when new hospitals within a common area (AHIA, 2010). There is
are being planned or refurbishments are commis- also the risk that preoperative patients
sioned. Australasian health facility guidelines, an transported in the same corridor may be
initiative of the AHIA, are also available to assist exposed to distressing sights and sounds.
Australian and New Zealand health departments Keeping doors closed and incorporating other
undertaking health facility projects to achieve the methods to maintain patient privacy can
standards for building, space, equipment, fit out minimise these risks (AHIA, 2010).
and furnishings, and these are the minimum stand- • Racetrack style (dual corridor). In this model,
ards for design (Carthey, 2010). the ORs are usually placed around a corridor
When designing the operating suite, the deci- containing equipment and supply areas (see
sion regarding the number of operating rooms Fig. 5-2). An outside ‘racetrack’ maybe used
(ORs) and recovery spaces is governed by many for the passage of contaminated equipment
factors, including the number, type and complexity and supplies (ACORN, 2016; AHIA, 2010). The
of surgical procedures to be undertaken and the aim is to manage the use of each corridor,
number of postoperative beds available. Periopera- reducing the presence or flow of clean and
tive team members—including nurses, surgeons contaminated items without duplicating
and anaesthetists—should be involved in the equipment, supplies and staff (AHIA, 2010).
98
CHAPTER 5 | The perioperative environment
Supplies & equipment

Clean-up
Operating room Operating room
area
Anaesthetic Exit Scrub Scrub Exit Anaesthetic

induction bay area area bay induction
Anaesthetic Exit Scrub Scrub Exit Anaesthetic

induction bay area area bay induction
Clean-up
area
FIGURE 5-1: Single corridor model

Source: Phillips (2013); AHIA (2010).
To CSD
Anaesthetic Anaesthetic
induction induction

Exit bay
Exit bay

Scrub area
Scrub area
Clean-up Clean-up
area area
Exit bay
Exit bay
induction induction
To PACU
FIGURE 5-2: Racetrack model

99
To CSD
induction induction
Exit lobby Operating Operating Exit lobby
Sterile supplies & equipment

room room
Scrub Scrub
area area
Clean-up Clean-up
area area
Scrub Scrub
area area
room room
induction induction
induction induction

Sterile supplies & equipment
room room
Scrub Scrub
area area
Clean-up Clean-up
area area
Scrub Scrub
area area
room room
induction induction
To CSD
FIGURE 5-3: Small clusters model

• Small clusters. This model clusters between safety, patient privacy and practicality (ACORN,
two and four ORs with a shared sterile stock 2016; AHIA, 2010). These units include:
room (see Fig. 5-3). Disadvantages include the • central sterilising department (CSD)
additional costs associated with duplicating
supplies in multiple sterile stock rooms • postanaesthesia care unit (PACU)
(ACORN, 2016; AHIA, 2010). • emergency department
The operating suite should have close or direct • intensive care unit (ICU)/high-dependency
links with other units for convenience, patient unit (HDU)
100
Patient Staff Supplies
Emergency/ICU/wards/ Change rooms Supplies received from stores

Unrestricted Admissions send patients to Tea rooms Loan set delivery
operating suite instrumentation for CSD
Operating room reception
greet visitors and staff
Patients enter holding bay Staff gather necessary Cleaning Sterilisation

Semi-restricted
equipment and supplies for undertaken in CSD

Induction rooms may be used
surgery Sterile items enter sterile stockroom
Sterile supplies gathered in
preparation for operation
Patient enters operating room Check operating room prior to list Set-up taken into the operating
Restricted
Prepare sterile set-up room for surgery (should be

checked by nursing staff)
Scrubbing, gowning & gloving
Surgery performed
Patients enter PACU Terminal cleaning of operating Leftover sterile supplies

after surgery room at end of list returned to sterile stock room
Semi-restricted
Discharged to ward or home Environmental cleaning Instruments taken into

clean-up room for
transportation to CSD
Linen/waste/sharps disposal
FIGURE 5-4: Correct traffic flow in and out of the operating suite
• surgical wards cart’ system for transporting soiled and contami-

• delivery suite nated items to the sterilising department for
decontamination.
• pathology
• blood bank
OPERATING SUITE ZONES
• medical imaging departments.
ACORN identifies three zones or areas in the periop-
erative environment: unrestricted, semi-restricted
TRAFFIC PATTERNS and restricted. These zones are determined by the
Traffic patterns are established to define movement activities performed therein and as a consequence
through the operating suite for personnel, equip- require different environmental controls and peri-
ment, supplies and instrumentation, and to prevent operative practices, such as air-conditioning and
the introduction of potential sources of contamina- perioperative attire, respectively (ACORN, 2016).
tion (see Fig. 5-4). Ideally, waste, contaminated
supplies and soiled instruments should not travel UNRESTRICTED
down the same corridor as clean and sterile sup- In the unrestricted areas there is unlimited access
plies. However, if this is necessary due to the suite’s to all personnel, who may wear either perioperative
design, measures must be undertaken to minimise attire or street clothes. These unrestricted areas
any potential contamination of clean with contam- are the entry points for patients, personnel, stock
inated supplies (ACORN, 2016; AHIA, 2010). Such and supplies; for example, staff changing rooms
a method could include using a sealed ‘closed (ACORN, 2016).
101
SEMI-RESTRICTED bay when the anaesthetist is ready to prepare a

Semi-restricted areas are limited to personnel patient for surgery. General anaesthesia may be
usually wearing perioperative attire, although some induced in the anaesthetic room or the patient
hospitals may allow staff wearing uniforms to may be transferred onto the operating table for
access to these areas; for example, PACU staff, ward induction—this may happen in smaller facilities
staff accessing the PACU (ACORN, 2016). Semi- without anaesthetic rooms, or because of anaes-
restricted areas include peripheral support areas, thetic preference and local protocol. Using anaes-
the pharmacy, holding bays, the PACU and corridors thetic rooms provides patient privacy, increases
leading to restricted areas (ACORN, 2016). throughput and reduces OR changeover time
(ACORN, 2016).
RESTRICTED
Restricted areas are limited to authorised personnel
STORAGE AREAS
wearing perioperative attire and include operating Areas should be set aside within the operating suite
or procedural rooms, sterile stock rooms and areas to receive and decant bulk supplies before they are
for the processing of sterile items (ACORN, 2016). distributed to specialty storage areas within the
suite (ACORN, 2016; AHIA, 2010, Queensland
Health, 2013b). Consumables and specialised equip-
OPERATING SUITE LAYOUT ment, such as microscopes and lasers, must be
CHANGING ROOMS stored in areas that are easily accessible from the
Secure designated male and female changing rooms ORs and anaesthetic bays (AHIA, 2010).
with lockers and a daily supply of laundered peri-
operative attire must be provided for the authorised STERILE STOCK ROOM
personnel (ACORN, 2016; AHIA, 2010; Queensland The sterile stock room is a restricted area requiring
Health, 2013a). personnel to wear perioperative attire including
headwear and environmental controls (ACORN,
RECEPTION 2016). Areas for storing sterile supplies must be
The reception area is an unrestricted area and a easily accessible from all ORs, in a central location,
place for patients, families, staff and visitors (e.g. cleaned regularly and kept free of dust, vermin
students, medical company representatives) to and insects. Additional information is provided in
access information, such as operating suite sched- Box 5-1.
ules. It is also the location of waiting areas and case
bookings, and a place to sign in or out any visitors STAFF ROOMS
to the operating suite (ACORN, 2016). It is the Because OR staff wear perioperative attire, a staff
boundary between the operating suite and the rest room should be located within the operating suite
of the hospital (AHIA, 2010). where staff can relax and have a meal break (ACORN,
2016; Queensland Health, 2013a). Another area
PREOPERATIVE HOLDING BAY should also be designated a meeting/education
The preoperative holding bay is a waiting area for room where staff meetings and in-service educa-
patients prior to surgery where admission proce- tion can be conducted and in which journals and
dures between the preoperative nurse and the peri- textbooks, as well as access to the organisation’s
operative nurse are carried out, such as patient intranet and the internet, are available to staff for
identification, confirmation of documentation and ongoing education purposes (ACORN, 2016; AHIA,
clinical handover. A nurse is usually assigned to 2010; Queensland Health, 2013c).
work in this area to monitor patients’ condition and
to help coordinate each OR’s schedule by calling for THE PACU
patients from preoperative areas in a timely manner The PACU is classified as a semi-restricted area;
(ACORN, 2016). however, the wearing of perioperative attire is at
the discretion of management at each hospital
ANAESTHETIC ROOMS (ACORN, 2016). The PACU needs to be accessible to
Anaesthetic rooms are located proximal to the OR perioperative staff as well as medical and other
and patients are transferred here from the holding staff wearing street clothes in the event of an
102
BOX 5-1 » DESIGN FEATURES FOR STORING STERILE SUPPLIES

• The sterile storage area is not to be used as a shared equipment storage space and outer packaging
boxes should not be placed on the sterile stock shelves due to potential of contamination from the
packaging with dust, insect infestations or other contaminants.
• Sterile packages and trays are ideally stored on a smooth, non-porous surface, such as open wire
shelving, which is at least 300 mm above the floor and 440 mm from the ceiling.
• The open shelving allows dust to fall to the floor and permits cleaning to take place more
effectively. Shelving must protect the integrity of the sterile stock, facilitate inventory management
and stock rotation and not allow dust to collect (e.g. no solid containers).
• The sterile stock room must be kept cool and dry, with a temperature of 18–25°C and a relative
humidity of 35–70% to prevent compromising the integrity of the sterile packages.
• Sterile supplies need to be kept away from direct sunlight; therefore, windows within the sterile
stock area are not considered ideal.
• To maximise storage space, many operating suites use mobile compactors.
• Consideration must be given to work health and safety concerns regarding the height of shelving
and the placement of heavy stock items.
SOURCE: ACORN (2016), AHIA (2010), QUEENSLAND HEALTH (2013B ) AND STANDARDS AUSTRALIA (2014).
emergency (Australian and New Zealand College of if it is located on a different floor to the operating
Anaesthetists [ANZCA], 2006). suite (AHIA 2010; Queensland Health, 2013b).
In the PACU, patients who have undergone The sterilising department layout must be
anaesthesia and/or surgery are provided care, so clearly defined to distinguish the decontamination
the PACU needs to be located close to the operating/ (dirty) and packaging/sterilising (clean) areas to
procedure rooms. The layout and design of the ensure a unidirectional work flow and reduce the
PACU needs to allow for good observation of all risk of cross-contamination (Standards Australia,
patients simultaneously (AHIA, 2010; ANZCA, 2014). Contaminated instruments should be deliv-
2006). Curtained cubicles may allow privacy for ered directly into the cleaning or decontamination
patients while still maintaining a wide space. Infec- room for processing (AHIA, 2010). All personnel
tious patients should be isolated in dedicated within this area must wear personal protective
bays while in the PACU (AHIA, 2010). The PACU equipment (PPE) while handling contaminated
requires appropriate lighting and wall colour to equipment. Additionally, hearing protection should
ensure accurate assessment of patients’ skin colour be used, as many instrument washers are a recog-
(ACORN, 2016). nised workplace health and safety hazard (ACORN,
2016). Decontamination areas incorporate negative
air pressure, whereas positive air pressure is used
STERILISING DEPARTMENT within the designated clean packaging/storage
The sterilising department’s largest client will areas (Queensland Health, 2013d). After the instru-
always be the ORs and therefore it must be located ments have been processed, they enter the clean
within easy access to facilitate the passage of clean side of the sterilising department, where specially
and contaminated instruments between the two trained staff check them, mark tray checklists and
departments. Enclosed carts or containers with lids package trays and instruments for sterilisation
should be used to transport contaminated instru- (ACORN, 2016). Following sterilisation, personnel
ments to the sterilising department. Separate clean must handle, transport and store items in a manner
and contaminated lifts should be used to transport that minimises the risk of contamination (Stand-
instruments to and from the sterilising department ards Australia, 2014).
103
SCRUB BAYS DEDICATED OPERATING ROOMS

Scrub bays provide sinks with running water and Some hospitals, particularly larger tertiary hospi-
access to antiseptic solutions to accommodate tals, dedicate ORs to specialty surgery such as
several members of the surgical team undertaking closed urology, orthopaedic, ophthalmic, endos-
the surgical scrub procedure simultaneously. To copy, robotic and/or hybrid surgery (ACORN, 2016).
facilitate adherence to aseptic technique, these This is beneficial as it allows specialised equip-
sinks need to be located directly outside the OR to ment, such as microscopes and non-standard OR
allow easy access to sterile gown and glove trolleys, tables, to remain within the OR, reducing the
which may be located in the scrub bay itself or potential for damage due to movement, although
within the OR. To prevent slip injuries, the floor fixed equipment may limit the flexibility of the OR
coverings in the scrub areas should be of a non-slip in smaller suites (ACORN, 2016; AHIA, 2010).
texture (AHIA, 2010).
HYBRID OPERATING ROOMS
STANDARD OPERATING ROOMS Interventional or hybrid ORs combine features of
An OR (sometimes called an operating ‘theatre’) the cardiac catheter unit (angioplasty suite) with
should have a designated entry point for the patient those of a standard OR. Hybrid ORs provide an
and clean supplies and a separate exit point for the environment for highly advanced imaging technol-
patient and waste (AHIA, 2010). The minimum size ogy for minimally invasive angioplasty procedures
recommended for a general OR is 42 m2, whereas a while maximising the additional infection control
large OR is 52 m2 (AHIA, 2010) (see Fig. 5-5). restrictions common to operating suites (Kaneko &
FIGURE 5-5: Modern operating room

Source: Shah, Patel & Singh (2012).
104
FIGURE 5-6: Hybrid operating room

Source: Wikipedia/Pfree (2014).
Davidson, 2014) and optimising patient outcomes diagnostic and surgical procedures are being carried
(see Fig. 5-6). These rooms have a control area for out (Hughes-Hallett, Mayer, Pratt, Vale & Darzi,
the radiographer, which facilitates a direct view of 2015). Minimally invasive surgery (MIS) techniques
the surgical field (Kaneko & Davidson, 2014), as include endovascular procedures, single-incision
well as the monitors, which are placed strategically laparoscopic surgery (SILS), natural-orifice translu-
to facilitate the simultaneous viewing of multiple minal endoscopic surgery (NOTES) and robotic
radiological images. A ceiling-mounted intraopera- surgery. See Chapters 10 and 13 for further
tive X-ray machine (‘C-arm’) moves parallel to the information.
table, capturing radiological images of the patient
(Kaneko & Davidson, 2014). Building codes require OPERATING SUITE
these rooms to have lead-lined walls and doors to
minimise radiation scatter (Kaneko & Davidson,
ENVIRONMENTAL CONTROLS
2014) and fixed warning signs that illuminate when The following environmental controls and design
the radiological screening is in progress (Queens- considerations are required to ensure that the peri-
land Government, 2010). The Australian and New operative setting complies with relevant building
Zealand Society of Cardiac and Thoracic Surgeons standards, and infection prevention and control
(ANZSCTS) currently recommends using a 55-m2 practices, and to facilitate cleaning regimes.
theatre for adult cardiac surgery (ANZSCTS, nd)
and a hybrid OR may be up to 110 m2 (Kaneko & WINDOWS
Davidson, 2014). Patient privacy (ACORN, 2016; AHIA, 2010) neces-
sitates the limited use of windows within the peri-
TECHNOLOGICAL ADVANCES IN THE operative setting. In addition, MIS requires low-lit
theatres to maximise views, while ORs where surgi-
OPERATING SUITE cal lasers are used require protective window cover-
Technology is constantly evolving and enhancing ings (ACORN, 2016). Hence, while natural light
new surgical procedures, which may require spe- from windows boosts morale, motivation and
cific medical devices and products. Indeed, surgical comfort, it may be preferable to have windows only
innovations and advances in imaging technology in the PACU and staff areas (ACORN, 2016; AHIA
over the past 50 years have revolutionised the way 2010; Al Benna, 2012; Queensland Health, 2013c).
105
CEILINGS, DOORS, FLOORS AND WALLS HUMIDITY

Ceilings should be made of seamless, non-reflective, The humidity inside the OR should be maintained
non-porous material to facilitate cleaning and at 50–60% (ACORN, 2016) to inhibit bacterial
prevent accumulation of dirt (AHIA, 2012; Queens- growth and decrease risks associated with static
land Health, 2013c). Similarly, light fittings must be electricity (Al Benna, 2012; Queensland Health,
flush-fitting and sealed, while walls should be 2013d). Humidification maintained around 55% is
seamless and tightly sealed at floor level to mini- also required when flammable agents are to be
mise entry of insects and to facilitate effective used (Queensland Health, 2013d). While a relative
cleaning (AHIA, 2012). Swing-type doors allow easy humidity of 35–70% is recommended for storage
access for hands-free entry to the OR; however, of sterile supplies (Standards Australia, 2014),
robust seals are required to maintain positive air humidity greater than 60% can cause condensation
pressure (ACORN, 2016). Doors and walls may and mould, which may compromise sterile stock, as
require protective strips to prevent damage from well as patient and staff safety (Al Benna, 2012;
heavy traffic and cleaning regimes (ACORN, 2016; Queensland Health, 2013c). Additionally, high tem-
AHIA, 2010; Queensland Health, 2013c). Floors are peratures and humidity can increase fatigue among
generally made of a smooth, seamless material, the surgical team and encourage insect infesta-
such as vinyl, which is impervious to moisture, tions; therefore, they are best avoided (Queensland
easily cleaned, stain-resistant, comfortable for long Health, 2013c).
periods of standing and suitable for wheeled traffic
(AHIA, 2010, 2012; Spagnolo, Ottria, Amicizia, Per- VENTILATION
delli & Cristina, 2013). The OR floor colour must
allow for contrast when personnel are looking for Air-conditioning systems are used to reduce the
small, dropped items (AHIA, 2010; Spagnolo et al., spread of airborne infectious organisms from one
2013) and floors in wet areas, including the sterilis- area to another (Queensland Health, 2013d). Dust
ing department, should be non-slip (AHIA, 2012). particles, textile fibres, skin fragments and respira-
Neutral wall and ceiling colours help to ensure tory aerosols that contain microorganisms are
accurate patient assessment, while a semi-matt released from surgical team members into the air
finish reduces glare for the perioperative team of the OR during surgery (Birgand, Saliou & Lucet,
(ACORN, 2016; Queensland Health, 2013c). 2015; Diab-Elschahawi et al., 2011; Spagnolo et al.,
2013). The risk of surgical site infection (SSI) from
microorganisms settling on the aseptic field or
TEMPERATURE entering directly into the operative site (Spagnolo
A temperature range of 18–24°C is recommended et al., 2013) is minimised by using a positive air
in the operating suite (ACORN, 2016). For individ- pressure system. Therefore, it is essential to main-
ual ORs, a narrower range of 20–22°C (ACORN, tain a high quality of air within the perioperative
2016) inhibits bacterial growth and is well tolerated environment.
by both patients and staff (Bayazit & Sparrow, The three types of ventilation systems used
2010). The OR temperature may need to be adjusted within the perioperative environment are as follows.
outside these ranges to accommodate some types
of surgery and/or the condition of individual • Conventional system. This system uses filtered,
patients. For example, patients undergoing in vitro recirculated air with a minimum of four fresh
fertilisation (IVF) procedures and paediatric, air changes each hour (ACORN, 2016).
trauma, obstetric and burns patients all require • Ultra clean air system. This system may
higher ambient temperatures as these patients are use a normal efficiency particulate air
highly susceptible to hypothermia (Hardcastle, filter to produce clean air and move it in a
Stander, Kalafatis, Hodgson & Gopalan, 2013). unidirectional motion or use a high-efficiency
Hardcastle and colleagues (2013) suggest an overall particulate air (HEPA) filter, which removes
higher range of 21–24°C for the operating suite particles over 0.3 µm in diameter with an
as this environmental control may also reduce efficiency of 99.97% (Spagnolo et al., 2013).
patients’ convective heat loss. See Chapters 7, 8 and Operating rooms in Australia and New
9 for information about inadvertent perioperative Zealand must have a minimum of 20 air
hypothermia (IPH). changes per hour and the air supplied to the
106
sterile stock room and OR must not be opening and closing of doors), hence it may be nec-
recirculated air (ACORN, 2016; Standards essary to ensure supplies are readily at hand (in the
Australia, 2012). OR, generally) during the course of surgery (Al
• Laminar airflow. With laminar airflow (LAF), Benna, 2012; Ogg, 2014a; Panahi, Stroh, Casper,
HEPA-filtered unidirectional air flows into the Parvizi & Austin, 2012). Procedure rooms where
OR above the operating table (de Korne et al., bronchoscopies and sputum collections occur
2012; Spagnolo et al., 2013). Contaminated air should use negative pressure (Ogg, 2014b).
is extracted through low-lying wall grids in the
OR, with up to 400 air changes per hour LIGHTING
(ACORN, 2016; de Korne et al., 2012; Ogg, Operating lights are ceiling mounted directly above
2014a; Spagnolo et al., 2013) (see Research the OR table to provide shadowless light on the
box 5-1). LAF systems are typically used for surgical site. Historically, incandescent lights were
orthopaedic and other implant surgery used; however, these radiated heat onto the surgi-
(Spagnolo et al., 2013). cal team. Recently, light-emitting diodes (LEDs)
Air-conditioning systems within the operating have been introduced (Knulst, Laurents, Stassen,
suite use positive pressure, which forces air from Grimbergen & Dankelman, 2009) and this technol-
the operating suite out into the external environ- ogy aims to eliminate this undesired effect. Fur-
ment. Positive air pressure is greater in the OR than thermore, blue-enriched white lights have been
the surrounding corridors and scrub areas, with the introduced to reduce optical strain during laparo-
exception of the sterile stock room, which has the scopic surgery and have been noted to be effective
same air pressure as inside the OR (Queensland in highlighting mucosal patterns and microvascular
Health, 2013b). Because the microbial count is details in endoscopy (Wong, Smith & Crowe, 2010).
higher in the air outside the OR (Spagnolo et al., The position of the operating light may require
2013), the OR doors must be kept closed at all times manipulation during surgery and sterile light
(other than the necessary passage of staff, supplies handles allow the surgical team to adjust the light.
and the patient) to reduce the risk of airborne con- There is a risk of contamination if unscrubbed per-
taminants entering the surgical field (Al Benna, sonnel readjust the light (Wong et al., 2010) due to
2012; Ogg, 2014a) (see Research box 5-2). The their proximity to the aseptic field. Members of the
microbial count is usually at its peak during skin surgical team may also wear headlights to improve
incision as this follows a period of maximum air illumination and visibility when working in deep
disturbance (staff gloving and gowning, patient cavities or in confined surgical sites and incisions.
draping, the movement of staff and frequent Surgeons routinely don and adjust their headlight
RESEARCH BOX 5-1: Laminar Air Flow
While LAF is biologically sound and has long been supported by previous studies, a recent meta-analysis
could not ultimately establish the effectiveness of LAF, as recent evidence indicates an increase in SSI
following hip replacement surgery performed under LAF (Diab-Elschahawi et al., 2011; Spagnolo et al.,
2013). Furthermore, a study undertaken by the New Zealand Joint Registry found no benefit from LAF or
space suits in reducing infection rates for early deep joint infections (Hooper, Rothwell, Frampton & Wyatt,
2011). Andersson and colleagues (2014) suggest that smoking, timing of prophylactic antibiotics, surgical
attire and hypothermia may also influence SSI rate. Research also suggests that the benefits of LAF may
be reduced by actions that disrupt air flows, such as the position of equipment, staff traffic patterns and
the frequency of door openings (Andersson et al., 2014; Andersson Bergh, Karlsson, Eriksson & Nilsson,
2012; Birgand et al., 2015; Iudicello & Fadda, 2013; de Korne et al., 2012). Taking into account these
contradictory results, it is reasonable to question the role of LAF ventilation in prevention of SSIs (Diab-
Elschahawi et al., 2011; Hooper et al., 2011; Spagnolo et al., 2013).
107
RESEARCH BOX 5-2: Operating Room Doors and Air-Conditioning Systems
As airborne contaminants can cause and even worsen infections, movements of staff, equipment and
supplies in the OR should be limited (Al Benna, 2012; Rovaldi & King, 2015). Although there is currently
no direct link between the number of people present inside the OR and the rate of SSIs, one study found
that as the number of people inside the OR increased, so did the incidence of SSIs (Al Benna, 2012;
Andersson et al., 2014). The study was unable to determine if this was due to the number of people or
the increased traffic. However, it is clear that air-conditioning efficacy decreases when OR doors are
opened (Al Benna, 2012; Andersson et al., 2014; Rovaldi & King, 2015).
Recent studies have explored the frequency and reasons that OR doors are opened during surgery. All
surgical specialities recorded a large percentage of door openings during surgery; however, the most
common were spinal surgery (50 door openings per hour), cardiac surgery (48 door openings per hour),
neurosurgery (42 door openings per hour) and joint replacement surgery (40 door openings per hour)
(Rovaldi & King, 2015). Reasons included supply issues 26%, staff meal breaks 20%, team members enter-
ing and leaving the OR 14%, and expert consultation 7%, while 27% of door openings were for no detect-
able reason or for social visits (Andersson et al., 2012). To attempt to reduce unnecessary door openings,
some hospitals place signs or tape at the entry of the OR door highlighting ‘joint in progress’ or ‘implants
in use’; however, the effectiveness of the signs diminishes over time because staff forget to remove the
sign following the surgery (Rovaldi & King, 2015).
prior to scrubbing to confirm full function and piece of electrical equipment including inspecting
ensure the required range of movement. electrical cords for any damage prior to use to
ensure correct functioning. It is the responsibility
of all staff to remove faulty equipment from use
ELECTRICAL SAFETY immediately (ACORN, 2016). Extension cords are
The large amount of electrical equipment used in not used within ORs due to the risk of accidental
the OR places both staff and patients at potential dislodgement and the trip hazard for staff (Stand-
risk of electrocution should equipment become ards Australia, 2004).
faulty or be mishandled by staff. However, a range There are two main types of electrical shock
of safety features are incorporated into the design against which staff and patients must be protected.
of ORs to reduce this risk. These include devices • Macroshock. This occurs when the body
such as line-isolation monitoring (LIM) panels and, inadvertently becomes a conductor of
within each OR, residual current devices (RCD), electrical current when in contact with faulty
which indicate faulty equipment or leakage of elec- equipment or leakage of current occurs. A
trical current by initiating an audible alarm. In person experiencing macroshock may exhibit
addition, an electrical fault will activate warning muscle contractions, breathing difficulties and
lights on the LIM panel and initiate the associated extreme pain. Normally, the skin provides
circuit breakers, subsequently interrupting the resistance to electrical current; however,
electrical supply to the RCD. during surgical procedures this protection
Australian and New Zealand healthcare facili- may be breached by the application of
ties are guided by the same standard on the safe use electrocardiograph (ECG) monitoring pads
of electricity in patient care areas (Standards Aus- and/or electroconductive gel. Ventricular
tralia, 2004). All electrical equipment must be fibrillation may occur as a result of the shock,
checked by the facility’s biomedical engineering depending on the part of the body in contact
department prior to installation and thereafter at with the current and the magnitude of the
regular intervals to ensure safe function and com- current. Line-isolation monitors are the first
pliance with standards. Staff should also check each line of defence against macroshock, and areas
108
BODY-PROTECTED ELECTRICAL AREA CARDIAC-PROTECTED ELECTRICAL AREA
FIGURE 5-7: Signage used to denote body- and cardiac-protected electrical areas
with this protection are termed ‘body within the OR. The ESU generates an electrical
protected’, using the symbol shown in Figure current at extremely high frequency, which cuts or
5-7 (Standards Australia, 2004). Macroshock is coagulates tissue (as well as variations of the latter,
the most common type of electrical shock. such as tissue desiccation or fulguration), thus pro-
• Microshock. In procedures where arterial viding a bloodless surgical field (Alkatout et al.,
catheters, pacing wires or other devices have 2012). There are two main types of diathermy:
direct connection to the heart, there is danger monopolar and bipolar, both of which have unique
of a microshock, which may cause a fatal applications.
ventricular fibrillation. Only very small
amounts of electrical current are needed to MONOPOLAR DIATHERMY
induce fibrillation when it is transmitted In monopolar diathermy, the current is usually
directly to myocardial tissue and there may be applied to the tissue through the use of a small
no external signs that the patient has suffered hand-held electrode, termed the ‘active’ electrode.
microshock. The line-isolation monitors that This may be in the form of a ‘diathermy’ pencil,
protect against macroshock incorporate blade, forceps, needlepoint, loop or ball depending
supplementary special earthing devices, which on the surgery being performed. The surgeon acti-
alert staff to current leakage well below the vates the current to cut or coagulate tissue by
level that would cause microshock (Standards means of a switch on the ‘pencil’, or using a foot
Australia, 2004). Areas that incorporate these pedal during closed urology or laparoscopic surgery
special earthing devices are termed ‘cardiac for example. The current then flows through the
protected’ and are identified using the symbol patient and exits via the patient return electrode,
shown in Figure 5-7. which is in contact with the patient’s body, return-
ing it to the ESU to complete the electrical circuit
ELECTROSURGICAL EQUIPMENT (see Fig. 5-8). The patient return electrode may be
The perioperative environment includes a range of an adhesive pad, which contains conductive gel
electrosurgical equipment that converts energy (see Fig. 5-9) or a large mat placed under the
from a high-frequency electrical current into heat patient (see Fig. 5-10) (Standards Australia, 2004)
that can cut and cauterise tissue (ACORN, 2016). (see Box 5-2).
However, all of these devices have the potential to
cause thermal injuries, interfere with implantable BIPOLAR DIATHERMY
devices, ignite fires and produce harmful smoke Bipolar diathermy uses a pair of fine forceps control-
plume (ACORN, 2016), imposing risks for patients led by the surgeon via a foot pedal. It is used com-
and the perioperative team. monly for coagulation of minor blood vessels in
neurosurgery, plastic or paediatric surgery (Stand-
THE ELECTROSURGICAL UNIT ards Australia, 2004). In this mode, the current
The electrosurgical unit (ESU, or diathermy flows down one tine of the forceps across the tissue
machine) is a commonly used electrical device that is grasped between the forceps and returns to
109
Abdomen (surgical site)

Electrical current From ESU generator
To ESU generator
and ground
Electrical current
Dispersive electrode
FIGURE 5-8: Monopolar electrosurgical circuit

Source: Fuller (2013).
FIGURE 5-10: Reusable patient return electrode capacitive pad

Source: Ball (2015).
through wet drapes, faulty leads, electrodes or

cables, or other contact of the patient’s skin with
metal (e.g. a hand touching the frame of the operat-
FIGURE 5-9: Single-use patient return electrode split pad ing table), the patient may suffer burns. Any damage
Source: Ball (2015). to the patient’s skin must be treated, reported, doc-
umented and investigated. Devices that may have
the ESU through the opposing tine (see Fig. 5-11). caused patient harm must be removed from use and
This mode does not require a patient return checked by a biomedical engineer (ACORN, 2016).
electrode. Burns to surgical or nursing staff may also occur
if the current used finds an alternative pathway
HAZARDS OF ELECTROSURGERY back to the ESU (e.g. through a hole in the glove
There is a risk of burns or electrocution during of the person applying the active electrode, or in
electrosurgery if the patient return electrode has cases where the insulation on endoscopic forceps
insufficient contact with the patient’s skin. If the is faulty). All ESUs have inbuilt alarm systems
current finds an alternative pathway back to earth to disable faulty equipment and alert staff to
110
BOX 5-2 » APPLICATION OF THE PATIENT RETURN ELECTRODE

Patient return electrodes (also known as dispersive electrodes or diathermy plates) may be single-use
adhesive plates (see Fig. 5-9) or reusable mats also known as capacitive pads (see Fig. 5-10). Depending
on local policy, the patient return electrode may be positioned by a patient care assistant (PCA) or an
orderly. In this circumstance, the nurse is responsible for confirming the correct placement of the
electrode (or patient contact with mat) and the condition of the patient’s skin following removal of the
electrode. The following safety points must be followed when positioning the patient return electrode:
• Select an appropriate patient return electrode for the patient’s age and size.
• Place a sheet between the patient and the reusable mat.
• Ensure skin is dry and free of hair to ensure good contact between skin and patient return electrode.
• Select well-vascularised tissue such as muscle (e.g. outer thigh or buttock) and avoid bony
protuberances, scar tissue and implants as these do not provide a sufficient safe area of
vascularised tissue.
• Place the patient return electrode as close as possible to the site of surgery.
• Apply the patient return electrode after patient positioning whenever possible, and re-assess if the
patient is re-positioned.
• Avoid pooling of fluids, such as antiseptic or alcoholic skin preparations and solutions and remove
any damp materials prior to draping (ACORN, 2016; Spruce & Braswell, 2012).
situations where the patient return electrode has

become detached from the patient (Standards Aus-
tralia, 2004) (see Box 5-3). Surgical plume is
another hazard associated with electrosurgery and
smoke evacuation equipment should always be
available during surgery (ACORN, 2016). The spe-
cific hazards of smoke plume are discussed later
under workplace health and safety.
RELATED EQUIPMENT
Electrosurgical devices have been developed that
incorporate enhanced haemostatic features; for
example, argon-enhanced electrosurgery. These
devices combine argon gas with electrosurgery to
improve the effectiveness of the coagulation mode
by producing rapid haemostasis that creates a
thinner, more flexible eschar, thus allowing the
surgeon greater visibility (ServiceMed, 2010).
FIGURE 5-11: The current formed in the electrosurgical unit (ESU) flows through
an insulated conductor of the bipolar forceps to exert its thermal action on the The use of ultrasonic technology to achieve
tissue. The current flows from the active jaw (electrode) to the inactive (neutral) haemostasis is now commonplace within the OR.
jaw of the electrode. The current flows back to the ESU via the insulated neural Ultrasonic technology uses high-frequency sound
limb of the bipolar forceps. Note that current flow to tissue is limited to that which waves to cut and coagulate tissue (Kneedler, Pfister
is enclosed between the active and the neutral electrodes (forceps jaws). & Moss, 2013). A handpiece held by the surgeon
Source: Baggish (2016). converts electrical energy into a mechanical vibra-
tion, at 55,000 cycles per second, which vaporises
tissue in a very precise manner, resulting in less
damage to surrounding tissue, no smoke and none
111
BOX 5-3 » SAFE USE OF ELECTROSURGERY

Due to the potential risk of injury and fire when using electrosurgery equipment, the perioperative
nurse should follow these safety considerations:
DO:
• Ensure all staff using the equipment are trained in the use of the specific device.
• Minimise the risks of surgical plume by using appropriate smoke evacuation equipment (see
Figs 5-13 and 5-14 later in the chapter).
• Use the lowest required power setting.
• Ensure alarm settings remain audible at all times.
• Place foot pedals in an impervious cover when the risk of fluid exposure is high (e.g. closed urology
surgery).
• Always inspect and confirm adequacy of the insulation when using minimally invasive surgical
instruments.
• Always use cannula systems made from the same material, either all metal or all plastic.
• Place the electrosurgical device in the holster/quiver when not in use.
• Use separate holsters/quivers for each device.
• Clean the active electrode regularly to prevent build-up of blood, tissue or eschar.
• Be cautious using the electrosurgical device in the presence of flammable liquids (e.g. alcoholic
prep solutions) and anaesthetic gases.
DO NOT:
• Place any fluids on the ESU.
• Tightly coil or loop the cable of the electrosurgical device.
• Use combined metal and plastic cannula systems.
SOURCE: ACORN (2016).
of the dangers associated with electrical currents as

seen with electrosurgery as no electricity passes to
LASER
or through the patient (Kneedler et al., 2013). ‘The The term laser is an acronym for ‘light amplifica-
clinical benefits of ultrasonic energy include the tion by stimulated emission of radiation’. Laser
elimination of direct coupling, capacitive coupling, energy is concentrated into a narrow beam or a
insulation failure, pad site burns, and stray electri- single wavelength. This means that laser energy
cal energy while allowing for precise cutting and can be used therapeutically. However, it can also
controlled coagulation’ (Kneedler et al., 2013 p. 19). travel great distances beyond the intended opera-
tive site with the potential to cause injury to the
Advanced bipolar instruments have also been patient and the perioperative team. Depending on
developed which incorporate a cutting blade to the wavelength, lasers are classified according to
allow both cutting and coagulation to be achieved the hazards associated with their emission (Aus-
by utilising a combination of compression and heat tralian Radiation Protection and Nuclear Safety
(Kneedler et al., 2013). These devices are safer to Agency [ARPANSA], 2015). Healthcare facilities use
use as they can sense tissue impedance as well as class 3b and 4 lasers and each has its own associ-
seal vessels up to and including 7 mm in diameter ated risks and mitigating strategies. The specific
(Kneedler et al., 2013). tissue applications and therapeutic benefits of
112
lasers are influenced by technical properties such

as laser wavelength. Similarly, lasers have specific
use and are not interchangeable between the
various surgical specialties. For example, in oph-
thalmology, the neodymium yttrium-aluminium-
garnet (Nd : YAG) laser beam is used to rupture a
clouded posterior capsule membrane following
cataract surgery; cosmetic surgeons may use the
erbium : YAG laser to resurface the skin; an ear,
nose and throat surgeon may use a carbon dioxide
(CO2) laser to remove a tumour from the vocal
cords; and a urologist may use a holmium : YAG
laser to ablate ureteric calculi.
LASER SAFETY
Class 3b and 4 lasers have the potential to cause
injury through effluent smoke generated and the
accidental deflection of the laser beam resulting in
eye or skin damage and/or fire, more likely in or on
the patient, so extreme caution should be used at
all times (ACORN, 2016; Smalley, 2011; Standards
Australia, 2011a). It is the responsibility of the laser
safety officer (LSO) to ensure that all safety meas-
ures are in place and that clinicians involved with
the use, storage and management of lasers are able
to comply with evidence-based standards of prac- FIGURE 5-12: Laser safety goggles
tice to minimise the risk of harm (ACORN, 2016; Source: Taken by L. Welstead.
Standards Australia, 2011b; Smalley, 2011).
In healthcare facilities using laser, only person-
nel who have completed a recognised laser safety
Facilities’ laser safety procedures highlight the
course and are familiar with the features, operation
need for ongoing education for laser safety staff
and specific safety requirements should operate the
(Smalley, 2011) and must identify the endorsed
laser (ACORN, 2016; Australian Standards, 2011b;
laser safe practices that align with the Australian
Smalley, 2011). The radiation safety officer (RSO)
Standard (2011b). Laser surgery generates surgical
for each facility must ensure that each OR, or each
plume and work health and safety precautions can
nominal ocular hazard area (NOHA), displays veri-
minimise the risks of exposure for personnel
fication that the environment has been specifically
(ACORN, 2016; Ministry of Health, NSW, 2015;
adapted for the particular laser (ACORN, 2016).
Smalley, 2011). The risks of surgical plume are
Similarly, ACORN (2016) indicates that all person-
addressed later in this chapter.
nel in the NOHA must wear the appropriate eye
protection (see Fig. 5-12). Additional fire preven-
tion strategies include the display of warning signs WORKPLACE HEALTH AND SAFETY
on the doors, the provision of PPE at all theatre Under the Work Health and Safety (WH&S) Act,
entry points and the placement of fire extinguish- everyone in the workplace is responsible for iden-
ing equipment within 5 m from the line of sight tifying risks and the potential harmful effects of
from the main entrance (ACORN, 2016; Standard those risks (ACORN, 2016; Commonwealth of Aus-
Australia, 2011b). tralia, 2011; Safe Work Australia, 2015). In addition
The risk of laser deflection is minimised by to the hazards already discussed with the use of
using non-reflective instrumentation and examin- electricity, electrosurgery and laser equipment,
ing the protective casings of fibre-optic cables to other hazards exist within the perioperative envi-
verify their integrity (Standards Australia, 2011b). ronment. All staff must be aware of these hazards
113
and adhere to risk minimisation strategies to set a maximum weight restriction of 7 kg for instru-
protect patients, their colleagues and themselves ment crates (Guy, 2013; Standards Australia, 2014).
(ACORN, 2016). Keeping a personal level of fitness and suppleness
is also recommended for all staff to prevent injuries
MANUAL HANDLING (Fragar & Depczynski, 2011).
As the average age of perioperative nurses increases, SURGICAL PLUME
so too do the work and age-related challenges
(Fragar & Depczynski, 2011). The physical chal- Surgical plume is produced when biological tissue
lenges experienced by the perioperative team may is disrupted or vaporised by energy-based surgical
result from the physical stressors imposed during equipment such as electrosurgical and ultrasonic
patient care, such as the posture maintained during devices, lasers (ACORN, 2016; Harkavy & Novak,
surgery (Wong et al., 2010) and the transfer and 2014) and high-speed surgical drills and saws
positioning of patients and equipment, which peri- (Ministry of Health, NSW, 2015). Surgical plume is
operative staff do many times within their daily made up of 95% water (steam) and 5% cellular
work practice (ACORN, 2016) (see Feature box 5-1). debris and includes visible and non-visible parti-
Compliance with WH&S legislation requires that cles (Ministry of Health, NSW, 2015). This cellular
facilities demonstrate and provide evidence that debris has been shown to contain a number of
these manual handling risks and other workplace dangerous toxins, chemicals, carcinogens, blood
hazards are identified and minimised (Common- and tissue particles, bacteria and viruses (Ministry
wealth of Australia, 2011). The most frequent work- of Health, NSW, 2015; ACORN, 2016; Harkavy &
related injuries reported include sprains and strains Novak, 2014). Over the past 30 years, numerous
(WorkCover NSW, 2013), which commonly occur studies have identified the potential diseases
during transfer and positioning of patients or equip- caused by exposure to surgical plume; the direct
ment. ACORN recommends that such activities contributing link between surgical plume exposure
involve a team of people working in a coordinated and the resultant disease remains the subject of
manner to ensure everyone’s safety (2016). Devices ongoing research (Harkavy & Novak, 2014) (see
such as slide sheets and air-assisted lateral transfer Feature box 5-2 and Fig. 5-13).
devices should be used when transferring patients Surgical plume and smoke evacuation units (see
(ACORN, 2016) (see Chapter 9 for further informa- Fig. 5-14) extract the plume via devices attached to
tion). In addition, Australia and New Zealand have the active electrode into an evacuation unit and
FEATURE BOX 5-1 » PREPARING THE OR AND EQUIPMENT FOR OBESE PATIENTS
Maintaining patient dignity during manual-handling activities, particularly with obese patients,
requires respect and sensitivity (Rowen, Hunt & Johnson, 2012), as well as careful planning to
ensure appropriate equipment and adequate numbers of staff are available. The perioperative
team must assess the OR and equipment and be coordinated in their activities to prevent injury
to the patient and themselves (Jamadarkhana, Mallick & Bodenham, 2013). Assessment may
include confirmation of the weight or capacity limits of equipment (operating table, frames and
supports, stirrups etc), testing of the operating table’s articulations and inspection of the position-
ing accessories (Jamadarkhana, et al., 2013). When applying weight or capacity limits, it is impor-
tant to note whether the identified limits are specific to the supine position only. Recommendations
must be sought from the device manufacturer when the patient’s weight is close to the device’s
capacity (Jaskunas, 2015). The National Health and Medical Research Council (NHMRC) has pub-
lished clinical practice guidelines for bariatric patients (2013) and these can be retrieved from
www.ausbig.com.au/resources/bariatric-articles-and-information. See Chapter 9 for further infor-
mation relating to the positioning of the bariatric patient.
114
FEATURE BOX 5-2 » INTERNATIONAL COUNCIL ON SURGICAL PLUME
ACORN is a founding member of the International Council on Surgical Plume (ICSP), a not-for-profit
council established in 2015 to eliminate surgical plume from the perioperative environment. The
goals of the ICSP are to provide education on the hazards of surgical plume, assist with obtaining
funding for new clinical studies and research, broadcast findings from existing studies, drive regu-
latory and workplace improvements, and develop clinically relevant international standards. To
learn more about the ICSP, visit www.plumecouncil.com.
Benzaldeyde methane
Acetonitrile furfural (aldehyde)
Benzene 3_methyl butenal (aldehyde)
Acetylene hexadecanoic acid
Benonitrile 6_methyl indole (amine)
Acroloin hydrogen cyanide
Butadiene 4-methyl phenol
Acrylonitrile indole (amine)
Butene 2-methyl propanol (aldehyde)
Alkyl benzene isobutene
3-butenenitrile methyl pyrazine
Surgical plume
Ethane pyrrole (amine)

Carbon monoxide phenol Ethene styrene
Creosol propene Ethylene toluene (hydrocarbon)
1-decene (hydrocarbon) 2-propylene nitrile Ethyl benzene 1-undecene (hydrocarbon)
2,3-dihydro indene pryidine Ethynyl benzene xylene
Formaldehyde
FIGURE 5-13: Chemicals identified in surgical plume

Source: Adapted from Hill, O’Neill, Powell & Oliver (2012).
should be considered essential equipment during

surgery (ACORN, 2016). These units contain char-
coal filters that remove the aerosol contaminants,
4
after which the filtered smoke plume may be recir-
culated into the OR air (Schultz, 2014). Personnel
in the immediate vicinity of the surgical plume are
at risk of inhaling particles for which the standard
surgical mask provides little protection (ACORN,
2016; Harkavy & Novak, 2014). The wearing of well-
fitting, high-filtration face masks (e.g. N95) by sur-
gical personnel is recommended during potential
1 3 disease-transmissible procedures where there is a
likelihood of surgical plume being inhaled (Harkavy
2 & Novak, 2014); for example, during surgical abla-
tion of human papillomavirus (genital warts).
1. Diathermy tip (active electrode)
2. Plume capture point and handpiece
3. Evacuation tubing
PREVENTION OF FIRE OR EXPLOSIONS
4. Evacuation unit Reports of fire occurring in Australasian hospitals
FIGURE 5-14: Surgical plume evacuator are infrequent; however, 40–50 incidents per year
115
BOX 5-4 » FIRES IN THE PERIOPERATIVE ENVIRONMENT

The VSCC (2014) has identified the following equipment and materials from the perioperative
environment as potential elements of the fire triad:
IGNITION SOURCE OXIDISERS FUELS

Electrosurgical devices Oxygen Fluids: alcohol-based skin preps and tissue glues
Lasers Nitrous oxide Materials: endotracheal tubes (ETT), laryngeal masks,
Gases formed in the patient’s bowel linen, drapes and dressings, hair and other tissues
The most common scenarios for airway fires are as follows:

• Tracheostomy. When electrosurgery (ignition) is used for the tracheal incision and there is a high
oxygen saturation (oxidiser), the ETT or vaporised tissue can become the fuel for an airway fire.
• Tonsillectomy. During electrosurgery (ignition), when there is a high oxygen leak (oxidiser), the mask
or uncuffed ETT (fuel) may be ignited with other dry materials such as packs, gauze or drapes (fuel)
(VSCC, 2014).
News media reports estimate that more than 650 fires occur annually in perioperative environments in
the United States, some of which have led to patient injuries such as burns and smoke inhalation, while
others have resulted in patient deaths. The following links include news media reports on catastrophic
fires, videos, interviews and re-enactments, which may be useful continuing education resources for
those working in perioperative environments:
• ‘Woman’s face catches on fire during surgery.’ (2011). Retrieved from http://vitals.nbcnews.com/
_news/2011/12/02/9168719-womans-face-catches-on-fire-during-surgery
• ‘Operating room fires hurt hundreds each year.’ (2011). Retrieved from www.today.com/id/45117440/
ns/today-today_health/t/operating-room-fires-hurt-hundreds-each-year/#.VUlz1vmqqko
• I smell smoke [DVD] (2011). Retrieved from http://infonews.co.nz/news.cfm?id=70697. This DVD from
the Anglesea Procedure Centre in Hamilton, New Zealand, re-enacts the events surrounding a fire
that broke out during laparoscopic gynaecological surgery.
can be expected within Australia and New Zealand, hair or the surrounding padding (ACORN, 2016;
with about 20% of these incidents involving the VSCC, 2014). Although rare, the potential exists for
patient’s airway (Victorian Surgical Consultative explosion when diathermy is used on hollow organs
Council [VSCC], 2014). The risks of fire and explo- containing flammable gases, such as the bowel
sion are high in the perioperative environment (Blazquez & Thorn, 2010; Standards Australia,
because oxygen and other flammable gases are in 2004). Similarly, devices that have the potential to
abundant supply (see Box 5-4). Many flammable ignite flammable or combustible substances must
materials such as drapes, sponges and packaging be positioned, holstered or placed in ‘stand-by’
are present and provide fuel for a fire or have the mode to minimise the risk of inadvertent activation
potential to be ignited by electrosurgical or laser (ACORN, 2016).
equipment in use (ACORN, 2016; VSCC, 2014). Also,
when alcoholic skin preparations or bone cement To mitigate the risk of fire and/or explosion,
are in use, special care must be taken, as these are engineering controls are detailed in the Australian
fire accelerants (ACORN, 2016; Blazquez & Thorn, Standards (2004) and identify bulk storage limits
2010). When skin preparations are in use all clini- of flammable/combustible substances and correlate
cians must ensure that the prepared operative area to the size of storage area. When the identified
is allowed to dry before the drapes are applied and capacity exceeds these limits, a designated flame-
specific attention is required to prevent the skin proof cabinet is required (Standards Australia,
preparation from pooling, soaking into the patient’s 2004). Likewise, gas cylinders or bottles, which are
116
recognised as a fire accelerant, require monitoring gloves is recommended (Australian Society for
and strict controls. In compliance with Australian Clinical Immunology and Allergy [ASCIA],
Standard 2030.1-2009 and guidelines, gas bottles 2010; Mercurio, 2011).
are required to be stored vertically and secured • Type IV or allergic contact dermatitis. This is
within a well-ventilated area (British Oxygen generally a delayed-type hypersensitivity to
Company [BOC], 2012). Furthermore, BOC (2012) the allergen. It usually takes 6–48 hours to
specifies that gas cylinders higher than waist- emerge after exposure and normally resolves
height should be transported on a cylinder trolley. when exposure ceases. Though not as severe
Full and empty gas cylinders must be stored sepa- as type I, the reaction may result in severe
rately to avoid confusion (BOC, 2012). morbidity. It is strongly recommended that
alternative products be used (ASCIA, 2010;
SENSITIVITIES AND ALLERGIES Mercurio, 2011).
Many irritants such as disinfectants, antiseptics • Type I or immediate hypersensitivity to latex.
and latex products are commonly used within the This is the most serious response to contact
perioperative environment. Healthcare facilities with latex products or inhalation of latex
risk-assess patients and staff to minimise the proteins. Reactions are characterised by a
potential for adverse events; however, individuals range of symptoms, including itchy and runny
have the potential to be sensitive to, or develop an eyes and nose, hives, angio-oedema (swelling),
allergy when exposed to, an irritant or substance respiratory distress and anaphylaxis (ASCIA,
(ACORN, 2016; Chaari et al., 2010). 2010; Mercurio, 2011).
The next part of this chapter focuses on latex
allergies and the risk management strategies PREVENTION OF LATEX ALLERGY
required when caring for latex-sensitive patients. There is no known cure for latex allergy and so
Latex is a common trigger within the perioperative prevention is the key. The most effective way to
environment but in Australia exposure to latex pro- prevent an allergy is to prevent further sensiti
teins has been reduced significantly with the intro- sation (ASCIA, 2010) (see Feature box 5-3). In
duction of alternative products (Worth & Sheikh, addition, it may be helpful to ensure hands are
2013). Historically, the allergen or proteins were washed after wearing latex gloves. Hands should
introduced into the perioperative environment via be kept free of abrasions and sores wherever pos-
patient care products made from latex rubber (Mer- sible, and barrier protection should be employed
curio, 2011). As the cumulative effect of allergens using a water-based hand-care product rather than
present within latex products predisposes patients oil-based products. If symptoms of latex allergy
and healthcare workers to a latex sensitivity or do occur, synthetic gloves should be used and
allergy, the range of latex products has decreased all contact with items containing latex avoided
(ACORN, 2016). Any product that contains latex (ASCIA, 2010).
must be clearly labelled, patients must be risk-
assessed and healthcare workers must be prepared OCCUPATIONAL EXPOSURE
to respond to signs of reaction promptly and appro-
This section discusses protection against exposure
priately (ACORN, 2016).
to radiation and chemicals in the perioperative
environment. See Chapter 6 for protection against
TYPES OF ALLERGIC REACTIONS TO LATEX exposure to infectious agents and Chapter 10 for
Allergic reactions can be wide-ranging. There are information on protection against sharps injuries.
three types of reactions:
• Irritant or contact dermatitis. This is the most RADIATION SAFETY
commonly reported problem. It is a local, The use of ionising radiation is an integral diagnos-
non-allergic skin reaction characterised by tic and/or therapeutic component of modern
redness, dryness, scaling, blistering and healthcare. This technology has the ability to opti-
cracking. Such changes may be caused by mise patient outcomes; however, perioperative
sweating, glove irritation or frequent hand nurses must also minimise the risks for patients by
washing. The use of cotton liners or non-latex providing additional shielding for adjacent areas of
117
FEATURE BOX 5-3 » LATEX-SENSITIVE PATIENT PRECAUTIONS
Patients with latex sensitivity must be cared for in an environment free from contact with latex
products. All operating suites should have designated latex-free kits containing all the equipment
necessary to care for a latex-sensitive patient. Requirements for caring for the latex-sensitive
patient include:
• all perioperative staff wearing synthetic gloves and removing or changing any items of
attire containing latex
• sourcing and using equipment that is latex-free
• posting signs denoting a latex-free environment on external doors
• protecting the patient from anything that may contain latex (e.g. arm boards and OR tables
that may contain latex should be covered with linen) (ASCIA, 2010).
anatomy. The Australian Radiation Protection and

Nuclear Safety Agency (ARPANSA) (2014) stipu-
lates standards of practice for the use of ionising
radiation with the purpose of promoting radiation
safety for the public and clinicians. Each facility
must ensure that its practices align with the legisla-
tive requirements for storage, use and monitoring
of compliance with the national standards (Queens-
land Government, 2010).
Exposure to ionising radiation in the periopera-
tive environment is often unavoidable, as image
intensification (II) or mobile radiography units are
used to check the placement of internally placed
appliances. Because the effects of ionising radia-
tion are cumulative and at the same time are
not seen or felt, constant vigilance is required to
ensure occupational exposure is kept to a minimum.
The single most effective protection against expo-
sure is avoidance by leaving the vicinity of the
radiation source. If this is not possible, staff should
stand behind mobile lead shields or wear the
FIGURE 5-15a: X-ray gown
endorsed PPE as described in Standards Australia Source: Taken by M. Davies.
AS/NZS 4543 (2000), which includes gowns, thyroid
and lower limb shields, goggles and gloves (see
Fig. 5-15a and b).
When a gown, shield or thyroid protector is
removed, it should be hung on a special gown
hanger or laid out flat to avoid folds that can crack
the protective barrier and render it ineffective (see
Fig. 5-16a and b). Protective equipment must
undergo regular checks to ensure its integrity has
been maintained (Standards Australia, 2000). Staff
regularly exposed may wear a dose meter badge FIGURE 5-15b: Thyroid protector
that is regularly checked to identify if occupational Source: Mupparapu (2005).
118
exposure limits are exceeded (ARPANSA, 2014). In

addition, a radiation warning sign must be posted
at the entrance to rooms where radiation is used,
and illuminating signs must be present at all
entrances to rooms where fixed X-ray generators
are housed (Queensland Government, 2010).
The intent of radiological PPE is to protect the
clinician from radiation exposure; however, it has
long been acknowledged that occupational-related
injuries such as spinal and joint issues have been
attributed to the additional weight of wearing the
lead gowns and protectors (Klein et al., 2009). Radi-
ological PPE has recently been redesigned and is
currently available in two weights: lead lined or a
comparatively lightweight construction made of a
composite material. However, some states and ter-
ritories do not support the use of lightweight PPE
aprons when fluroscopy is used (ARPANSA, 2011).
It has long been accepted that pregnant women
should not be exposed to radiation, nor should they
be required to be in an OR or proximal to the device
when in use (Department of Health, Western Aus-
tralia, 2006; Monash University, 2013).
FIGURE 5-16a: X-ray protective equipment: appropriate care
CHEMICAL SAFETY
Many chemicals are used prior to and during the
provision of care within the OR. For example, deter-
gents are used during environmental cleaning,
while enzymatic instrument cleaners, high-grade
disinfectants and chemical sterilising products
such as peracetic acid are used in the reprocessing
of surgical instrumentation. Toxic chemicals and
drugs such as bone cement and cytotoxic agents are
adjunct therapies, used to optimise the surgical
intervention, while chemicals such as formalde-
hyde are used as fixatives for pathology specimens.
To maintain a safe work environment so that staff
are not exposed to hazards when handling chemical
agents, some basic principles must be employed.
Staff using chemicals and cytotoxic agents should
be educated on safe use and handling, as well as
management in the event of an accidental expo-
sure, including where spill kits and other items
required are stored. All staff should know where to
access the safety and data sheets (SDS), which
provide all the relevant information about the
chemicals in their workplace (ACORN, 2016). Simi-
larly, all chemicals should be stored, used and
disposed of according to the manufacturer’s recom-
mendations and state/territory or national guide-
FIGURE 5-16b: X-ray protective equipment: inappropriate care lines (ACORN, 2016).
119
When exposure cannot be avoided, staff must induction or the performance of surgical protocols
don PPE; this will vary depending on the chemical such as the SSC or surgical count (Ford, 2015). See
agent present. It may include gloves, eye protection Feature box 5-4.
and sometimes long-sleeved impervious gowns
and gauntlets. A number of chemicals emit vapours
that cumulatively could be detrimental to the peri- PREPARATION OF THE
operative team’s well-being, so specialised equip- OPERATING ROOM
ment has been engineered such as orthopaedic
Prior to commencing the daily work scheduled
helmet/hood systems and pre-packed vacuum
within the OR, the assigned nurses must carry out
mixing systems to minimise exposure to bone
a full check of the environment to ensure that all
cement fumes (Schlegel, Strum, Eysel & Breusch,
essential items are present, clean and in working
2010; Downes, Rauk & VanHeest, 2014). Staff
order. These items include but may not be limited
education and procedures outlining endorsed prac-
to the operating lights and table, instrument trol-
tices are required when specific chemicals such
leys, ESU, suction equipment, positioning aids,
as methylmethacrylate (MML)—a component of
linen skips and rubbish bags. If any item is not
bone cement—are in use. When scrubbed staff are
clean or is found to be missing or faulty, the nurse
handling bone cement, MML is known to increase
must take corrective action before the patient
the permeability of sterile gloves, negating their
enters the OR. The team should collaborate to place
effectiveness (Leggat, Smith & Kedjarune, 2009).
equipment with care to avoid congested work
Where possible, air concentrations should be moni-
spaces and to remove trip hazards associated with
tored regularly and kept within prescribed limits,
leads and power cords. The anaesthetic, circulating
and exhaust fans, fume cabinets and ventilation
and instrument nurses should discuss any specific
units should be used (Leggat et al., 2009). Diligent
requirements for the patients on the operating list
use of PPE is effective in protecting staff from the
with the anaesthetic and surgical teams and support
potential risks associated with chemical agents in
staff as part of team briefings or during the SSC
the perioperative environment (Downes et al.,
(ACORN, 2016). Any additional equipment required
2014), although the effectiveness is reliant on the
for the procedure (e.g. PPE such as laser safety
user/wearer complying with the manufacturers’
goggles and signage, positioning equipment, micro-
guidelines.
scopes, harmonic scalpel and so forth) must be
NOISE acquired and checked for cleanliness and function-
ality prior to its use (ACORN, 2016).
Environmental noise may be hazardous to the peri-
operative team, affecting their concentration and/
or communication (see Chapter 2 for further dis-
ROOM CLEANING
cussion). The verbal communication that occurs Prior to admitting a patient to the OR, the periop-
regularly between team members is not always erative team should ensure that all rubbish and
essential or patient-related (Ford, 2015). Research linen from the previous patient have been removed
by Wong and colleagues (2010) reported that the from room (ACORN, 2016). All contaminated furni-
loudest noise levels were recorded during the pre- ture, equipment, floors, walls and lights must be
paratory phase of the operation, which coincides cleaned with hospital-approved cleaning agents
with patient induction. Noise, distractions and between each patient episode. Similarly, the team
interruptions may compound the complexity of should spot-clean any blood and body fluid spills
each clinician’s role and impose an undesirable that may occur during the patient’s care. Any equip-
effect on the multiple tasks and decisions that are ment that is not required for the subsequent patient
required (Hicks, Wanzer & Goeckner, 2011). By con- should be cleaned after use and returned to its des-
trast, it has been suggested that music may enhance ignated storage area (ACORN, 2016).
the surgeon’s performance and reduce the patient’s
and intraoperative team’s stress levels (Wong et al., TERMINAL CLEANING
2010). The perioperative nurse should be alert to On completion of the day’s surgical procedures,
the negative impact of noise levels on patients the OR should be terminally cleaned. Terminal
and the team and should limit noises and other cleaning specifically involves a thorough cleaning
non-essential communication, particularly during of the equipment within the OR, as well as the
120
FEATURE BOX 5-4 » SIGHTS, SOUNDS AND SMELLS IN THE

PERIOPERATIVE ENVIRONMENT
Patients may feel anxious when they enter the unknown environment of the OR (Davis-Evans,
2013). It is an intimidating environment because of the cool temperature, narrow operating table,
surgical attire, sounds from technical equipment, and sight and sounds of the surgical instrumen-
tation being unpacked and prepared (Bergman, Stenudd & Engstrom, 2012; Davis-Evans, 2013).
Some authors suggest that perioperative team members work together to prevent the patient
from seeing or hearing things that may frighten them (Kelvered, Ohlen & Gustafsson, 2011). This
could be achieved by opening surgical supplies out of the patient’s view, placing drapes in front
of the patient, quietly performing the surgical count while the anaesthetic nurse interacts with
the patient and ensuring that all team members are wearing clean perioperative attire and shoes.
Patients under regional anaesthesia may be distracted by or fearful of the ambient sounds heard
from the surgery such as saws, drills and crackling sounds, and conversations between staff
members (Bergman et al., 2012; Palmer, 2013). In one study patients have reported a sense of
inferiority and being invisible in the OR when staff joke around and laugh with each other using
their own internal jargon (Forsberg, Soderberg & Engstrom, 2013). In this study, a patient described
their concern that the staff were having too much fun and would forget to do their job while they
were asleep. Patients under regional anaesthesia do not like the smell of the antiseptic used on
their skin but identify it as giving the OR a sense of being a sterile environment (Bergman et al.,
2012). The ESU also provides an unwelcome smell in the OR during its use in surgery (Weinberg,
Saleh & Sinha, 2015).
adjacent areas and corridors in the immediate WASTE MANAGEMENT

vicinity. All cleaning should be undertaken with
an approved hospital cleaning agent, using lint- Correct segregation of waste is essential for infec-
free cloths and mechanical friction to remove tion control purposes (ACORN, 2016). Similarly,
contamination and debris. Depending on individ- environmental awareness is the team’s responsibil-
ual local operational work instruction, designated ity, and this includes managing the volume and
cleaning staff may be allocated to terminally clean effect caused by the generation of clinical waste
the OR; however, it remains the responsibility of within the department and/or facility (ACORN,
perioperative nurses to ensure that the required 2016). In supporting staff to minimise waste, effec-
cleaning regime has been followed and the integ- tive strategies should include communicating and
rity of the room and equipment is maintained educating the perioperative team in the facility’s
in readiness for the next day. Another activity waste management endorsed local procedure
at the end of the day is the restocking of supplies (ACORN, 2016). Should recycling services be avail-
and the placement of furniture and equipment to able, appropriate specification for each substance
ensure that every item is replaced in anticipation must be identified and monitored to ensure the
of the next patient. This is particularly relevant for consistent placement of waste in the designated
OR readiness for emergency surgery (or disaster receptacle (ACORN, 2016). Waste can be divided
preparedness). into the following:
In addition to cleaning between procedures • General waste—items that are not heavily
and terminal cleaning, each facility must maintain soiled or saturated in blood or body fluids
a schedule of periodic environmental cleaning (e.g. paper, packaging, masks, gloves,
and maintenance, with the corroborating docu- dressings) (ACORN, 2016).
mentation verifying that it has been carried out • Clinical/contaminated waste—items saturated
according to hospital and infection control proto- in blood or body fluids that have the potential
cols (ACORN, 2016). to cause disease (e.g. used swabs and sponges,
121
or the contents of suction canisters). These

items require regulated disposal methods,
CONCLUSION
which may include incineration, autoclaving The perioperative environment is a complex and
or chemical disinfection prior to disposal challenging one, with many environmental risks
as landfill (ACORN, 2016; Queensland and potentially hazardous substances present for
Government, 2015). Note that there may be patients and staff. This chapter has described design
some exceptions, such as when facilities have features and work practices that can reduce the
a culturally sensitive process to return excised risk of injury and create a safe patient care environ-
tissue to the patient and/or family (Canterbury ment and workplace for staff. These design features
District Health Board, 2011). begin with a well-planned physical environment
• Recyclable/reposable waste—items that the with designated zones and coordinated traffic pat-
hospital is able to either recycle on site or terns for patients, staff and equipment. These are
transport to contractors for recycling supported by environmental controls such as air-
(e.g. plastic bottles, paper, instrument wraps, conditioning with a small range in ambient room
endostaplers, diathermy pencil/cables, temperature, humidity and airflow, and a range of
stainless steel) (ACORN, 2016). practices including perioperative attire and PPE,
• Cytotoxic waste—items contaminated by storage of supplies and cleaning regimes. When
cytotoxic drugs used for chemotherapy. These working with surgical equipment the perioperative
items have the potential to cause harm to nurse needs to assess and manage any workplace
healthcare clinicians, waste management health and safety issues. All members of the peri-
handlers and the public, so strict disposal operative team require an understanding of how,
methods are required, such as incineration at when and why equipment, devices and supplies are
high temperatures (ACORN, 2016; Queensland used to minimise risk of injury and to ensure safe
Government, 2015). patient care.

1. Operating suite layout
You have been asked to join the team designing a new suite of four operating rooms. The team has
selected a single-corridor layout with mirrored design for the paired ORs (whereby each OR layout is
a mirror image of the layout in the adjacent OR).
• What are the advantages and disadvantages of a single-corridor layout? Provide rationales for
your answers.
• What are the advantages and disadvantages of mirrored design for the OR? Provide rationales
for your answers.
2. Electrical safety
Mr Saunders is a 68-year-old male who is to undergo a right total knee replacement in your theatre.
He is 174 cm tall and weighs 120 kg. He has previously received a left total hip replacement.
• Discuss the precautions that should be considered when checking the ESU prior to com
mencement of surgery and applying the patient return electrode. Provide rationales for your
answers.
• Mr Saunders is positioned for surgery, the patient return electrode has been applied and he
has been prepped and draped. Soon after surgery commences the surgeon asks for the ESU
settings to be increased. List the checks you would make prior to increasing the power settings
on the ESU and explain why these checks are important.
122
3. Work health and safety

There are many precautions taken to maximise radiation safety for patients and staff working in the
perioperative environment.
• Outline the radiation safety PPE available for staff to wear during radiological exposure and
explain why this protective equipment must be handled carefully.
• Outline other aspects of radiation safety that protect your patients, your colleagues and your-
self. Explain why these are important.
4. Fire in the operating theatre
You are a perioperative nurse working inside the OR. The fire alarm sounds in the corridor outside
your OR and you are told to prepare to evacuate your patient. What do you need to do, with your team
members, to safely transfer this patient to another area to continue with the procedure? Give reasons
for your answers.
Association of periOperative Registered Nurses Al Benna, S. (2012). Infection control in operating theatres.
www.aorn.org Journal of Perioperative Practice, 22(10), 318–322.
Australasian Healthcare Facility Guidelines Alkatout, I., Schollmeyer, T., Hawaldar, N. A., Sharma, N., &
www.healthfacilityguidelines.com.au Mettler, L. (2012). Principles and safety measures of electro-
surgery in laparoscopy. Journal of the Society of Laproendo-
Australasian Society of Clinical Immunology and scopic Surgeons, 16(1), 130–139. doi:10.4293/1086808
Allergy 12X13291597716348.
www.allergy.org.au
Andersson, A., Bergh, I., Karlsson, J., Eriksson, B., & Nilsson,
Australian College of Operating Room Nurses K. (2012). Traffic flow in the operating room: An explorative
www.acorn.org.au and descriptive study on air quality during orthopedic
Australian Department of Health and Ageing trauma implant surgery. American Journal of Infection Control,
www.health.gov.au 40, 750–755. doi:10.1016/j.ajic.2011.09.015.
Australian Government WH&S Acts, regulations and code Andersson, A., Petzold, M., Bergh, I., Karlsson, J., Eriksson, B.,
of practice & Nilsson, K. (2014). Comparison between mixed and
www.business.gov.au/business-topics/employing-people/ laminar airflow systems in operating rooms and the influ-
workplace-health-and-safety/Pages/whs-acts-regulations ence of human factors: Experiences from a Swedish ortho-
-and-codes-of-practice.aspx pedic center. American Journal of Infection Control, 42,
665–669. doi:10.1016/j.ajic.2014.02.001.
Australian Radiation Protection and Nuclear Safety
Agency Assem, M., Ouda, B., & Wahed, M. (2011). Evaluation of an
www.arpansa.gov.au operating theatre design by a software program (OUDA:
www.arpansa.gov.au/Publications/Codes/rpsF-1.cfm operating theatre design analyser). International Journal of
Database Management Systems, 3(3), 69–76. doi:10.5121/
Infection Prevention & Control Nurses College ijdms.2011.3306.
www.infectioncontrol.co.nz
Australasian Health Infrastructure Alliance (AHIA). (2010).
International Council on Surgical Plume Australasian healthcare facility guidelines. Part B: Health facil-
www.plumecouncil.com/about.html ity briefing and planning, Version 4. Retrieved from <http://
Perioperative Nurses College of New Zealand Nurses healthfacilityguidelines.com.au/guidelines.aspx>.
Organisation Australasian Health Infrastructure Alliance (AHIA). (2012).
www.nzno.org.nz/groups/colleges/perioperative_nurses Australasian healthcare facility guidelines. Part D: Infection
_college prevention and control, Version 5. Retrieved from <http://
Standards Australia healthfacilityguidelines.com.au/AusHFG_Documents/
www.standards.org.au Forms/AllItems.aspx>.
123
Australian and New Zealand College of Anaesthetists Hospitals-Services/Health-Professionals/CDHB-Policies/

(ANZCA). (2006). Professional documents of the Australian and Clinical-Manual/Pages/default.aspx>.
New Zealand College of Anaesthetists. PS4. Recommendations Carayon, P., Xie, A., & Kianfar, S. (2014). Human factors and
for the postanaesthesia recovery room. Retrieved from ergonomics as a patient safety practice. BMJ Quality and
<www.anzca.edu.au/resources/professional-documents>. Safety, 23, 196–205. doi:10.1136/bmjqs-2013-001812.
Australian and New Zealand Society of Cardiac and Thoracic Carthey, J. (2010). Australasian health facility guidelines
Surgeons (ANZSCTS). (nd). Guidelines for the establishment of user survey: New South Wales. Retrieved from <http://
an adult cardiac surgery unit.Retrieved from <www.anzscts.org/ healthfacilityguidelines.com.au/references.aspx>.
policies-and-clinical-practice-guidelines>.
Chaari, N., Sakly, A., Amri, C., Mahfoudh, A., Henchi, M. A.,
Australian College of Operating Room Nurses (ACORN). Khalfallh, T., et al. (2010). Occupation allergy in healthcare
(2016). ACORN standards for perioperative nursing 2016– workers. Recent Patents on Inflammation & Allergy Drug Dis-
2017. Adelaide: Author. covery, 4(1), 65–74.
Australian Radiation Protection and Nuclear Safety Agency Commonwealth of Australia. (2011). Work health and safety
(ARPANSA). (2011). Radiation and health fact sheets: Aprons regulations 2011. Select Legislative Instrument 2011,
for protection against x-rays. Yallambi, Victoria: Author. No. 262. Retrieved from <www.comlaw.gov.au/Details/
Retrieved from <www.arpansa.gov.au/radiationprotection/ F2011L02664>.
Factsheets/index.cfm>.
Davis-Evans, C. (2013). Alleviating anxiety and preventing
Australian Radiation Protection and Nuclear Safety Agency panic attacks in the surgical patient. AORN Journal, 97(3),
(ARPANSA). (2014). Fundamentals for protection against ion- 355–363. doi:10.1016/j.aorn.2012.12.012.
izing radiation. Radiation Protection Series F-1. Yallambi,
Victoria: Author. Retrieved from <www.arpansa.gov.au/ de Korne, D., Van Wijngaarden, J., Van Rooji, J., Wauben, L.,
Publications/Codes/rpsF-1.cfm>. Hiddema, U., & Klazinga, N. (2012). Safety by design: Effects
of operating room floor marking on the position of surgical
Australian Radiation Protection and Nuclear Safety Agency devices to promote clean air flow compliance and minimise
(ARPANSA). (2015). Lasers and intense pulsed light (IPL) infection risks. British Medical Journal Quality and Safety, 21,
sources used for cosmetic purposes [Fact sheet.] Yallambi, 746–752. doi:10.1136/bmjqs-2011-000138.
Victoria: Author. Retrieved from <www.arpansa.gov.au/
radiationprotection/Factsheets/index.cfm>. Department of Health, Western Australia. (2006). Radiation
and pregnancy environmental health guide. Environmental
Australian Society for Clinical Immunology and Allergy Health Directorate, Department of Health, Western Aus-
(ASCIA). (2010). ASCIA guidelines for hospital management of tralia. Retrieved from <www.public.health.wa.gov.au/3/716/
latex allergic patients. Retrieved from <www.allergy.org.au/ 1/environmental_health_hazards.pm>.
health-professionals/papers/management-of-latex-allergic
-patients/about-guidelines>. Diab-Elschahawi, M., Berger, J., Blacky, A., Kimberger, O.,
Oguz, R., Kuelpmann, R., et al. (2011). Impact of different-
Baggish, M. S. (2016). Atlas of pelvic anatomy and gynecologic sized laminar air flow versus no laminar air flow on bacte-
surgery (4th ed.). St Louis: Elsevier Saunders. rial counts in the operating room during orthopedic surgery.
Ball, K. A. (2015). Surgical modalities. In J. Rothrock (Ed.) & American Journal of Infection Control, 39, e25–e29.
D. McEwen (Assoc. Ed.), Alexander’s care of the patient in doi:10.1016/j.ajic.2010.10.035.
surgery (15th ed., pp. 211–252). St Louis: Elsevier Mosby. Downes, J., Rauk, P. N., & VanHeest, A. E. (2014). Occupational
Bayazit, Y., & Sparrow, E. (2010). Energy efficiency compari- hazards for pregnant or lactating women in the orthopaedic
son of forced-air versus resistance heating devices for peri- operating room. Journal of the American Academy of Ortho-
operative hypothermia management. Energy, 35, 1211–1215. paedic Surgeons, 22(5), 326–332.
doi:10.1016/j.energy.2009.09.026. ElBardissi, A. W., & Sundt, T. M. (2012). Human factors and
Bergman, M., Stenudd, M., & Engstrom, A. (2012). The experi- operating room safety. Surgical Clinics of North America, 92,
ence of being awake during orthopaedic surgery under 21–35. doi:10.1016/j.suc.2011.11.007.
regional anaesthesia. International Journal of Orthopaedic and Ford, D. (2015). Speaking up to reduce noise in the OR.
Trauma Nursing, 16, 88–96. doi:10.1016/j.ijotn.2011.08.004. AORN Journal, 102(1), 85–88. <http://dx.doi.org/10.1016/
Birgand, G., Saliou, P., & Lucet, J. (2015). Influence of staff j.aorn.2015.04.019>.
behaviour on infectious risk in operating rooms: What is the Forsberg, A., Soderberg, S., & Engstrom, A. (2013). People’s
evidence? Infection Control and Hospital Epidemiology, 36(1), experiences of suffering a lower limb fracture and under
93–106. doi:10.1017/ice.2014.9. going surgery. Journal of Clinical Nursing, 23, 191–200.
Blazquez, E., & Thorn, C. (2010). Fires and explosions. Anaes- doi:10.1111/jocn.12292.
thesia and Intensive Care Medicine, 11(11), 455–457. Fragar, L., & Depczynski, J. (2011). Beyond 50. Challenges at
British Oxygen Company (BOC). (2012). Guidelines for gas work for older nurses and allied health workers in rural
cylinder safety. Retrieved from <www.boc-gas.com.au/en/ Australia: A thematic analysis of focus group discussions.
index.html>. BMC Health Services Research, 11(42), 1–13.
Canterbury District Health Board. (2011). Returning of tissue/ Fuller, J. (2013). Surgical technology: Principles and practice
body parts to patients. Retrieved from <www.cdhb.health.nz/ (6th ed.). St Louis: Saunders.
124
Guy, B. (2013). The crate weight project. The Dissector, 41(3), Knulst, A., Laurents, P., Stassen, M., Grimbergen, C., &
30–34. Dankelman, J. (2009). Choosing surgical lighting in the
LED era. Surgical Innovation, 16(4), 317–323. doi:10.1177/
Hardcastle, T., Stander, M., Kalafatis, R., Hodgson, R., &
1553350609353766.
Gopalan, D. (2013). External patient temperature control in
emergency centres, trauma centres, intensive care units and Leggat, P., Smith, D., & Kedjarune, U. (2009). Surgical applica-
operating theatres: A multi-society literature review. South tions of methyl methacrylate: A review of toxicity. Archives
African Medical Journal, 103(9), 609–611. doi:10.7196/ of Environmental & Occupational Health, 64(3), 207–212.
SAMI.7327. doi:10.1080/19338240903241291.
Harkavy, L., & Novak, D. (2014). Clearing the air: Surgical Mercurio, J. (2011). Creating a latex-safe perioperative envi-
smoke and workplace safety practices. OR Nurse Journal, 8(6), ronment. OR Nurse Journal, 5(6), 18–25.
1–7. Michael, S., Baggish, M. D., FACOG, Mickey, M., & Karram,
Hicks, R., Wanzer, L., & Goeckner, B. (2011). Perioperative M. D. Atlas of Pelvic Anatomy and Gynecologic Surgery (4th
pharmacology: A framework for perioperative medication ed.). Copyright © 2016 by Elsevier, Inc. All rights reserved.
safety. AORN Journal, 93(1), 136–142. doi:10.1016/j.aorn. Ministry of Health, NSW. (2015). GL2015_002. Work health
2010.08.020. and safety. Controlling exposure to surgical plume. Sydney:
Hill, D., O’Neill, J., Powell, R., & Oliver, D. (2012). Surgical Author. Retrieved from <www.health.nsw.gov.au/policies/
smoke: A health hazard in the operating theatre. A study to pages/default.aspx>.
quantify exposure and a survey of the use of smoke extrac- Monash University. (2013). Radiation use during pregnancy or
tor systems in UK plastic surgery units. Journal of Plastic, breast feeding [Procedure.] Retrieved from <www.monash
Reconstructive & Aesthetic Surgery, 65(7), 911–916. .edu.au/ohs>.
doi:10.1016/j.bjps.2012.02.012.
Mupparapu, M. (2005). Radiation protection guidelines for
Hooper, G., Rothwell, A., Frampton, C., & Wyatt, M. (2011). the practicing orthodontist. American Journal of Orthodontics
Does the use of laminar flow and space suits reduce early and Dentofacial Orthopedics, 128(2), 168–172.
deep infection after total hip and knee replacement? The
ten year results of the New Zealand Joint Registry. The National Health and Medical Research Council (NHMRC).
Journal of Bone and Joint Surgery, 93(1), 85–90. (2013). Clinical practice guidelines for the management of
overweight and obesity in adults, adolescents and children in
Hughes-Hallett, A., Mayer, E. K., Pratt, P. J., Vale, J. A., & Darzi, Australia. Melbourne: National Health and Medical Research
A. W. (2015). Quantitative analysis of technological innova- Council. Retrieved from <www.ausbig.com.au/resources/
tion in minimally invasive surgery. The British Journal of bariatric-articles-and-information>.
Surgery, 102(2), 151–157. doi:10.1002/bjs.9706.
Ogg, M. (2014a). Allowing OR doors to remain open during
Iudicello, S., & Fadda, A. (2013). A road map to a compre- and between procedures. AORN Journal, 100(5), 543–545.
hensive regulation on ventilation technology for operating doi:10.1016/j.aorn.2014.08.001.
rooms. Infection Control and Hospital Epidemiology, 34(8),
858–860. Ogg, M. (2014b). Negative pressure rooms. AORN Journal,
100(5), 545. doi:10.1016/j.aorn.2014.08.001.
Jamadarkhana, S., Mallick, A., & Bodenham, A. R. (2013).
Intensive care management of morbidly obese patients. Palmer, L. (2013). Anaesthesia 101: Everything you need to
Continuing Education in Anaesthesia, Critical Care & Pain 3. know. OR Nurse Journal, 7(4), 20–29.
doi:10.1093/bjaceaccp/mkt040. Panahi, P., Stroh, M., Casper, D., Parvizi, J., & Austin, M. (2012).
Jaskunas, M. (2015). The bariatric patient’s surgical journey. Operating room traffic is a major concern during total joint
OR Nurses Journal, January, 31–39. doi:10.1097/01.ORN. arthroplasty. Clinical Orthopaedics and Related Research,
0000457109.55496.55. 470(10), 2690–2694.
Kaneko, T., & Davidson, M. (2014). Use of the hybrid operat- Phillips, N. (Ed.), (2013). Berry & Kohn’s operating room tech-
ing room in cardiovascular medicine. Circulation, 130, 910– nique (12th ed.). St Louis: Mosby.
917. doi:10.1161/circulationaha.114.006510. Queensland Government. (2010). PR100:2010. Standard for
Kelvered, M., Ohlen, J., & Gustafsson, B. (2011). Operating premises: Ionising radiation sources. Retrieved from <www
theatre nurses’ experience of patient-related intraoperative .health.qld.gov.au/radiationhealth/legislation/standards
nursing care. Scandinavian Journal of Caring Sciences, 26, .asp>.
449–457. Queensland Government. (2015). Guideline: Clinical and
Klein, L., Miller, D., Balter, S., Laskey, W., Haines, D., Norbash, related waste. Retrieved from <https://www.ehp.qld.gov.au/
A., et al. (2009). Occupational health hazards in interven- era/clinical-and-related-waste-em1329.pdf>.
tional laboratory: Time for a safer environment. Radiology, Queensland Health. (2013a). Capital infrastructure require-
250(2), 538–544. ments (2nd ed.). Volume 3: Architecture and health facility
design. Section 1: Principles. Retrieved from <www.health
Kneedler, J., Pfister, J., & Moss, R. (2013). Advanced energy:
.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-374-3.1.pdf>.
The perioperative perspective. An online continuing education
activity. Pfiedler Enterprises. Retrieved from <www.pfiedler Queensland Health. (2013b). Guideline: Storage design for
.com/ce/1127/index.html>. sterile and non-sterile stock storage for new and refurbished
125
healthcare facilities. Retrieved from <www.health.qld.gov.au/ Standards Australia. (2014). AS/NZS 4187 Reprocessing of
chrisp/sterilising/sterile-stock-storage-V1.0.pdf>. reusable medical devices in health service organizations.
Queensland Health. (2013c). Capital infrastructure require- Sydney: Author.
ments (2nd ed.). Volume 3: Architecture and health facility Victorian Surgical Consultative Council (VSCC). (2014).
design. Section 2: Manual. Retrieved from <www.health Victorian Surgical Consultative Council triennial report
.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-374-3.2.pdf>. 2011–2013. Retrieved from <www.health.vic.gov.au/vscc/
Queensland Health. (2013d). Capital infrastructure require- publications.htm>.
ments (2nd ed.). Volume 4: Engineering and Infrastructure. Weinberg, D., Saleh, M., & Sinha, Y. (2015). Twelve tips
Retrieved from <www.health.qld.gov.au/qhpolicy/docs/gdl/ for medical students to maximise learning in theatre.
qh-gdl-374-4.3.pdf>. Medical Teacher, 37, 34–40. doi:10.3109/0142159X.2014
Rovaldi, C. J., & King, P. J. (2015). The effect of an interdisci- .932899.
plinary QI project to reduce OR foot traffic. AORN Journal, 101, Wong, S. W., Smith, R., & Crowe, P. (2010). Optimizing the
667–678. <http://dx.doi.org/10.1016/j.aorn.2015.03.011>. operating theatre environment. ANZ Journal of Surgery, 80,
Rowen, L., Hunt, D., & Johnson, K. L. (2012). Managing obese 917–924. doi:10.1111/j1445-2197.2010.05526x.
patients in the OR. OR Nurse Journal, 3, 26–35. doi:10.1097/01. WorkCover NSW. (2013). Work health and safety essentials for
ORN.0000412324.97287.aa. nurses and midwives. NSW Nurses and Midwives’ Association.
Safe Work Australia. (2015). Exposure to multiple hazards Retrieved from <www.nswnma.asn.au/?s=Work+Health+and
among Australian workers. Canberra: Author. +Safety+Essentials+for+Nurses+and+Midwives>.
Schlegel, U., Strum, M., Eysel, P., & Breusch, S. (2010). Pre- Worth, A., & Sheikh, A. (2013). Prevention of anaphylaxis
packed vacuum bone cement mixing systems. A further step in healthcare settings. Clinical Immunology, 9(9), 855–869.
in reducing methylmethacrylate exposure in surgery. Annals doi:10.1586/1744666X.2013.828871.
of Occupational Hygiene, 54(8), 955–961. doi:10.10.1093/
annhyg/meq045. FURTHER READING
Schultz, L. (2014). An analysis of surgical smoke plume Dasari, K., Albrecht, M., & Harper, M. (2012). Effect of forced-
components, capture, and evacuation. AORN Journal, 99(2), air warming on the performance of operating theatre
289–298. laminar flow ventilation. Anaesthesia, 67, 244–249. doi:
ServiceMed. (2010). Argon-enhanced electrosurgery. Retrieved 10.1111/j.1365-2044.2011.06983.x.
from <www.servicemed.eu/index.php?option=com_content Flowers, J. (2012). Fire safety in procedural areas. Journal
&view=article&id=255:argon-enhanced-electrosurgery&c of Radiology Nursing, 31(1), 13–19. doi:10.1016/j.jradnu.
atid=67:electrosurgery&Itemid=284&lang=en>. 2011.10.007.
Shah, J., Patel, S., & Singh, B. (2012). Jatin Shah’s head and Gianella, M., Hahnloser, D., Rey, J., & Sigrist, M. (2014). Quan-
neck surgery and oncology (4th ed.). Philadelphia: Elsevier. titative chemical analysis of surgical smoke generated
Smalley, P. (2011). Laser safety: Risks, hazards, and control during laparoscopic surgery with a vessel-sealing device.
measures. Laser Safety, 20(2), 95–106. Surgical Innovation, 21(2), 170–179. doi:10.1177/155335
0613492025.
Spagnolo, G., Ottria, G., Amicizia, D., Perdelli, F., & Cristina,
M. (2013). Operating theatre quality and prevention of sur- Hill, D., O’Neill, J., Powell, R., & Oliver, D. (2012). Surgical
gical site infections. Journal of Preventative Medicine and smoke: A health hazard in the operating theatre. A study
Hygiene, 54(3), 131–137. to quantify exposure and a survey of the use of smoke
extractor systems in UK plastic surgery units. Journal of
Spruce, L., & Braswell, M. L. (2012). Implementing AORN’s Plastic, Reconstructive & Aesthetic Surgery, 65, 1–6.
recommended practices for electrosurgery. AORN Journal, doi:10.1016/j.bjps.2012.02.012.
95(3), 373–384. doi:10.1016/j.aorn.2011.12.018.
Hirsch, T., Hubert, H., Fischer, S., Lahmer, A., Lehnhardt, M.,
Standards Australia. (2000). AS/NZS 4543.3.2000 Protective Steinau, H., et al. (2012). Bacterial burden in the operating
devices against diagnostic medical X-radiation. Part 3: Protec- room: Impact of airflow systems. American Journal of Infec-
tive clothing and protective devices for gonads. Sydney: Author. tion Control, 40, e228–e232. doi:10.1016/j.ajic.2012.01.007.
Standards Australia. (2004). AS/NZS 2500 Guide to the safe Hohler, S. (2015). Latex allergies: Protecting patients and
use of electricity in patient care. Sydney: Author. staff. OR Nurse Journal, 9(1), 12–18. doi:10.1097/01.
Standards Australia. (2011a). AS/NZS IEC 60825.1:2011 ORN.0000457107.47873.aa.
Safety of laser products: Equipment classification and require- Moatari-Kazerouni, A., Chinniah, Y., & Agard, B. (2014).
ments. Sydney: Author. Integrating occupational health and safety in facility
Standards Australia. (2011b). AS/NZS IEC 60825.14:2011 layout planning, part 1: Methodology. International Journal
Safety of laser products: A user guide. Sydney: Author. of Production Research, 53(11), doi:10.1080/00207543.2014
Standards Australia. (2012). AS/NZS 1668.2 The use of venti- .970712.
lation and airconditoning in buildings. Part 2: Mechanical Mowbray, N., Ansell, J., Warren, N., Wall, P., & Torkington, J.
ventilation in buildings. Sydney: Author. (2013). Is surgical smoke harmful to theater staff? A
126
systematic review. Surgical Endoscopy, 27, 3100–3107. Smalley, P., & Cubitt, J. (2015). Clean air in surgery: A new
doi:10.1007/s00464-013-2940-5. ACORN initiative. ACORN Journal, 28(3), 38–39.
Quay, P. (2011). Fire evacuation from an operating theatre. Varu, V., Greenberg, J., & Lee, J. (2013). Improved efficiency
Private Hospital Magazine, August, 44–45. Retrieved from and safety for EVAR with utilization of a hybrid room. Euro-
<www.apha.org.au/wp-content/uploads/2011/08/044 pean Journal of Vascular and Endovascular Surgery, 46(6),
_PH0811_Fire_R2.pdf>. 675–679. doi:10.1016/j.ejvs.2013.09.023.
Royal Children’s Hospital, Melbourne. (nd). Biomedical engi- Waitemata District Health Board. (2002). Report into the
neering electrical safety. Retrieved from <www.rch.org.au/ operating fire incident. Retrieved from <www.medsafe.govt
bme_rch/electrical_safety>. .nz/downloads/alertWaitemata.pdf>.
127
Chapter 6
INFECTION PREVENTION
AND CONTROL
JANNELLE CARLILE AND MARGARET EVANS
LEARNING OUTCOMES
• Differentiate between microorganisms and their pathogenicity
• Discuss the human body’s defence mechanisms against infection
• Explore measures to minimise the transmission of pathogens in the perioperative environment
• Identify the principles of standard and transmission-based precautions
• Apply the principles of aseptic technique in perioperative practice
• Discuss the methods of sterilisation and disinfection
KEY TERMS
asepsis
aseptic field
aseptic technique
double gloving
gowning
healthcare-associated infection
microorganisms
personal protective equipment
scrubbing
skin preparation
sterile
sterilisation
surgical conscience
128
CHAPTER 6 | Infection prevention and control
reproduce itself in 20 minutes and give rise to over

INTRODUCTION a million bacterial cells in about 10 hours (Lee &
This chapter presents fundamental aspects of infec- Bishop, 2013). Bacteria are the most common cause
tion prevention and control and the application of of surgical site infections (SSIs), with staphylococci
the principles of asepsis, which are the cornerstone and streptococci being responsible for many of
of perioperative nursing practice. The infective these (Lee & Bishop, 2013; Spry, 2015.) Most bac-
process is discussed, along with modes of transmis- teria found in the perioperative environment are
sion and how the body combats pathogenic micro- shed from the skin of personnel (Spry, 2015); thus
organisms. Environmental controls enacted to hand hygiene is the most efficacious way of coun-
reduce the spread of infection, along with standard tering their spread.
and transmission-based precautions, are described
and their practical application discussed. The prin- GRAM-POSITIVE COCCI
ciples of asepsis, the practical application of aseptic Staphylococci
technique and the concept of surgical conscience Staphylococci (e.g. Staphylococcus aureus and
are examined; also addressed is the surgical scrub, Staphylococcus epidermidis) are round or spherical-
and the methods of prepping and draping the surgi- shaped Gram-positive bacteria, and are part of the
cal patient and creating an aseptic field. Infection normal flora found on the skin and mucous mem-
control as an adverse event is briefly explored. branes of the nasopharynx, urethra and vagina.
Methods of sterilisation and disinfection complete They can coexist in these areas without any adverse
this chapter. effect on the host and those that live on the skin
are termed transient organisms. Staphylococci can
survive for long periods in the air, dust, bedding and
CLASSIFICATION AND TYPES clothing, making cleanliness of the perioperative
OF MICROORGANISMS environment paramount (Spry, 2015). These bacte-
In order to understand the infective process and the ria are transmitted from the hands of the host to
measures taken to prevent transmission of micro- another person, where they can subsequently have
organisms, it is necessary to review aspects of significant negative effects. For example, they can
microbiology. It is beyond the scope of this text to enter the wound of a surgical patient and cause a
explore microbiology in depth but a brief examina- wound infection; more seriously, exotoxins secreted
tion of the particular organisms of concern, in rela- by S. aureus can cause toxic shock syndrome which,
tion to the care of surgical patients, is presented. if left untreated, can be fatal (Lee & Bishop, 2013;
Two main classifications of microorganisms are Spry, 2015). Staphylococci are strongly associated
described by Burton and Engelkirk (2014): with healthcare-associated infection (HAI, also
known as nosocomial infection).
• cellular (e.g. bacteria, algae, protozoa and fungi)
• acellular (e.g. viruses and prions). Streptococci
Streptococci are responsible for a wide range of
Microorganisms of special interest to perioperative
diseases and infections. These include throat and
nurses include several types of bacteria, fungi,
wound infections, pneumonia, septicaemia and
viruses and prions, which are outlined below; this
necrotising fasciitis. Streptococcus pyogenes is fre-
does not include all microorganisms that may be
quently implicated in SSIs. Streptococci tend to be
found in the hospital setting.
more virulent than staphylococci; however, they
are much more likely than the latter to be sensitive
BACTERIA to penicillin (Spry, 2015.). Streptococci can be a
Bacteria are simple, unicellular organisms contain- normal resident of the upper airway, vagina and
ing internal structures, such as a nucleus, cyto- anus (Lee & Bishop, 2013; Spry, 2015) and are
plasm, plasmids and ribosomes (Lee & Bishop, spread via direct and indirect contact, causing
2013). Even though there are thousands of types of infection and illness in susceptible populations.
bacteria, very few cause disease/infection. Bacteria
are extremely adaptable and survive and grow in Enterococci
various environments, often multiplying rapidly. Enterococci are bacteria normally found in the gas-
For example, a single Escherichia coli bacterium can trointestinal tract and female genital tract. They
129
cause infections such as SSIs and bloodstream with surfaces for 10 minutes (National Health and
infections (BSIs). They can be transmitted via the Medical Research Council [NHMRC], 2010; Spry,
hands of a healthcare worker or contaminated 2015).
equipment to susceptible, high-risk patients,
including surgical patients (Spry, 2015). They are
becoming an increasingly significant hospital path- FUNGI
ogen because strains of enterococci have developed There are two major types of fungi—yeast and
resistance to the antimicrobial drug vancomycin, moulds—and many are beneficial to humans; for
which is the last-resort treatment for methicillin- example, moulds are a source of antibiotics (Lee &
resistant Staphylococcus aureus (MRSA) (Lee & Bishop, 2013). They are often termed ‘nature’s orig-
Bishop, 2013). inal recyclers’ because they secrete enzymes that
decompose dead plant and animal matter, turning
them into absorbable nutrients. Although of less
GRAM-POSITIVE RODS significance within the perioperative setting, some
Clostridia are Gram-positive anaerobic bacteria fungal strains, such as Candida albicans, cause
that can cause serious illness due to their ability to localised infections in the mouth and reproductive
produce endospores which can survive for many tract, which have the potential to become systemic
years in a dormant state and are highly resistant to infections. Fungi have been isolated in the nail beds
drying, heat and routine disinfection procedures of nurses who wear acrylic nails, even following
(Spry, 2015). When conditions improve, the endo normal surgical scrub techniques. This has led to
spores germinate into new bacterial cells and can policies prohibiting acrylic and gel-coated nails
cause significant infections, which can be fatal. within the operating suite due to the danger of
Examples are Clostridium perfringens, which can transmitting fungal infections to patients (Austral-
cause gas gangrene, and Clostridium difficile (C. dif- ian College of Operating Room Nurses [ACORN],
ficile), which forms part of the normal flora of the 2016; NHMRC, 2010).
large bowel. However, the normal flora can become
Aspergillus fumigatus is a fungus commonly
disrupted in patients taking high doses of antibiot-
found in the environment and it may be liberated
ics, particularly over a prolonged period. This allows
into the air in and around the perioperative envi-
C. difficile to release toxins that can cause signifi-
ronment during routine maintenance work and
cant complications such as dehydration, kidney
building renovations and via air-conditioning vents.
failure, toxic megacolon and bowel perforation.
Strict infection prevention and control risk man-
Current treatment is with the use of metronidazole
agement practices must be implemented to mini-
and, in severe cases, vancomycin, combined with
mise any potential outbreaks of aspergillosis when
strict infection control measures (Cheng et al.,
any maintenance requiring entry into the roof
2011).
space or building works within close proximity to
C. difficile is transmitted by contact with an the operating suite is being conducted. Such an
infected person or objects; due to its highly infec- infection can be lethal to immunosuppressed
tious nature patients with C. difficile should not be patients in particular (Pelaez et al., 2012).
admitted to the operating suite unless requiring
urgent surgery. Management of patients with C. dif-
ficile in the perioperative environment requires VIRUSES
strict infection prevention and control measures. A virus (from the Latin virus meaning toxin or
Contact precautions should be followed and hand poison) is a microscopic organism. Viruses are
washing using antimicrobial soap and water, rather among the smallest known infectious agents and
than alcoholic-based hand rub, is required to are responsible for causing severe, often fatal infec-
mechanically dislodge the organism from skin sur- tions (e.g. hepatitis C). Viruses replicate by invad-
faces. Following the patient’s procedure the envi- ing a host cell and using its DNA/RNA, protein and
ronment will require thorough cleaning. Once all other nutrients to survive and reproduce. In the
visible contaminants have been removed using a process, they damage or destroy the host cell. The
neutral detergent, surfaces must be cleaned with reproductive process concludes when the host cell
a bleach-based solution, which is left in contact bursts (cell lysis), spreading new viruses to nearby
130
cells, where the process is repeated (Lee & Bishop, implicated in unusual neurodegenerative disorders,
2013). This process stimulates an antibody response including bovine spongiform encephalopathy (BSE)
in the infected person. or ‘mad cow disease’ and, in humans, Creutzfeldt-
Hepatitis-causing viruses are among the most Jakob disease (CJD) (Lee & Bishop, 2013). The latter
common viruses and there are five identified viral is thought to be due to an intracellular accumula-
strains (hepatitis A, B, C, D, E). The strains of most tion of an abnormal form of a normal prion protein
concern to perioperative nurses are hepatitis B and found throughout the body and brain and appears
C viruses. These blood-borne pathogens along with to assist the neurons to communicate and transport
human immunodeficiency virus (HIV) can be trans- minerals. The disease can have a long incubation
mitted through contact with blood and body fluids period, sometimes lasting years, and is most often
during invasive procedures. This may be through fatal (Lee & Bishop, 2013). Prions are unusually
exposure to a sharps injury or via splashes into resistant to conventional chemical and physical
unprotected eyes or mucous membranes. sterilising methods; special protocols for managing
instruments that have been used on infected or
potentially infected patients are discussed later in
PRIONS this chapter (Spry, 2015). Table 6-1 summarises the
Prions are small infectious particles consisting common microorganisms found in the periopera-
of protein only with no nucleic acid. They are tive environment.
TABLE 6-1: Microorganisms Commonly Found in the Perioperative Environment
MICROORGANISM SOURCE/LOCATION MODE OF TRANSMISSION

Aspergillus fumigatus Dust from maintenance work in Airborne
proximity to operating room Direct contact
Clostridium difficile Large bowel Direct contact
Escherichia coli Intestinal tract Faeces

Urinary tract Urine
Direct contact
Hepatitis virus Blood Blood-borne

HIV Body fluids Direct contact
Mycobacterium tuberculosis Respiratory tract Airborne

Urinary tract Droplet
Direct contact
Pseudomonas Urinary tract Direct contact

Intestinal tract Urine
Water Faeces
Staphylococci Skin, hair, bedding Direct contact

Upper respiratory tract Airborne
Serratia marcescens Urinary tract Direct contact

Respiratory tract Water
Streptococci Oronasopharynx Direct contact

Skin, perianal area Airborne
SOURCE: ADAPTED FROM PHILLIPS (2013).
131
DEVELOPMENT OF RESISTANCE TO RESERVOIR

ANTIMICROBIAL DRUGS The microorganisms responsible for the majority
It is thought that the overuse and inappropriate use of HAIs originate from either the patient’s own
of antibiotics is a major factor in the emergence of body flora (endogenous infections) or external
resistant pathogens such as carbapenem-resistant (exogenous) sources such as other patients, staff or
enterobacteriaceae (CRE), extended spectrum beta equipment. Some microorganisms exist harmlessly
lactamase (ESBL) and multidrug-resistant tubercu- on patients’ skin, in hair follicles, sweat glands
losis (MDR-TB). This, combined with a reduction in (staphylococci) or within the bowel as normal flora
the discovery and development of new antibiotic (E. coli). However, when these microorganisms
agents, is placing patients at risk of prolonged enter another area of the body, they can cause
recovery from infections—and in some cases infection (e.g. E. coli can cause bladder infections
patients will die from drug-resistant infections. and S. aureus causes SSIs). Both transient and resi-
Australian hospitals have introduced antimicro- dent microorganisms are found on the skin (ACORN,
bial stewardship programs with the aim of reducing 2016) and these can be transferred by direct con-
unnecessary use of antibiotics, optimising their use tact between patients, healthcare workers, visitors
and promoting antibiotics less likely to select resist- and equipment, or by transfer to other body sites
ant bacteria. In New Zealand the Ministry of Health within the same patient, where infection can sub-
has an Antibiotic Resistance Advisory Group that sequently develop. Transient microorganisms are
undertakes a similar function (Australian Commis- easily removed by good hand hygiene (Spry, 2015).
sion on Safety & Quality in Healthcare [ACSQHC/
the Commission], 2014; Duguid & Cruickshank, PORTAL OF EXIT
2011; NZ Ministry of Health, 2007). These emerging For microorganisms to continue infecting other
resistant pathogens, along with those most com- hosts, they must have a means of leaving the body.
monly known (MRSA and vancomycin-resistant This may be via blood or other body fluids, faeces
enterococci [VRE]) that are frequently implicated in or droplets from the respiratory tract (Spry, 2015).
SSIs, will pose serious ongoing threats to surgical
patients (Lee & Bishop, 2013). TRANSMISSION
With the exception of airborne microorganisms
RISK MANAGEMENT OF the transmission of microorganisms cannot occur
unassisted. In the hospital setting, the most
MICROORGANISMS common mode of transmission is through people;
The process of infection can be likened to the links this is mainly via the hands of healthcare workers,
in a chain—break any of the links and infection can other patients or visitors directly touching the
be prevented (Spry, 2015). There are six links in the patient or through the use of contaminated objects
chain of infection: (NHMRC, 2010). Vigilance in cough etiquette, hand
1. infectious agent hygiene and the use of aseptic technique is the
most efficient method of preventing the transmis-
2. reservoir sion of microorganisms. Understanding the routes
3. portal of exit and sources of transmission is vital if this link in
the chain is to be broken.
4. transmission
5. portal of entry PORTAL OF ENTRY
6. susceptible host. The body has natural barriers to prevent the entry
of microorganisms, including the skin, mucous
INFECTIOUS AGENT membranes and their various secretions, such as
An infection results from microorganisms invading tears, mucus and acid produced by the stomach.
and multiplying in the host. Pathogenic microor- However, these defences can be breached in a
ganisms in the form of bacteria, viruses and fungi number of ways:
are the causative agents in wound and systemic • Inhalation. Dust and water droplets that carry
infections suffered by patients. microorganisms can be transferred by people
132
BREAKING THE CHAIN OF INFECTION
INFECTIOUS Rapid, accurate

Treatment of AGENT
underlying identification of
Bacteria Fungi organisms
diseases Viruses Rickettsiae Employee health
Protozoa
SUSCEPTIBLE
HOST Environmental
Recognition of Immunosuppression RESERVOIRS sanitation
high-risk Diabetes - Surgery - Burns People
patients Equipment Disinfection/
Cardiopulmonary
INVOLVES ALL Water sterilisation
HEALTH
PROFESSIONALS Proper attire
Aseptic
technique Hand washing
PORTAL OF YOU PORTAL OF
ENTRY EXIT Control of
Catheter Mucous membrane GI track Excretions Secretions excretions and
care Respiratory tract Skin droplets secretions
Broken skin
Wound MEANS OF
Rubbish and waste
care Hand washing TRANSMISSION
Isolation disposal
Direct contact Fomites
Ingestion Airborne
Food handling
Sterilisation Airflow control
FIGURE 6-1: Prevention strategies that break the chain of infection
and enter the patient via the respiratory Figure 6-1 demonstrates how implementing
system (e.g. TB, influenza, measles). prevention strategies can break a link in the chain
• Inoculation. Microorganisms can enter the skin of transmission and safeguard the patient.
when the skin is breached through a sharps
injury, trauma, a planned surgical incision or NORMAL BODY DEFENCES
dermatitis.
Whether or not a person develops an infection as a
• Ingestion. Microorganisms can enter the result of invasion by microorganisms will depend
intestinal tract through contaminated water on the susceptibility of that person (the host) and
or food. the virulence of the microorganism. It will also
depend on the body’s ability to defend itself against
SUSCEPTIBLE HOST the invading pathogens.
Patients undergoing surgery become susceptible
hosts when their skin barrier is breached by a surgi- EXTERNAL BARRIERS
cal incision. Their immune system is also compro-
External barriers include the skin, mucous mem-
mised, further increasing their susceptibility to
branes and their respective secretions; these are the
infection. Others who have increased susceptibility
body’s first line of defence in preventing infection.
include those:
The epidermal layer of the skin contains a protein,
• who are very young or elderly keratin, which provides substantial resistance to
• with poor nutritional status bacterial enzymes and toxins. The dermal layer of
skin contains sebum-secreting sebaceous glands,
• with the presence of underlying conditions, which lower the pH of the skin, inhibiting the
such diabetes, vascular disease, or chronic growth of some bacteria and fungi (Lee & Bishop,
renal or liver failure 2013). Mucous membranes heal quickly despite
• who are immunocompromised (e.g. patients much wear and tear, and their sticky, mucous secre-
receiving chemotherapy) (NHMRC, 2010). tions trap foreign particles and microorganisms.
133
Breaching the skin with a planned surgical incision

bypasses this defence, increasing the risk of inva-
INFECTION AS AN ADVERSE EVENT
sion by pathogenic organisms. Infection is one of the most frequent adverse events
associated with surgical procedures and/or inter-
INFLAMMATORY RESPONSE ventions. Data from 2010 show that 200,000 HAIs
The onset of inflammation is a non-specific defence. occur in Australian hospitals each year (NHMRC,
It is the body’s response to tissue damage and is 2010). The cost of HAIs can be measured in terms
evoked following any injury (e.g. physical, chemi- of increased morbidity and mortality, increased
cal, radiation) or invasion by microorganisms. The length of stay in hospital and an increase in both
function of inflammation is to clear the injured site human and clinical resources (ACSQHC/the Com-
of cellular debris and any pathogens present, and mission, 2012). Worldwide, HAIs and the present
to enable tissue repair to commence (Spry, 2015). threat from multi-resistant organisms (MROs) con-
Once the inflammatory response is evoked, several stitute one of medicine’s greatest challenges. To
biochemical mediators are released, localised combat them, healthcare facilities are implement-
vasodilation occurs and plasma fluid (containing ing MRO-specific policies, including in the operat-
leucocytes and proteins) moves into the injured ing suite, which is discussed later in the chapter
area. This causes the four outward signs of inflam- (NHMRC, 2010; NZ Ministry of Health, 2007). In
mation: redness, heat, swelling and pain (Lee & 2013–2014, 1621 cases of S. Aureus bloodstream
Bishop, 2013). If the inflammatory response does infections were reported in Australian public hos-
not eliminate all organisms or foreign material, pitals; such an infection has the potential to be a
healing of the injury is delayed and chronic inflam- serious threat to patients’ health (National Health
mation can result, which can persist for weeks or Performance Authority [NHPA], 2015).
even months (Lee & Bishop, 2013). See Chapter 11 Surgical patients have a three-fold greater risk
for further information about wound healing. of HAIs compared to other patients (ACSQHC/the
Commission, 2012). Despite compelling evidence
IMMUNE RESPONSE about the effectiveness of hand hygiene in reducing
The immune response, the third line of protection, the spread of infection within healthcare facilities,
is a specific body defence. Immunity is the capacity compliance remains problematic. For a surgical
of the body’s immune system to defend itself suc- patient, an HAI in the form of an SSI can be a
cessfully against potentially infectious agents. serious postoperative complication, resulting in
Immunity is acquired in two ways. pain, delayed healing, longer hospital stay, pro-
• Active immunity is acquired when the body has longed use of antibiotics and, in some cases, even
been exposed to or suffered an infection; this death. Every effort must be made both within the
is ‘naturally acquired’ immunity. Artificially operating suite and in ward areas to reduce the risk
acquired active immunity results from of SSIs. A recent study by Schultz (2015) suggests
immunisation, such as with vaccines (e.g. that surgical plume generated by electrosurgical
diphtheria) given in childhood. equipment may contain aerosolised viable bacteria
and that evacuating plume can play a role in reduc-
• Passive immunity may be natural and occurs ing SSIs (see Feature box 6-1). For more informa-
when antibodies are transferred from a tion on surgical plume, see Chapter 5.
person with immunity to another who does
not have immunity (e.g. from a mother to her
fetus across the placental barrier) (Lee & INFECTION PREVENTION AND
Bishop, 2013), or it may be artificial and can
be conferred with injections of immune
CONTROL PRACTICES
globulins. For example, hepatitis B Successful infection prevention and control prac-
immunoglobulin injections may be given to tices focus on prevention; this involves identifying
a non-immune healthcare worker following hazards and classifying associated risks. In turn,
a sharps injury and potential exposure to this requires healthcare facilities to develop infec-
hepatitis B virus. Unlike active immunity, tion prevention and control risk management plans,
passive immunity is relatively short-lived ideally within a clinical governance framework, to
(Lee & Bishop, 2013). minimise the risk of preventable HAIs (NHMRC,
134
FEATURE BOX 6-1 » EVACUATION OF SURGICAL PLUME MAY REDUCE SSIs
Surgical plume generated by electrosurgery or laser contains a cocktail of toxic gases, live viruses
and bacteria (Hill, O’Neill, Powell & Oliver, 2012). Evidence strongly suggests that if inhaled by
perioperative personnel, surgical plume can cause disease (ACORN, 2016; Harkavy & Novak, 2014).
A laboratory study by Schultz (2015) suggests that viable bacteria aerosolised in surgical plume
could be reduced by using a surgical plume evacuator; in turn, this would reduce contamination
of the surgical wound and SSIs. Further studies are required in a clinical environment to establish
whether similar results can be replicated.
FEATURE BOX 6-2 » CHANGE IN ACORN STANDARDS TERMINOLOGY
The 2016 ACORN standard on asepsis changed the terminology used to describe what has been
traditionally been known as sterile field or sterile technique. Sterile is defined as ‘free from micro-
organisms’; items remain sterile as long as they are unopened in a sterilised, uncompromised
package. Once opened and placed onto the surgical field, the item is exposed to airborne patho-
gens within the operating room or procedural area and therefore cannot be accurately termed
sterile. The more accurate language of aseptic has been adopted by ACORN and is reflected in this
book in terms such as aseptic field (instead of sterile field) and aseptic technique (instead of sterile
technique).
2010; Society for Healthcare Epidemiology of ENVIRONMENTAL CONTROLS

America [SHEA], 2014). Elements of successful Chapter 5 discussed aspects of the perioperative
infection prevention and control include quality environment, noting that many operating suite
and risk management policies, effective work prac- design features are necessary for good infection
tices and procedures, and adequate physical facili- prevention. These include the concept of the three
ties and operational controls (NHMRC, 2010; NZ zones of the perioperative environment. Personnel
Ministry of Health, 2007; Spry, 2015). As many entering the semi-restricted and restricted zones of
major infection risk factors can be found within the the operating suite must be correctly dressed in
perioperative setting, specific requirements to perioperative attire in order to minimise the entry
prevent infection are needed (NHMRC, 2010). of microorganisms found on the outside (street)
For nurses entering the perioperative environ- clothing of personnel (ACORN, 2016).
ment for the first time, the array of rules and pro-
tocols can appear bewildering. While most policies HEALTHCARE PERSONNEL ATTIRE
are based on research evidence, some (particularly
aseptic principles discussed later in the chapter) Correct perioperative attire (see Fig. 6-2) and pro-
are based more on common sense, logic and rational cedures for wearing/cleaning these items include
thinking. Regardless of origin, policies and pro the following:
tocols provide perioperative personnel with bound- • Loose-fitting, tightly-woven cotton pants and
aries within which they can apply infection tops or dresses minimise the friction and
prevention principles. chafing caused by tight-fitting clothing, which
The 2016 ACORN Standards, which guide Aus- subsequently cause the dispersal of epithelial
tralian perioperative nursing practice, have under- skin cells into the environment.
gone some important changes in terminology • Hair is a significant source of microorganisms,
related to asepsis—see Feature box 6-2. so caps or scarves are worn to cover the hair
135
environment, as demonstrated in an early

study by Neely and Maley (2000).
• Long-sleeved gowns with cuffed wrists or
‘warm-up’ jacket are recommended to prevent
the dispersal of epithelial skin cells from the
arms.
• Warm-up jackets are worn buttoned up and
gowns are fastened at the back to prevent
flapping and possible contamination of the
aseptic field.
• Closed-toe, non-slip, low-heeled, well-fitting
shoes, which are easy to clean and made of
material that is impervious to fluids and
penetration by sharp items are necessary in
the operating suite (ACORN, 2016; SHEA,
2014). The use of shoe coverings for infection
control reasons is not warranted, as no cause-
and-effect relationship has been demonstrated
between footwear and SSIs. Furthermore, there
is an increased risk of cross-infection when
FIGURE 6-2: Correct perioperative attire
the wearer touches the coverings to apply/
remove them. It is highly recommended that
staff wear shoes that are designated for wear
completely and beards require balaclava-type only in the operating suite to avoid
headwear. Headwear may be disposable; transmission of microorganisms to and from
however, many perioperative staff wear the home environment (ACORN, 2016).
brightly coloured headwear and these items • Jewellery can harbour microorganisms and
should be laundered in an approved may be dislodged and drop onto the aseptic
commercial laundry or by the healthcare field. Within the operating suite, jewellery
facility. Domestic washing machines are should be limited to plain ear studs, a wedding
unsuitable as they do not reach the ring and a thin chain necklace (which can be
temperatures required to destroy enclosed within the perioperative attire). Body
microorganisms (ACORN, 2016.) piercing jewellery should be removed if it
• Street clothes should not be worn underneath cannot be confined within the perioperative
perioperative attire as they are heavily attire (ACORN, 2016).
contaminated. • Nails should be kept short, 0.5 cm in length. All
• Perioperative attire should be changed on nail polish should be removed, as cracked nail
leaving and re-entering the suite. polish can harbour microorganisms and cannot
be cleaned effectively during routine or surgical
• Perioperative attire should be changed daily
hand washing. False nails and nail extensions
and whenever it is visibly wet, soiled or
can harbour fungal infections, which may be
contaminated. As with reusable caps, personal
transmitted to the patient, and should be
perioperative attire requires commercial
avoided (ACORN, 2016; NSW Health, 2007).
laundering (ACORN, 2016; Association of
periOperative Registered Nurses [AORN], • Lanyards should not be worn as they are rarely
2014). Early studies have shown that cleaned and there is a danger of them
microorganisms can live on fabrics which, dangling close to the aseptic field, increasing
when transported home, can place workers the risk of contamination (ACORN, 2016).
and their families at risk of infection. • Personal items such as briefcases, handbags
Similarly, contamination from home can be and backpacks should not be brought into the
brought back into the perioperative restricted area of the operating suite as they
136
FEATURE BOX 6-3 » THE FATHER OF INFECTION CONTROL
In May 1847 in Vienna, Ignaz Phillip Semmelweis (1818–1865) provided evidence of the signifi-
cance of hand washing to prevent the spread of puerperal sepsis. Semmelweis, an obstetrician,
observed that the maternal mortality rate in women attended by doctors was 20%, which was
four to five times greater than in women attended only by midwives.
Semmelweis identified that midwives did not attend the anatomical laboratories where autopsies
were carried out. Following the death of a colleague who accidentally cut his finger during an
autopsy and died a few days later, it was discovered at autopsy that he had died from the same
causative microorganism responsible for puerperal sepsis. This finding moved Semmelweis to
immediately implement a rigorous hand washing policy using 4% chlorinated lime solution prior
to the examination of women in labour. The results almost immediately lowered maternal mortal-
ity rates and a full year after the implementation of Semmelweis’ hand-washing policy the mortal-
ity rate from puerperal sepsis had dropped to 1.2%.
However, these results were not published for another 14 years and, although Semmelweis had
many who supported his findings, there were those who opposed the idea of the doctor being the
cause of the spread of puerperal sepsis. Semmelweis was not recognised for his findings until
after his death. Although Semmelweis’ antiseptic practices were ultimately adopted by the medical
community throughout the world, he was never given the recognition during his lifetime that he
so richly deserved (Best & Neuhauser, 2004).
are known to harbour microorganisms NHMRC, 2010; World Health Organization [WHO],
(ACORN, 2016). 2009). The value of hand hygiene was recognised by
Semmelweis in the nineteenth century (see Feature
STANDARD PRECAUTIONS box 6-3). Alcohol-based hand rub containing chlor
Standard precautions are the first-tier approach to hexidine is superior in effectiveness to soap and
infection prevention and control and must be water, but if hands are contaminated with blood or
applied at all times. They are designed to reduce the body fluids or are physically dirty then antimicro-
transmission of microorganisms from both recog- bial soap and water are required (Hand Hygiene
nised and unrecognised sources. Standard precau- Australia [HHA], 2013).
tions protect patients and healthcare workers and In 2009 WHO launched its global ‘Save Lives:
apply when there is a risk of exposure to blood Clean Your Hands’ program centred on the
(including dried blood) and body substances, secre- ‘5 Moments of Hand Hygiene’ (HHA, 2013; WHO,
tions and excretions (excluding sweat), regardless 2009). ‘5 Moments of Hand Hygiene’ are performed:
of whether or not they contain visible blood. Non-
1. before touching a patient
intact skin and mucous membranes (including the
eyes) are portals of entry and must be protected. 2. before commencing a procedure
Standard precautions involve consistently applying 3. after a procedure or body fluid risk exposure
safe work practices and protective barriers, regard-
4. after touching a patient
less of the patient’s known infectious status
(ACORN, 2016; AORN, 2014; NHMRC, 2010). 5. after touching the patient’s surroundings.
While carrying out the ‘5 Moments’ may be straight-
HAND HYGIENE forward in a ward setting, the nature of periopera-
Hand hygiene is the single most important practice tive practice requires some modification to place
to reduce transmission of infectious agents in them within the perioperative context and environ-
healthcare settings (AORN, 2014; Health Quality ment. Table 6-2 provides examples of perioperative
and Safety Commission New Zealand, 2015; application.
137
TABLE 6-2: ‘5 Moments of Hand Hygiene’ in the Perioperative Environment
MOMENT EXAMPLE
1. Before touching a patient in any • Placing a theatre cap on the patient’s head
way, before any non-invasive • Touching the patient’s armband
treatment or observation • Transferring the patient onto the operating table
• Positioning or repositioning the patient
• Touching any medical device connected to the patient (e.g. IV pump or
anaesthetic machine*)
• Applying calf compressors or tourniquet
2. Before a procedure • Opening sterile items onto the aseptic field

• Inserting intravenous access devices
• Intubation
• Inserting a urinary catheter
• Prior to donning non-sterile gloves
3. After a procedure or body fluid • Following Moment 2

exposure • Removing gloves following contact with body tissue during surgery
• Suctioning of airway
• Extubating the patient
• Contact with used specimen jars/pathology samples
• Cleaning spills of blood, urine, faeces or vomit from the patient’s
surroundings, bag
4. After touching a patient • After Moment 1
5. After touching the patient’s • Cleaning the operating table

immediate surroundings when • Positioning devices, linen, patient notes (transported with the patient
the patient has not been touched on or under the patient’s bed; thus become part of the patient zone)
• Cleaning the anaesthetic bay and operating room following the
patient’s departure
*THE ANAESTHETIC MACHINE, INCLUDING THE TOUCH SCREEN, KNOBS AND TUBING, MUST BE CLEANED BETWEEN PATIENTS AS THIS BECOMES
PART OF THE PATIENT AND IS TOUCHED FREELY BY THE ANAESTHETIST DURING THE PROCEDURE.
SOURCE: ADAPTED FROM HHA (2015).
PERSONAL PROTECTIVE EQUIPMENT documenting the count or leaving the operating

Personal protective equipment (PPE) must be room to collect extra items from sterile stockroom.
worn during activities when there is a risk of contact Wearing gloves during these activities risks con-
with blood or body fluids. PPE consists of the fol- tamination of the items touched and transmission
lowing items. of microorganisms (ACORN, 2016; AORN, 2014).
Non-sterile gloves Face masks

Non-sterile gloves provide an effective barrier when Face masks have been an important component of
touching contaminated equipment, blood and body infection prevention practices for many years. Ini-
fluids. However, wearing gloves is no substitute for tially they were used to prevent the transmission of
proper hand hygiene. Gloves should be removed microorganisms from healthcare staff to patients.
after completing a task, the hands cleansed and a However, a number of research studies have cast
fresh set of gloves donned before engaging in doubt of the efficacy of face masks to protect
further activities involving potentially contami- patients (Webster et al., 2010) and the focus has
nated items. Circulating nurses should not wear shifted to their current use predicated on the need
gloves when opening aseptic supplies, answering to protect healthcare workers as part of PPE.
telephones, entering data into the computer, However, there is sufficient evidence to warrant the
138
use of face masks to prevent the droplet spread of colleagues, by taking standard measures to avoid
oropharyngeal flora during insertion of spinal or injury. Injuries can be caused by needles, scalpels
epidural anaesthesia and this provides sufficient and instruments used during procedures, when
evidence to warrant their continued use during cleaning instruments and when disposing of used
surgery (ACORN, 2016; Australian and New Zealand needles. Chapter 10 provides detailed information
College of Anaesthetists [ANZCA], 2013; Loveday about sharps safety; however, examples of standard
et al., 2014; Spry, 2015). While local policy should safety measures include:
be followed in relation to the wearing of masks and • using instruments, rather than fingers, to
staff should make themselves aware of relevant grasp needles, retract tissue and load/unload
research on this topic, the following practices are needles and scalpels
currently recommended:
• instrument nurse letting members of the
• Masks should be worn in the operating suite surgical team know when sharps are being
when open aseptic set-ups, supplies or passed
scrubbed personnel are present.
• avoiding hand-to-hand passing of sharp
• Masks should be combined with eye protection instruments by using a puncture-proof
to protect the mucous membranes and container and using a predetermined neutral
conjunctiva of the wearer when exposure to zone
body fluids may occur (Loveday et al., 2014).
• using round-tipped scalpel blades instead of
• Masks should meet appropriate Australian and pointed sharp-tipped blades (NHMRC, 2010).
New Zealand standards and protect the wearer
from potential splashes during operative or In addition, wearing a second pair of surgical gloves,
invasive procedures (ACORN, 2016; ANZCA, ‘double gloving’, has been shown to provide added
2013; NHMRC, 2010). protection against puncturing the inner gloves and
minimising sharps injury (ACORN, 2016; AORN,
• Ensure that the mask covers both the nose and 2014; Loveday et al., 2014; SHEA, 2014).
the mouth, and tie it securely at the back of
the head. Respiratory hygiene and cough etiquette
• Change masks frequently—at least every 2 Coughing and sneezing increase the risk of spread-
hours to maintain effectiveness in preventing ing potential infectious particles. Where possible,
dispersal of flora from the wearer’s oropharynx cough into the crook of the arm or sneeze into a
(Kelkar, Gogate, Kurpad, Gogate & Deshpande, tissue then place the tissue immediately into a bin.
2013). Hand hygiene should be performed afterwards
• Remove the mask by handling the ties only to (AORN, 2014; Centers for Disease Control and Pre-
avoid contact with the area that has covered vention [CDC], 2015).
the nose and mouth. Cleanse hands after
removing the mask. Food and drink in clinical areas
Eating and drinking should not occur in the operat-
• Do not wear the mask loosely or leave it
ing suite, other than in designated staff rooms.
around the neck (NSW Health, 2007).
There are risks that blood or body fluids may con-
taminate food that is then eaten by staff, or that
Eye protection
work surfaces used for setting up sterile equipment
Eye protection in the form of face shields, goggles will become contaminated by food and drink. Dis-
and/or visors must be worn to protect the mucous carded food can also attract insects, which can lead
membranes of the eyes, nose and mouth during to contamination of aseptic surfaces and equip-
activities when there is a likelihood of sprays or ment. Apart from the infection control risks, there
splashes of blood or body fluids (ACORN, 2016; are work health and safety concerns with spillage of
AORN, 2014). hot liquids located in work areas (ACORN, 2016;
AORN, 2014). Finally, from a patient sensitivity per-
Sharps safety spective, a patient who has been fasting for a number
All staff must take precautions to prevent sharps of hours is unlikely to appreciate seeing or smelling
injuries not only to themselves, but also to their food or drink when they enter the operating suite.
139
ENVIRONMENTAL CLEANING (ACORN, 2016; AORN, 2014; NHMRC, 2010). It is

Following each procedure all horizontal work sur- recommended that patients with airborne or droplet
faces (e.g. trolleys, operating table, bench tops) infections wear a surgical mask when being trans-
should be cleaned using neutral detergent. Floors ported within the hospital to reduce the risk of
should be cleaned using clean mop heads and infecting other people (NHMRC, 2010).
clean water for each operating room. Rubbish and
linen bins should be emptied and receptacles CONTACT PRECAUTIONS
cleaned. Any visible blood or body substances on Contact precautions are intended to prevent the
any surfaces should be cleaned as soon as prac transmission of MROs (e.g. MRSA, VRE or C. diffi-
ticable during the procedure and areas such as cile) by direct or indirect contact with the patient
operating lights, ceilings, walls and other fixtures or the patient’s environment. Contact precautions
should be inspected after each case. PPE should are applied to patients known to be infected or
be worn by personnel carrying out environmental colonised with these MROs. As these organisms
cleaning (ACORN, 2016). (See Chapter 5 for further may be present on the patient’s skin, clothing, bed-
information.) clothes and equipment, healthcare workers must
wear aprons or gowns, gloves, protective eye wear
TRANSMISSION-BASED PRECAUTIONS and masks when participating in direct patient
Transmission-based precautions are the second- care activities. All items of protective equipment
tier approach to infection prevention and control. must be disposed of once contact with the patient
These precautions are applied when standard pre- has been completed and hand hygiene performed
cautions alone are not adequate to prevent airborne, (Spry, 2015). There should be restricted access
droplet or contact transmission of microorganisms. to the operating room, with only essential person-
On occasions a combination of these transmission- nel present. Similarly, only essential equipment
based precautions will be required, such as when required for the procedure should be in the operat-
a patient has norovirus and is vomiting (ACORN, ing room and where possible disposable equipment
2016; AORN, 2014; NHMRC, 2010). should be used. These measures will assist in reduc-
ing the risk of microorganisms being spread within
AIRBORNE PRECAUTIONS the operating room (ACORN, 2016; AORN, 2014).
Airborne transmission of microorganisms occurs
because the organisms are extremely small (less ENVIRONMENTAL CLEANING FOLLOWING USE OF
than 5 microns) and they float in air currents or are CONTACT PRECAUTIONS
disseminated in dust particles that are suspended Due to the virulence of MROs and the ease at which
in the airflow. Examples of infections requiring air- they can be spread through direct or indirect
borne precautions are TB, severe acute respiratory contact, cleaning alone with neutral detergent is
syndrome (SARS), measles and chickenpox. Maxi- not sufficient. Specific cleaning regimes should
mum protection requires the use of close-fitting P2 be implemented using a two-step approach: envi-
or N95 masks, which do not allow the passage of ronmental cleaning using neutral detergent on all
microorganisms, fitted correctly according to the surfaces, followed by cleaning with sodium hypo
manufacturer’s recommendations (ACORN, 2016; chlorite or other approved solutions (ACORN, 2016;
AORN, 2014; NHMRC, 2010; Spry, 2015). NHMRC, 2010). Staff should be familiar with the
specific local policies in relation to environmental
DROPLET PRECAUTIONS cleaning following the use of contact precautions.
Droplet transmission involves larger particles gen-
erated when a person sneezes or coughs. Droplets PATIENT CONSIDERATIONS IN
are greater than 5 microns (e.g. influenza, menin- INFECTION PREVENTION
gococcal) and fall to the floor within 1 metre of the The NHMRC (2010) advocates the use of a ‘care
source. On occasions, procedures such as suction- bundle’ approach to infection prevention. This is
ing, diathermy and nebulisers may cause these a critical set of evidence-based processes applied
droplets to become airborne, requiring airborne to patient care; see Table 6-3. This approach is
precautions. The P2 and N95 masks are effective also supported by the Society for Healthcare Epide-
in preventing transmission of droplet infections miology in America and provides a consistent,
140
TABLE 6-3: Example of a ‘Care Bundle’ Approach to Preventing SSIs
PRACTICE ELEMENTS
Antimicrobial prophylaxis • Antimicrobial stewardship is a key strategy in reducing MROs
• The key principle is to administer appropriate antibiotics between 30 and 60
minutes prior to the incision; in patients undergoing extended surgery or when
excessive bleeding occurs, consideration may be given to administering a
second dose of antibiotics
Hair removal • Body hair around the proposed surgical site can be a source of infection and
may need to be removed prior to surgery
• Hair removal, if required, should be carried out as close to the time of surgery
as possible
• Clippers or a depilatory agent should be used outside the operating room
Control blood glucose • Glucose levels can affect wound healing

• Hypo- and hyperglycaemia should be avoided by regular monitoring of at-risk
patients
Maintain normothermia • Body temperature should be maintained ≥36°C

• Even mild hypothermia can increase SSI rates as it may directly impair
neutrophil function or impair it indirectly by triggering subcutaneous
vasoconstriction and subsequent tissue hypothermia (see Chapters 8 and 9 for
further information)
Optimise tissue oxygenation • Oxygen should be administered during and immediately following surgery
Skin preparation products • Alcohol has highly bactericidal properties

• Products combining an antimicrobial agent and alcohol may provide greater
effectiveness at removing transient and resident microbial count (see section
on skin preparation)
Use WHO Surgical Safety • The WHO SSC reduces perioperative risks to patients and improves team
Checklist (WHO SSC) communication (see Chapters 3 and 9 for further information)
Perform surveillance • High-risk or high-volume procedures should be identified and monitored
Provide feedback on SSI to staff • Feedback improves performance and identifies areas for practice to be reviewed
SOURCE: ACORN (2016), NHMRC (2010) AND SHEA (2014).
structured approach to infection prevention (ACORN, 2016). Aseptic technique aims to prevent
(NHMRC, 2010; SHEA 2014). The approach has sufficient quantities of pathogenic microorganisms
been shown to have a significant effect on reducing from being introduced to surgical sites by hands,
SSIs when used in combination with other well- surfaces and equipment. Therefore, unlike sterile
established infection prevention measures as technique, aseptic technique is achievable and
described in this chapter. must be strictly adhered to in order to minimise
contamination of the wound and prevent infection,
thus aiding an uneventful postoperative recovery
ASEPSIS AND ASEPTIC TECHNIQUE (NHMRC, 2010; Spry, 2015).
Asepsis can be defined as the absence of patho- The patient is the centre of the aseptic field,
genic microorganisms on living tissue (Spry, 2015), which comprises personnel wearing scrub attire
while sterile means free from microorganisms. and those areas of the patient, operating table,
Items used in surgical procedures are wrapped and instrument trolleys and other furniture that are
sterilised, remaining sterile until they are opened covered in aseptic drapes. Aseptic practices guide
141
perioperative nurses’ actions; for example, when OPENING STERILE SUPPLIES

opening sterile supplies, moving in and around the The circulating nurse provides a link between the
aseptic field or setting up aseptic instrument trol- aseptic field and the sterile supplies required for a
leys. Application of the principles and practices of surgical procedure. The nurse needs to be able to
aseptic technique, which are necessary to create open and transfer sterile items safely onto the
and maintain an aseptic field, rely on the periop aseptic field. Prior to opening a sterile item, the
erative nurse and other members of the surgical circulating nurse must wash his or her hands and
team exercising a surgical conscience (Spry, 2015). do the following:
In some instances, the principles provide arbitrary
boundaries only, but they assist the perioperative • examine the external sterility indicator—this
nurse to determine where aseptic areas start and will indicate whether the item has been
end, thus contributing to safe practice. Aseptic through a sterilisation process
technique utilises the principles of asepsis as • check the expiry date—although an event
follows: (e.g. dropping a sterile item) rather than time
• All personnel within the aseptic field must is the determining factor, some companies
wear a sterile gown and gloves and touch only place an expiry date on items
sterilised items. • check that the item is securely sealed and its
• Unscrubbed personnel must touch only packaging is intact—if not, discard it
non-sterile items. • assess for watermarks or any dampness—their
• Sterile drapes must be used to create an aseptic presence indicates strikethrough has occurred,
field around the proposed operative site. and the item can no longer be considered
sterile.
• Items used within the aseptic field must be
sterile. If any doubt exists about the sterility or integrity of
• Only the horizontal surfaces of tables draped a package, it should be discarded (ACORN, 2016).
with sterile drapes are considered aseptic; any
item that hangs below table-top level is PUTTING PRINCIPLES INTO PRACTICE
considered contaminated (because items that Putting aseptic principles into practice can be
fall below the horizontal surface cannot be daunting for the beginning perioperative nurse.
monitored). However, practising techniques under supervision
• All items introduced onto the aseptic field will ensure that skills and dexterity are developed.
must be opened, dispensed and transferred by To follow are some practical hints for opening and
methods that maintain their sterility and presenting sterile items to the aseptic field:
integrity. • If the sterility of an item is in doubt, consider
• The aseptic field must be monitored at all it contaminated and discard.
times and never left unattended (aseptic fields • Remain a safe distance (at least 30 cm) away
can be accidently contaminated and not from the aseptic field and always face the
reported). aseptic field to avoid accidental contamination.
• All personnel moving around the aseptic field • To open a sterile bundle, open the first fold
should do so in a manner that maintains the towards you (see Fig. 6-3a), then move around
integrity of the aseptic field. to the opposite side of the bundle and open
• Unscrubbed personnel should not lean across the second fold (see Fig. 6-3b), to avoid
the aseptic field because leaning across the leaning across the aseptic field.
aseptic field increases the risk of skin squames • Open a wrapped sterile article without your
falling onto and contaminating the aseptic hands touching the inside wrapper (see
field. Fig. 6-4). Open the outer wrapper edge
• Unscrubbed personnel should not walk furthest away from you first and the nearest
between two aseptic fields as this can lead to wrapper edge last. Secure all open wrapper
contamination of the aseptic fields (Spry, edges to avoid contamination while making
2015; ACORN, 2016). the item available to be retrieved by the
142
FIGURE 6-5: The circulating nurse presenting a sterile item to the instrument
nurse
scrubbed person (see Fig. 6-5). See Feature box

6-4 for discussion on ‘flipping’ items onto the
aseptic field.
B
• Articles dropped on the floor are no longer
FIGURE 6-3: Opening a sterile bundle
considered sterile and must be discarded;
after picking articles up off the floor, the
hands should be cleansed (Spry, 2015;
ACORN, 2016).
POURING LIQUIDS ONTO AN ASEPTIC FIELD

Any fluids added to the aseptic field must first be
checked by the instrument nurse to ensure that
they are the correct fluid and in date. Points to
remember:
• Do not reach over the aseptic field.
• Pour liquid carefully to prevent splashing onto
the aseptic field.
• Pour the total contents of the bottle into a
container such as a jug, which should then be
labelled (see Fig. 6-7).
• Do not recap and reuse, as contamination
could occur when recapping.
• Do not allow any drips from the side of
the bottle to fall onto the aseptic field
FIGURE 6-4: Unwrapping a sterile item (Spry, 2015).
143
FEATURE BOX 6-4 » TO FLIP OR NOT TO FLIP: A PRACTICE ISSUE FOR DISCUSSION
‘Flipping’ refers to the practice of transferring the aseptic contents of small, sterilised packaged
items onto the aseptic field. It is a skill that most nurses will have practised in wards and other
departments when setting up aseptic fields to undertake procedures such as dressing changes. It
is used when the nurse is working without assistance and must open all supplies before washing
hands and donning sterile gloves.
Although previously acknowledged as an acceptable practice in emergency situations (e.g. ACORN,
2012), flipping is no longer condoned nationally or internationally (e.g. Operating Room Nurses
Association of Canada [ORNAC], 2015). In the perioperative environment where nurses are working
in teams, it is recommended practice that the instrument nurse take the aseptic item from the
circulating nurse using forceps to reduce the possibility of contamination (ACORN, 2016).
The need to flip items has been significantly reduced by the introduction of sterile ‘custom packs’.
These packs contain a wide range of disposable items previously opened individually and trans-
ferred using the flipping technique onto the aseptic field. ACORN (2016) states that the instrument
nurse should be able to monitor items added to the aseptic field and notes that poorly executed
flipping can increase air turbulence, causing particles to land on the aseptic field and compromis-
ing sterility.
This poses a dilemma for perioperative nurses who are highly likely to witness flipping. For
example, prior to performing the surgical scrub, the instrument nurse and other members of the
surgical team frequently use a flipping technique to open their surgical gloves on the gown trolley.
In emergency situations or when the instrument nurse is busy, the circulating nurse may be
required to flip items such as gauze squares or sutures directly onto the aseptic field (see Fig.
6-6a and b).
Nurses should have regard for the ACORN standards and follow local policy regarding this issue.
Where flipping is still practised, nurses should ensure that they receive adequate education and
supervised practice of this technique so that they are confident and skilful when opening aseptic
supplies in emergency situations.
A B
FIGURE 6-6: Demonstration of flipping items onto aseptic field
144
SURGICAL CONSCIENCE
A surgical conscience is defined as an individual’s
professional honesty and inner morality system,
which allows no compromise in practice whether a
breach occurs within the team or when working
alone. For example, if a member of the surgical
team contaminates a glove or piece of equipment,
the breach must be pointed out immediately to
prevent any compromise to the patient’s safety. The
patient’s well-being must be placed above any
personal/professional embarrassment or fear of
speaking up. The surgical team must share respon-
sibility for monitoring and correcting the actions of
team members if a breach of asepsis is noted (Spry,
FIGURE 6-7: Pouring fluid into a gallipot on an aseptic field 2015; ACORN, 2016).
ASEPTIC NON-TOUCH TECHNIQUE

MOVING AROUND THE OPERATING ROOM The aseptic non-touch technique (ANTT) puts into
Movement of personnel within the operating room practice many principles of asepsis that nurses
increases the risk of transmission of microorgan- have practised for many years in ward areas when
isms and possible contamination of aseptic fields undertaking dressings and other minor aseptic pro-
leading to SSIs (SHEA, 2014). In order to reduce cedures. In the United Kingdom the ANTT Project
unnecessary movement, forward planning is needed has been implemented in hospitals and community
along with consideration of the following: care organisations since 1993 to promote the use of
• There should be minimal personnel in any a standardised technique.
operating room. The risk of transmitting Standardised terminology has been developed
airborne contaminants increases with the when describing equipment and procedures involv-
number of personnel in the room. Each ing ANTT:
operating suite should have a policy in • Key part is a part of the equipment that must
relation to the number of visitors permitted remain aseptic (e.g. the syringe hub or cannula
within each operating room. All visitors hub). Key parts must be identified and
should observe infection control policies and protected at all times.
be monitored for compliance (Spry, 2015;
ACORN, 2016). • Key site is an area on the patient or
equipment that provides a direct entry
• Talking should be kept to a minimum to point for microorganisms into the body.
reduce droplet spread (ACORN, 2016). This entry point would normally be aseptic
• All the requirements for the procedure should or require cleansing prior to the insertion
be placed in the operating room prior to of the key part (e.g. urethral meatus,
commencement to reduce the need to cannulation site or IV access point)
repeatedly exit and enter the operating room (NHMRC, 2010).
to access equipment. Standard ANTT is practised in perioperative and
• The doors of the operating room should be proceduralist settings for procedures that are
kept closed and opened only when required. simple, of short duration and involve only a few key
Frequent opening and closing of doors creates parts or sites (e.g. insertion of IV cannulae or injec-
air currents and alters the normally positive tion into an IV line/port) (NHMRC, 2010). For
pressure airflow within the operating room standard ANTT the aseptic field is termed ‘general’.
itself, further increasing the possibility of Surgical ANTT is required when procedures are
airborne contaminants (sourced from more complex and longer in duration, and involve
personnel, supplies and equipment) entering numerous key parts and key sites (e.g. the insertion
the wound (ACORN, 2016). of a spinal anaesthetic, invasive monitoring and,
145
most obviously, surgical procedures). For surgical • Principles of scrub technique using aqueous
ANTT the aseptic field is termed ‘critical’ and antimicrobial solution:
requires the use of sterilised drapes, instruments 1. First scrub of the day is 5 minutes in length
and equipment; additionally, all members of the and includes use of sterile sponge and nail
surgical team must wear a gown and gloves that cleaner.
have been sterilised (NHMRC, 2010).
2. Subsequent scrubs are 3 minutes as the
THE SURGICAL SCRUB cleaning of nails is not required.
Before the surgeon(s) and instrument nurse(s) can 3. Prepare a sponge/nail cleaner, maintaining
prepare or enter an aseptic field, they must perform it in an aseptic manner until it is required.
a surgical scrub, followed by donning sterile gown 4. Turn tap on to an even flow to prevent
and gloves according to local hospital policy. The splashing.
practice of surgical scrubbing is integral to reduc-
5. Antimicrobial solution applied to hands and
ing SSIs and the procedure is carried out to elimi-
arms should remain in contact with the skin
nate transient flora and reduce resident flora from
according to manufacturer’s instructions.
the hands and forearms, leaving residual antimi-
crobial agent on the skin to inhibit the growth of 6. When applying solution, work from hands to
microorganisms. A broad-spectrum antimicrobial the elbow, using a circular motion to move
solution that is fast-acting, persistent and has a up the arms, and do not return to the hands.
cumulative effect is recommended (ACORN, 2016). 7. When rinsing hands and arms, water should
Currently, aqueous antimicrobial solutions such as flow from cleanest areas (the hands) to less
povidone-iodine and chlorhexidine are commonly clean areas (elbows)—that is, always keep
used. However, WHO (2009), NHMRC (2010) and hands above elbows (see Fig. 6-8).
SHEA (2014) guidelines recommend the use of
alcohol-based products as they have greater anti- 8. After completing the surgical scrub, hold
microbial efficacy, having a more rapid effect and a hands above the waist and dry using a sterile
broader spectrum of activity (Spry, 2015). Alcohol- towel, before donning a sterile gown (ACORN
based scrub solutions have been in common usage 2016).
in Europe for many years and are now in use in
Australasia.
Before the surgical scrub personnel should:
• be dressed in perioperative attire
• remove rings and confine/remove all other
visible jewellery, such as earrings and neck
chains
• don surgical mask and eye protection
• don radiation protective gowns and thyroid
protection, if applicable
• perform an inspection of the hands, paying
close attention to any breaks in the skin
• open a sterile gown pack and add sterile gloves
to it.
Australian and New Zealand professional peri-
operative organisations provide detailed descrip-
tions of the surgical scrub and each operating suite
should display the technique for all staff to follow.
Although the actual technique may differ between
areas, the basic principles for surgical scrubbing
remain the same. FIGURE 6-8: Rinsing hands. Note the hands are higher than the elbows.
146
• Principles of scrub technique using alcohol scrub

solution:
1. Prior to the first scrub of the day, perform a
one-minute hand wash using antimicrobial
solution, washing the nails and arms thor-
oughly to the elbow.
2. Dry the hands and arms thoroughly (the
efficacy of the alcohol is diminished if used
on wet skin).
3. Apply the correct amount of alcohol scrub
solution (approximately 5 mL) to hands and
arms in accordance with ACORN standards
(2016) and the manufacturer’s instructions.
4. The contact time of the scrub solution will
depend on the type and percentage of
alcohol within the solution and the presence
of added antimicrobials.
5. Subsequent alcohol scrubs require a social
handwash and careful drying if the hands
FIGURE 6-9: Donning a sterile gown
are visibly dirty prior to the application of
the alcohol solution (ACORN, 2016).
Regardless of the solution used, it is important
that correct technique is taught to all new staff and GLOVING
used consistently to ensure the effectiveness of the
antimicrobial solutions and reduce the risk of SSIs. Glove perforation may cause contamination of the
patient’s surgical site and also puts the wearer
GOWNING at risk of exposure to blood-borne pathogens.
Sterile gowns are worn to provide a barrier to Although no current evidence exists to suggest that
prevent the transfer of microorganisms to the double gloving (wearing two sets of gloves) reduces
patient during the surgical procedure. Their manu- SSIs, double gloving is a recommended practice as
facture must meet relevant international standards it does reduce the risk of glove penetration, particu-
(EN 13795, 2011) for disposable, resposable (i.e. larly in high-risk procedures such as orthopaedic
limited reuse gowns) and reusable gowns. Reusable surgery that uses drills, chisels and so on (Spry,
and disposable sterile gowns are folded differently 2015; ACORN, 2016).
and so the technique for donning may vary. Closed gloving is the recommended method to
However, the main principles for gowning are as don gloves as it reduces the risk of contaminating
follows (see also Fig. 6-9): the sterile gloves by the bare hands. With the hands
• The gown must be folded in a manner that remaining inside the cuffs, remove one glove from
enables the inside of the gown to be handled the packet with one hand and with the palm of the
with surgically clean hands. other hand uppermost, place the glove onto the cuff
with the fingers of the glove pointing towards the
• Minimise handling during donning procedure. wrist, the thumb down and the folded edge of the
• Extend both arms into sleeves simultaneously. glove flush against the edge of the cuff of the gown.
• Do not extend hands through gown cuffs—this With both hands working inside the gown sleeves,
allows for closed gloving (see below). use the thumbs to hold onto the edge of the glove
cuffs. Using one motion, stretch the glove out and
• Keep arms bent at the elbows and above the over the hand and insert the gown cuff into the
waist. glove. Grasp both the glove and the gown, manoeu-
• Have an unscrubbed person secure the ties at vring the hand through the cuff into the glove (see
the back of the gown. Fig. 6-10). Repeat the procedure for the other hand.
147
FIGURE 6-10: Donning sterile gloves FIGURE 6-11: Scrubbed person
The second pair of gloves is then donned by sliding method of donning a replacement glove is for
each gloved hand into the second pair. another aseptic member of the team to assist with
Once both pairs of gloves are donned, there is the gloving.
one final action taken to complete gowning. There If both gown and gloves become contaminated,
are side tapes on the front of the gown that require both must be removed and the donning procedure
assistance from a scrubbed or unscrubbed person is carried out as previously described. Once gowned
(depending on the type of gown) to turn the wearer and gloved (see Fig. 6-11), the scrubbed person
so that the tapes are secured at the front of the must stay close to the aseptic field and not move
gown. The effect of this manoeuvre is to close out of the operating room into semi-restricted or
the back panel of the gown. It does not mean that unrestricted areas as this will increase the risk of
the back is sterile, but it provides all-round protec- cross-infection.
tion to the wearer. At the conclusion of the procedure, the outer-
Once gowned and gloved, the areas considered most pair of gloves, which may be visibly contami-
aseptic are from the tips of the fingers to the elbows nated, may be removed and discarded prior to
and from the nipples to the waist. This arbitrary applying the dressing. When removing gown and
boundary allows the wearer to monitor any obvious gloves, to avoid contamination of bare hands, the
contamination by unscrubbed persons or equip- gown is removed first, rolled up so the inner surface
ment. Should contamination occur, then the gown is on the outside and discarded. This is followed by
or gloves, or both, depending on the extent of the removal of the inner gloves by gloved surface touch-
contamination, must be removed and replaced ing gloved surface to remove one glove and then
(ACORN, 2016). placing a ‘clean’ finger inside the remaining glove,
In assisted (open) gloving, one scrubbed person which is then pulled off. This method protects bare
gloves another scrubbed person; this may occur skin from the contaminated outer surface of the
should the wearer contaminate a glove intraopera- glove.
tively. Closed gloving cannot be achieved because The surgical team must discard gowns, gloves
the cuffs should not be pulled back over the hands and masks in a manner that confines and contains;
as they are now contaminated. Therefore, the safest that is, into contaminated waste containers within
148
the operating room. The mask should be removed

by touching the strings only to prevent contamina-
tion of the hands from blood or body fluids that
may have splashed onto the mask. The hands should
be cleansed following removal of the gown, gloves,
mask and visor (ACORN, 2016).
SKIN PREPARATION OF THE PATIENT

A patient’s surgical outcome can be adversely
affected by developing an SSI, so to reduce this risk
preoperative skin preparation (‘prepping’) is
undertaken just prior to the commencement of the
procedure with the aim of removing soil and tran-
sient and resident microorganisms from the
patient’s skin using an antimicrobial agent. Com-
monly used antimicrobial skin preparation solu-
tions include a choice of aqueous povidone-iodine
or chlorhexidine (ACORN, 2016). Evidence from a
study by Darouiche and colleagues (2010) sug- FIGURE 6-12: Circular prepping technique
gested that the addition of alcohol to antimicrobial Source: Rothrock (2015).
agents may provide a solution with greater effec-
tiveness at reducing the microbial count on the
patient’s skin. However, a Cochrane Review in 2013 to prep the patient based on any allergies the
concluded there was insufficient evidence to favour patient may have, the type of procedure to be
one solution, recommending that more research carried out and the surgeon’s preferences. Prepara-
is required in this area (Dumville et al., 2013). tion of the operative site is carried out by the
However, in practice, alcohol-based solutions (e.g. surgeon or instrument nurse using gauze swabs
2% chlorhexidine with 70% alcohol) are commonly dipped in antimicrobial solution, observing aseptic
used, particularly in orthopaedic and neurosurgery, technique. Skin cleansing commences from the
depending on the surgeon’s preference. cleanest area, usually the proposed operative site,
and proceeds in concentric circles or squares out-
SAFE USE OF ALCOHOL-BASED SKIN wards to the least clean areas. Using a clean swab
PREPARATION SOLUTIONS (no double dipping), this process is repeated several
Strict safety measures must be exercised when times, with the prepared area wide enough to allow
alcohol-based solutions are used in order to reduce extension of the incision if required (see Fig. 6-12).
the risk of ignition and fire when electrosurgery is Commercially packaged single-use antimicrobial
in use (ACORN, 2016; Spry, 2015). Care must be impregnated swab sticks are available as an alter-
taken to ensure that the alcohol dries completely native for skin preparation.
and all vapours have evaporated prior to the patient Areas that have a high microbial count (e.g.
being draped and electrical equipment activated. groin, umbilicus, body orifices, open wounds or
The alcohol-based solution must not be kept in the stomas) should be prepared last using a separate
operating room and should be stored according to swab. The preparation of these areas is also carried
the manufacturer’s and government guidelines. All out in reverse; that is, the cleaner, peripheral areas
staff must be trained in the use of alcohol-based are cleansed first prior to cleansing the more heavily
solutions with local policies in place to manage its contaminated areas, even though these may be
safe use within the perioperative environment the operative site. The surgical principle is to
(NSW Health, 2011). work from the cleanest to the least clean area
(Spry, 2015).
PREPPING PROCEDURE The antimicrobial solution should not be
Following positioning of the patient and Time Out, allowed to pool under the patient as this can cause
a suitable antimicrobial solution should be selected skin maceration. Plastic-backed absorbent sheets
149
can be placed under the patient to collect any • Hold the drapes above waist level and, once in
excess solution. These sheets can then be removed place, do not move them. If a drape requires
prior to placing the sterile drapes on the patient, repositioning, it should be discarded and a
thereby minimising the risk of skin damage and new one used.
potential fire if alcohol-based solutions are used • Drape the incision site first and work towards
(Spry, 2015; ACORN, 2016). the periphery, draping from aseptic to
The current practice of prepping in concentric contaminated.
circles/squares is being challenged, with one study • Protect the gloved hands from contamination
(Silva, 2014) suggesting that a back and forth by ‘cuffing’ the drape over them during
motion with the prepping solution may be more placement (Spry, 2015).
effective in removing transient and resident
microbes because such action creates greater fric- • International standards recommend the use
tion which penetrates the deeper layers of the skin. of disposable drapes as they provide a more
Although the research was based on preparation of efficient microbial and moisture barrier
the skin prior to venepuncture rather than a surgi- than reusable linen drapes. The passage of
cal procedure, evidence for a change in practice is moisture through drapes can compromise the
growing (Hadaway, 2012; Tung, 2013). Further aseptic field (see below) and endanger the
research is required to replicate the results in a surgical team by exposing them to blood
surgical context. and body fluids (European Committee for
Standardization (CEN) (2011). Disposable
drapes can be incorporated into custom packs
DRAPING THE PATIENT and reduce the amount of debris liberated into
A critical aseptic field within which surgery can be the environment when compared to traditional
carried out is created using sterile drapes that are linen drapes.
strategically placed on the patient in a manner that
exposes only the operative site and isolates it from STRIKETHROUGH
surrounding areas. Within this defined aseptic field, Gowns and drapes act as barriers to prevent the
the surgical procedure takes place and all those transmission of microorganisms from contami-
involved must be dressed in sterile gowns, gloves nated to aseptic areas. If moisture penetrates the
and personal protective attire. The drapes covering gowns or drapes, it permits the passage of microor-
the patient’s body provide an area on which instru- ganisms from a contaminated surface to an aseptic
ments and equipment, such as suction tubing and surface; this is termed strikethrough. The need to
the active diathermy electrode (handpiece), can be prevent strikethrough is a critical factor in main-
placed (Spry, 2015). taining an aseptic field and is achieved by the use
Reusable linen or synthetic single-use drapes of waterproof drapes and gowns (or by the use of
used in the creation of the aseptic field should be plastic aprons under gowns made of permeable
made of materials that inhibit the migration of material). However, if strikethrough occurs on
microbial particles and moisture. Drapes may be either gown or drapes, they must be replaced (NSW
available as single items or they may be packaged Health, 2007). On completion of the surgical pro
in predetermined configurations for specific surgi- cedure and following the application of a wound
cal procedures. They are folded in such a manner as dressing, the drapes are removed immediately
to facilitate easy opening and placement on the using a ‘contain and confine’ approach, as described
patient. Reusable drapes are held in place with for the removal of gowns and gloves.
towel clips or sutures, whereas single-use drapes
have an adhesive section to secure them in place
without slippage. INSTRUMENT CLEANING,
Points to consider when handling drapes are as
DECONTAMINATION AND
follows: STERILISATION
• Handle drapes as little as possible, as excessive All reusable medical devices (RMDs) used on
movement can cause air currents and dispersal a patient during a surgical procedure or investi
of dust particles. gative process must be decontaminated, cleaned,
150
TABLE 6-4: General Criteria for Reprocessing and Storage of RMDs in Health Service Organisations
LEVEL OF RISK PROCESS STORAGE

Critical (a medical device that • Clean as soon as possible after using • Sterility should be maintained
comes into contact with the • Sterilise by moist heat after cleaning • Packaged RMD should be stored
vascular system or sterile tissue • If the RMD is heat-sensitive, sterilise to prevent environmental
and that must be sterile at the using an alternative process (e.g. contamination in a designated
time of use) automated low-temperature storage area to protect RMD
chemical sterilising process, liquid • RMDs processed through a liquid
chemical sterilising process or chemical sterilising process
ethylene oxide sterilising process) should be used immediately
Semi-critical (a medical device • Clean as soon as possible after using • Store to prevent environmental
that comes into contact with • Sterilise by moist heat after cleaning contamination in a designated
mucous membranes or non- • If the RMD will not tolerate moist storage area to protect RMD
intact skin e.g. flexible heat sterilisation, use a low-
endoscopes) temperature sterilisation process or
thermal disinfection, or disinfection
using a high-level, instrument-grade
chemical disinfectant
Non-critical (a medical device • Clean as necessary with detergent • RMD shall be stored in a
that only comes into contact solution clean dry place to minimise
with intact skin and not mucous • If further treatment is necessary, environmental contamination
membranes e.g. stethoscope, disinfect with compatible low-level
sphygmomanometer cuff) or intermediate-level, instrument-
grade disinfectant after cleaning
SOURCE: ADAPTED FROM STANDARDS AUSTRALIA (2014).
inspected, packaged and sterilised or disinfected material prevents the sterilising agent coming into
before reuse to reduce the risk of cross-infection. contact with all surfaces of the item and results in
Spaulding first proposed a system of classifying failure to achieve sterilisation.
infection risk and the appropriate processing The cleaning process begins in the operating
methods in 1968 (Spry, 2015). A modified Spauld- room during the procedure with the instrument
ing’s table is shown in Table 6-4. nurse wiping used instruments with a sponge damp-
The standards for decontamination, cleaning ened with water to keep them free of blood and
and sterilising RMDs are detailed in Australian and tissue debris. Particular attention should be given
New Zealand Standard AS/NZS 4187 (Standards to the tips and joints of the instruments to prevent
Australia, 2014). This standard provides a detailed build-up of blood and tissue on the instruments,
description to assist staff in sterilising departments which may hinder their effective use by the surgeon.
and the operating suite. AS/NZS 4187 (Standards This also helps reduce the bioburden. Instruments
Australia, 2014) has adopted the European and with lumens should be flushed through with sterile
international standards. water to prevent blockage. Heavily contaminated
instruments should be cleaned in a splash bowl con-
DECONTAMINATION AND CLEANING taining water within the aseptic field (McCarthy,
The first step in the reprocessing of RMDs is decon- 2015). Normal saline should not be used for cleaning
tamination, a process by which physical or chemical as it is corrosive and can damage the instruments.
agents are used to clean inanimate objects or sur- At the conclusion of the procedure, reusable instru-
faces (Spry, 2015). Before RMDs can be sterilised, ments and equipment are returned to the central
they must be thoroughly cleaned of all organic sterilising department (CSD), where manual and
material (bioburden). Failure to remove this mechanical cleaning takes place (ACORN, 2016).
151
The CSD may be located adjacent to or situated PACKAGING

some distance from the operating suite. RMDs must The aim of packaging the instruments and equip-
be transported to the CSD in covered trolleys as an ment is to protect the sterilised items against con-
infection prevention measure (Standards Australia, tamination until they are opened ready for use in a
2014). In the CSD, the trays of RMDs are loaded into surgical procedure. A variety of packaging materials
a large instrument washer, often called a tunnel are available and their choice depends on the item
washer, which washes, rinses and dries the instru- to be packaged and the sterilising process to be
ments as they move through the washer. Instru- used. The packaging material must comply with
ments such as scissors and clamps must be fully relevant international standards and provide an
opened to allow all surfaces to be thoroughly effective barrier against potential contamination
cleaned. Drying the instruments is an important (Standards Australia, 2014; ACORN, 2016). Exam-
part of the decontamination process as wet instru- ples of packaging materials include:
ments quickly become colonised with microorgan-
isms (Standards Australia, 2014; ACORN, 2016). • single-use wraps made from synthetic polymer
Specialised instruments and equipment such as products for wrapping trays
endoscopes, drills and delicate instruments are • self-sealing pouches made of specialised paper
processed separately as they have individual clean- or plastic for individual items
ing requirements. Fully automated reprocessing • trays or containers in which metal
systems are now widely used to clean endoscopes instruments, endoscopes and drills can be
(see Chapter 13 for further information). packaged; they are made of moulded plastic or
metal with perforations to allow penetration
INSPECTION, ASSEMBLY AND PACKAGING by the sterilising agent.
INSPECTION Once assembled, the tray/container is wrapped
Following mechanical washing and drying, all in packaging material (this may vary depending on
instruments are visually inspected by the trained the material and local policy) and folded in a
CSD staff to ensure that there are no damage or manner that allows subsequent opening using
defects and that the item is functioning correctly aseptic technique. An easy-peel label identifying
(i.e. scissors are sharp, the jaws of clamps are prop- the tray is placed on the external surface. Once the
erly aligned). To sterilise an item that is not func- item has been used, this label can be placed on a
tioning correctly could place the patient at risk tracking form and remains in the patient’s notes.
should it fail during surgery, and cracks within the This enables items to be traced back to the patient
instrument can harbour microorganisms rendering should an investigation into a fault in the sterilisa-
the sterilisation process ineffective (ACORN, 2016; tion process be required. Depending on the sterilis-
Standards Australia, 2014). ing agent to be used, the wrapping material will be
sealed using a specialised chemical indicator tape,
ASSEMBLY which will change colour during the sterilising
Surgical instruments can be assembled in trays or process. This becomes a visual check that the item
packaged individually. All operating suites have a has undergone the sterilisation process and is
range of instrument trays to cater for the proce- checked by the circulating nurse prior to opening
dures they commonly perform (e.g. laparotomy, the item. The change in colour of the external indi-
hysterectomy, orthopaedic trays). There is also a cator tape alone does not guarantee sterility of the
general tray of instruments to which individual item. Other sterilising parameters must be met
items may be added, depending on the procedure. before sterility is assured and these are discussed
All trays are standardised and contain a specified below. However, if the indicator tape is found not
number and type of instruments identified on a tray to have changed colour, the item must be consid-
list, which is packaged and sterilised with the tray. ered unsterile and not used.
The tray list is used by the instrument and circulat- Commercially packaged single-use items con-
ing nurses to check the contents preoperatively and tain information from the manufacturer in the form
postoperatively to ensure that no items are inad- of symbols on the package. These indicate the serial
vertently left inside the patient (ACORN, 2016; number, sterilisation method, that the item is for
Standards Australia, 2014). single use, whether it is latex-free (if appropriate)
152
Symbol for ‘Serial Number’. This symbol shall be

SN followed by, or above, the manufacturer’s serial
number.
Symbol for ‘Batch Code’. This symbol shall be adjacent

LOT to the manufacturer's batch code. The batch code may
also be referred to as the lot number or batch number.
2005-06-30 2001-06
Use by date e.g. Date of manufacture
use by 30 June 2005 e.g. manufactured
June 2001
Symbol for method of sterilisation
2
STERILE EO
using ethylene oxide.
Symbol for method of sterilisation

Do not re-use Attention (see STERILE R
using irradiation.
(use once) instructions for use)
FIGURE 6-13: Commonly used symbols and their meanings

Source: Symbols from International Organisation for Standardisation (ISO) (2012). ISO 15223-1 Medical devices—Symbols to be used with medical device labels, labelling
and information to be supplied—Part 1: General requirements. ISO 15223-1: 2012—Reproduced with permission from SAI Global Ltd.
and required storage conditions. This information METHODS OF STERILISATION

should be checked to ensure that all the manufac- STEAM
turer’s instructions are adhered to. Figure 6-13
Saturated steam under pressure is one of the most
illustrates examples of commonly used symbols
effective and commonly used methods of sterilisa-
and their meanings.
tion. It is an inexpensive method and can be used
on items capable of withstanding high tempera-
STERILISATION tures (121–134°C), such as metal instruments and
Sterilisation is defined as ‘the complete elimina- bowls. Steam sterilisation takes place in specially
tion or destruction of all forms of microbial life’ designed sterilisers (autoclaves), into which trays
(Spry, 2015). All items introduced into the aseptic and individual items are carefully arranged to allow
field must be sterile in order to minimise the risk all surfaces to come into contact with the saturated
of surgical site (or other) infection and to promote steam. The autoclaves are pre-programmed to
an uneventful recovery. A number of different reach and maintain a specific temperature, pres-
methods are used to sterilise items used during sur- sure and time ratio depending on the type of load
gical procedures. Their use is based on the physical being sterilised (i.e. settings differ for metal ware,
properties of the item to be sterilised. For example, moulded plastic, linen or mixed loads).
metal instruments, plastic disposable items, cotton The autoclave chamber is sealed and the steri-
swabs and linen drapes all require a different sterilisation process begins with the creation of a
lisation method. Table 6-5 outlines methods of vacuum inside the chamber, which is achieved by
sterilisation: the ‘biological indicator’ is the organ- sucking out all the air. Following removal of all
ism used to test the microbial destruction capabili- the air, steam under pressure is introduced into
ties of the specific sterilising process. the chamber and the temperature rises to the
153
TABLE 6-5: Methods of Sterilisation
EXAMPLE OF WRAPPING BIOLOGICAL

METHOD PROCESS ACTION ITEMS MATERIAL INDICATOR
Steam using Steam under Destroys Stainless steel Linen Geobacillus
autoclaves pressure cellular Linen Cotton/polyester stearothermphilus
protein Moulded plastic Paper
Cellulose/
synthetic wrap
Heat-stable
pouches
Dry heat (rarely Hot air oven Oxidises Powders, oils, Metal canisters Bacillus subtilis
used in cellular paraffin gauze Aluminium foil niger
hospital protein Glass tubes,
settings; used bottles
commercially)
Ethylene oxide 100% ethylene Alkylation: Laparoscopes Paper pouches Bacillus subtilis
oxide gas chemical Cardiac catheters Perforated rigid niger
interference, containers
which
inactivates
reproductive
process
Gas plasma Low-temperature Disrupts Telescopes Linen Bacillus subtilis

hydrogen cellular Drills Cellulose/ niger
peroxide vapour activity Cameras synthetic wrap
Peracetic acid Low-temperature Disrupts Laryngoscope Unwrapped in Geobacillus

liquid peracetic cellular blades, flexible specialised stearthermophilus
acid 35% activity endoscopes (e.g. rigid tray
gastroscopes) within
sterilising
processor
Gamma Cobalt-60 isotape Destroys Sponges Paper Bacillus pumilus

radiation cellular DNA Surgical gloves Plastic
Petroleum gauze Cellulose
SOURCE: ADAPTED FROM STANDARDS AUSTRALIA (2014) AND SPRY (2015).
pre-programmed setting; for example, 121°C at DRY HEAT

103 kPA for 15 minutes. This is called ‘holding time’ Dry heat sterilisation using the traditional hot air
when the actual sterilisation of the items takes oven is rarely seen in healthcare facilities, but may
place. When this is completed, the steam is with- be available commercially for sterilising paraffin
drawn and the load is left to dry, using the residual gauze or Vaseline.
heat in the metal walls. In the final stage of the
process, filtered air is introduced, which returns the ETHYLENE OXIDE GAS
chamber to normal atmospheric pressure. Ethylene oxide (ETO) gas is a low-temperature (36–
The steam sterilising process is designed to 60°C) chemical method of sterilisation that is suit-
sterilise large loads of instruments within a central able for items that cannot be exposed to the high
sterilising department, the end result of which is a temperatures associated with steam or to dry heat.
wrapped, sterile item. ETO is a highly toxic agent and exposure can cause
154
severe toxic reactions such as nausea, vomiting computerised. It is the size of a large suitcase, with
and respiratory difficulties in healthcare workers. a lid and an interchangeable internal tray that
Therefore, strict work health and safety controls accommodates a variety of equipment or a specially
exist to protect operators of ETO sterilisers. Many configured tray to fit a flexible endoscope. A con-
larger healthcare facilities have ETO sterilising nection kit fits onto the exposed ends of the inter-
equipment and this method is used by many com- nal lumen system to ensure that the sterilising
mercial suppliers of disposable items (e.g. surgical agent passes through each lumen. Once the lid is
sponges, custom packs). closed and the processor activated, the active per-
ETO is very effective in sterilising items such as acetic acid mixes with water and is fed over and
rubber, silicone and polyethylene products, espe- through the endoscope for a period of 6 minutes,
cially those with narrow lumens, and telescopes followed by two rinse cycles, which uses filtered
and drills. Items for sterilising are wrapped in water to flush the peracetic acid away. The whole
single-use packaging or pouches and placed in the cycle takes approximately less than 30 minutes and
ETO steriliser, where the temperature and humidity the result is a wet, sterile scope ready for immediate
are controlled before the ETO gas is introduced. use (Spry, 2015).
The time taken to sterilise items can be up to As with all items, thorough cleaning of the
2 hours and, as ETO is absorbed into the items, endoscope must occur prior to sterilisation, using
there must be a further 2–12 hours’ aeration time mechanical cleaning to ensure that all lumens are
to ensure that the ETO has been completely elimi- free of debris and bioburden (Spry, 2015; Standards
nated from the items before they can be used (Spry Australia, 2014). The end product of peracetic acid
2015; Standards Australia, 2014). is environmentally safe acetic acid and water. (See
Chapter 13 for further information on reprocessing
GAS PLASMA of endoscopes.)
The gas plasma method uses hydrogen peroxide
vapour and plasma to create a state under which GAMMA RADIATION
items such as cameras, telescopes and drills can be Many commercially packaged products that are
sterilised under low-temperature conditions. This unsuitable for sterilisation by chemical or heat
method has, in many instances, superseded ETO processes are sterilised by irradiation using the
because it is a less toxic and more rapid form of isotope cobalt-60, which produces gamma rays.
sterilisation. Gas plasma involves the introduction Gamma rays can penetrate large cartons of items,
of hydrogen peroxide vapour into a closed vacuum making this an economical method for large medical
chamber through which radiofrequency waves are companies to sterilise items such as ointments,
introduced, creating an electromagnetic field and sponges, plastic drapes and surgical gloves. This
conditions that kill microorganisms. The cycle time method is suitable for commercial application only.
is approximately 30–60 minutes, depending on the
model of steriliser, and the by-products are oxygen CREUTZFELDT-JAKOB DISEASE
and water, thus making it substantially more envi- The causative prions of Creutzfeldt-Jakob disease
ronmentally sound than ETO (Spry, 2015). (CJD) are highly resistant to conventional decon-
tamination and sterilisation methods. Special pro-
PERACETIC ACID tocols are required to manage instruments if they
Peracetic acid is a low-temperature, liquid chemical have been used on patients known or thought to be
method of sterilisation that is suited for use at risk of carrying the disease. Ideally, single-use
with endoscopes that cannot be exposed to high instruments should be used, but this may not prove
temperatures. Commercially produced processing to be practical. Many institutions quarantine reus-
systems are increasingly used within operating able instruments used on suspected CJD patients
rooms where flexible endoscopes (e.g. gastroscopes) until test results from the patient have been
are used frequently and require sterilisation close obtained. Negative results will mean that routine
to the time of use. The active ingredient used in decontamination and sterilisation processes can
them is peracetic acid 35%, which is highly corro- be followed. Positive results will require instru-
sive and is therefore used in combination with an ments to be reprocessed using combinations of ger-
anticorrosive agent. The processing unit is fully micidal solutions for mechanical cleaning followed
155
by steam sterilisation at temperatures and pres- prior to using the instruments. If the integrator
sures in excess of those routinely required for steam strip has not changed colour, the item must not
sterilisation (Spry, 2015). The management of be used, as sterilisation may not have occurred
equipment exposed to CJD prions is still evolving (Standards Australia, 2014).
as further research is carried out on this highly
infective, but fortunately rare, disease (Department BIOLOGICAL
of Health, 2013). Biological indicators are standardised preparations
of bacterial spores that are included as part of the
MONITORING STERILISATION PROCESSES routine testing processes of sterilisers to demon-
All sterilising methods must undergo validation strate whether sterilisation conditions have been
processes to ensure that items are sterile and may be met. Biological indicators are inoculated with a
safely used on patients. The validation process refers known concentration of spore preparations, which
to documented procedures for obtaining, recording will be different depending on the sterilisation
and interpreting results needing to show that a process that is being tested. For example, the spores
process will consistently produce a sterile item. used to test steam sterilisation conditions are those
This commences with the commissioning of new of Geobacillus stearothermophilis. Following expo-
sterilising equipment and ongoing regular perform- sure to the sterilisation process, the indicators are
ance qualifications comprising microbiological and examined to ascertain if the spores have been
physical parameters (Standards Australia, 2014). destroyed, to ensure that this testing parameter has
been met.
PHYSICAL No one testing parameter alone will verify that
Regular maintenance, monitoring and testing of all sterilisation conditions have been met. Sterilisa-
sterilisers take place to ensure that they are function is achieved when all the physical, chemical and
tioning correctly in accordance with AS/NZS 4187 biological parameters have been met (Standards
(Standards Australia, 2014). All sterilisers have Australia, 2014).
external gauges, thermometers, timers and compu-
ter printouts to monitor their functions. Internal TRACKING AND TRACEABILITY
sensors can provide information about tempera- The ability to track instruments and trace patients
ture, pressure and humidity for every load. Docu- is an integral component of safety and risk manage-
mentation of these parameters is performed to ment processes. Written and computerised records
provide permanent records so as to provide retro- are maintained within the sterilising department to
spective proof that all loads have passed through provide retrospective proof that an item has satis-
the sterilisation process satisfactorily. factorily passed through a sterilisation process.
These records are important should an outbreak of
CHEMICAL infection occur and where investigations demon-
External indicators appear on the outside of each strate that there may have been a breakdown in the
package; these change colour when the item has sterilisation process. Patients who have undergone
passed through a sterilisation process. These may procedures during the period in question and who
be incorporated into the wrapping material, as in may have been infected need to be traced and their
pouches, or as a separate tape or spots attached to infectious status investigated. Tracking systems
the outside of the wrapped item. Different types of rely on trays of instruments having barcodes that
external indicators are required for each type of are scanned during decontamination and reproc-
sterilisation method. The external indicators do not essing, with the data stored on computer for future
demonstrate that the item is sterile but they do reference. The recommended tracking system is one
provide an important visual indicator that the item that is able to track individual instruments back to
has undergone a sterilisation process. a specific patient and involves laser or chemical
An internal chemical indicator strip, known as etching of RMDs (Standards Australia, 2014).
an integrator, is placed inside with the items to
assess the complete penetration of steam or chemi- DISINFECTION
cal vapours. If the sterilisation parameters have Disinfection is described as a process of destroying
been met, the strip changes colour, and this is veri- all pathogenic organisms except spores from inani-
fied at the point of use by the instrument nurse mate objects (Spry, 2015). The process can be used
156
on items identified as semi-critical or non-critical 18–22°C and a humidity range of 35–68%. The
(see Table 6-4). Disinfection involves the use of storage area must be regularly cleaned and free of
liquid chemical disinfectants, which can be classi- dust, insects and vermin. Any departure from these
fied as high, intermediate or low level depending on optimum conditions may compromise the sterility
their killing capabilities. As with items for sterilisa- of the sterile items. Stock should be regularly rotated
tion, effective decontamination of the items or sur- to ensure economical use of items, with attention
faces using enzymatic cleaners, detergents and paid to the date of manufacture (i.e. older items
water must occur prior to disinfection (Spry, 2015). used first). See Chapter 5 for further information.
Staff should wear personal protective attire when
using disinfecting agents as contact can produce
adverse skin or respiratory effects. Material safety CONCLUSION
data sheets (MSDS) containing information on each Understanding the modes of transmission of infec-
chemical, its use, possible adverse effects and first tion and applying the principles of infection pre-
aid and spill management should be available vention and control are a critical part of perioperative
within the operating suite and CSD. nurses’ role in keeping themselves and patients
safe during the perioperative period. The focus of
STORAGE OF STERILE EQUIPMENT this chapter has been on assisting perioperative
Following sterilisation, RMDs and single-use items nurses to implement a range of strategies aimed at
from external medical companies are stored in a preventing or minimising the risk of infection in
stockroom within the restricted area of the operat- the surgical patient. Perioperative nurses must
ing suite. Sterility of RMDs and single-use items is work in collaboration with other members of the
event- rather than time-related and relies on the healthcare team to monitor infection control prac-
environment being controlled at a temperature of tices constantly to ensure quality care for patients.

1. Perioperative attire
• Describe the items of perioperative attire you will change into when you arrive at work in the
operating suite. Provide a rationale for each piece of attire you wear.
2. Sterilisation procedures
• Prior to opening sterile items for a procedure what checks will you carry out to confirm that
the item is sterile? Explain the reason for each check.
3. Aseptic technique
• While circulating for a surgical procedure you notice one of the surgeons contaminates her
glove repositioning the operating light. How would you handle this situation? Provide ration-
ales for your approach.
4. Infection control
• The next patient on the operating list requires contact precautions to be used. Describe how
you will prepare the operating room and yourself to manage the patient and provide rationales
for your actions.
Creutzfeldt-Jakob Disease (CJD) Support Group Network

RESOURCES www.cjdsupport.org.au
Aseptic Non Touch Technique (ANTT) Department of Health (Australia)
www.antt.org www.health.gov.au
Centers for Disease Control and Prevention (CDC) Department of Health (NZ)
www.cdc.gov www.health.govt.nz
157
Hand Hygiene Australia Infectious Diseases guidelines for the diagnosis and treat-
www.hha.org.au ment of Clostridium difficile infection. Medical Journal of Aus-
National Health and Medical Research Council tralia, 194(7), 353–358.
www.nhmrc.gov.au Darouiche, R. O., Wall, M. J., Jr., Itani, K. M., Otterson, M. F.,
Perioperative Nurses College of New Zealand Nurses Webb, A. L., Carrick, M. M., et al. (2010). Chlorhexidine alcohol
Organisation versus povidone iodine for surgical site antisepsis. New
www.pnc.org England Journal of Medicine, 362(1), 18–26.
Society for Healthcare and Epidemiology of America (SHEA) Department of Health. (2013). CJD infection control guide-
www.shea-online.org lines. Retrieved from <www.health.gov.au/internet/main/
publishing.nsf/content/icg-guidelines-index.htm>.
The Cochrane Collaboration
www.Cochrane.org/index.htm Duguid, M., & Cruickshank, M. (2011). Antimicrobial steward-
ship in Australian hospitals. Sydney: Australian Commission
World Health Organization (WHO) 5 Moments of Hand on Safety and Quality in Health Care.
Hygiene
www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and Dumville, J. C., McFarlane, E., Edwards, P., Lipp, A., Holmes,
_When_Brochure.pdf A., & Liu, Z. (2013). Preoperative skin antiseptics for prevent-
ing surgical wound infections after clean surgery. Cochrane
Database of Systematic Reviews, (4), Art. No.: CD003949,
VIDEO RESOURCES doi:10.1002/14651858.CD003949.pub4.
Closed gloving method European Committee for Standardization (CEN). (2011). EN
https://www.youtube.com/watch?v=oilp-Auh7ok 13795. Surgical drapes, gowns and clean air suits, used as
medical devices for patients, clinical staff and equipment.
Self-gowning and gloving General requirements for manufacturers, processors and prod-
https://www.youtube.com/watch?v=jwcSdJlx17E ucts, test methods, performance requirements and performance
levels. Retrieved from <www.cen.eu/Pages/default.aspx>.
REFERENCES
Hadaway, L. (2012). Short peripheral intravenous catheters
Association of periOperative Registered Nurses (AORN). and infections. Journal of Infusion Nursing, 35(4), 230–238.
(2014). Perioperative standards and recommended practices.
Denver, CO: Author. Hand Hygiene Australia (HHA). (2013). 5 moments of hand
hygiene. Retrieved from <www.hha.org.au/UserFiles/file/
Australian and New Zealand College of Anaesthetics Manual/HHAManual_2010-11-23.pdf>.
(ANZCA). (2013). PS28 guidelines on infection control in
anaesthesia. Melbourne: Author. Harkavy, L., & Novak, D. (2014). Clearing the air: Surgical
smoke and workplace safety practices. OR Nurse, 8(6), 1–7.
Australian College of Operating Room Nurses (ACORN). doi:10.1097/01.ORN.0000453446.85448.2f.
(2012). Standards for perioperative nursing, including nursing
roles, guidelines, position statements, competency standards. Health Quality and Safety Commission New Zealand. (2015).
Adelaide: Author. Infection prevention and control programme. Retrieved from
<www.hqsc.govt.nz/our-programmes/infection-prevention-
Australian College of Operating Room Nurses (ACORN). and-control/projects/hand-hygiene>.
(2016). Standards for perioperative nursing, including nursing
roles, guidelines, position statements, competency standards. Hill, D. S., O’Neill, J. K., Powell, R. J., & Oliver, D. W. (2012).
Adelaide: Author. Surgical smoke: A health hazard in the operating theatre. A
study to quantify exposure and a survey of the use of smoke
Australian Commission on Safety and Quality in Healthcare extractor systems in UK plastic surgery units. Journal of
(ACSQHC/the Commission). (2012). Healthcare associated Plastic & Reconstructive Aesthetic Surgery, 65(7), 911–916.
infections: Action guide. Sydney: Author. doi:10.1016/j.bjps.2012.02.012.23.
Australian Commission on Safety and Quality in Healthcare International Organization for Standardization (ISO). (2012).
(ACSQHC/the Commission). (2014). Antimicrobial steward- ISO 15223-1. Medical devices: Symbols to be used with medical
ship clinical care standard. Sydney: Author. device labels, labelling and information to be supplied.
Best, M., & Neuhauser, D. (2004). Ignaz Semmelweis and the Retrieved from <https://www.iso.org/obp/ui/#iso:std:iso
birth of infection control. Quality Safety Health Care, 13, :15223:-2:ed-1:v1:en>.
233–234. Kelkar, U., Gogate, B., Kurpad, S., Gogate, P., & Deshpande, M.
Burton, G., & Engelkirk, P. (2014). Microbiology for the health (2013). How effective are face masks in operation theatre?
sciences. Philadelphia: Lippincott Williams & Wilkins. A time frame analysis and recommendations. International
Journal of Infection Control, 9(i1), doi:10.3396/ijic.v9i1.003.13.
Centers for Disease Control and Prevention (CDC). (2015).
Cover your cough: Stop the spread of germs that can make you Lee, G., & Bishop, P. (2013). Microbiology and infection
and others sick! Retrieved from <www.cdc.gov/flu/protect/ control for health professionals (5th ed.). Sydney: Pearson
covercough.htm>. Australia.
Cheng, A., Ferguson, J., Richards, M., Robson, J., Gilbert, G., Loveday, H., Wilson, J., Pratt, R., Golsorkhi, M., Tingle, A.,
McGregor, A., et al. (2011). Australasian Society for Bak, A., et al. (2014). National evidenced-based guidelines
158
for preventing healthcare-associated infections in NSH Standards Australia. (2014). AS/NZS 4187. Reprocessing of
hospitals in England. Journal of Hospital Infection, 86, reusable medical devices in health service organizations.
S1–S70. Sydney: Author.
McCarthy, J. (2015). Sutures, needles and instruments. In J. Tung, A. (2013). Best practices for central line insertion.
Rothrock & D. McEwen (Eds.), Alexander’s care of the patient International Anesthesiology Clinics, 51(1), 62–78.
in surgery (15th ed., pp. 186–210). St Louis: Mosby. Webster, J., Croger, S., Lister, C., Doidge, M., Terry, M., & Jones,
National Health and Medical Research Council (NHMRC). I. (2010). Use of face masks by non-scrubbed operating room
(2010). Australian guidelines for the prevention and control of staff: A randomized controlled trial. ANZ Journal of Surgery,
infection in healthcare. Retrieved from <https://www.nhmrc 80(3), 169–173. doi:10.1111/j.1445-2197.2009.05200.x.
.gov.au/guidelines-publications/cd33>. World Health Organization (WHO). (2009). WHO guidelines
National Health Performance Authority (NHPA). (2015). on hand hygiene in healthcare. Retrieved from <http://
Healthcare-associated Staphylococcus aureus bloodstream apps.who.int/iris/bitstream/10665/44102/1/9789241597
infections in 2013–2014. In Focus: Hospital Performance. 906_eng.pdf>.
April. Retrieved from <www.myhospitals.gov.au>.
Neely, A., & Maley, M. (2000). Survival of enterococci and
staphylococci on hospital fabrics and plastic. Journal of Clini- FURTHER READING
cal Microbiology, 38(2), 724–726. Australian Commission on Safety and Quality in Health Care
NSW Health. (2007). Infection control policy. Policy directives. (ACSQHC/the Commission). (2014). Antimicrobial prescribing
PD2007_036. Sydney: Author. practice in Australia: Results of the 2013 National Antimicro-
bial Prescribing Survey. Sydney: Author.
NSW Health. (2011). Safe use of alcohol-based skin prepara-
tions for surgical and anaesthetic procedures. Safety Informa- Gillespie, S., & Bamford, K. (2012). Medical microbiology
tion Sheet 001/11. Sydney: Author. and infection at a glance (4th ed.). Chichester, UK: John Wiley
& Sons.
NZ Ministry of Health. (2007). Guidelines for the control
of multi-drug resistant organisms in New Zealand. Welling- Noorani, A., Rabey, N., Walsh, S. R., & Davies, R. J. (2010). Sys-
ton: Author. Retrieved from <www.moh.govt.nz/moh.nsf/ tematic review and meta-analysis of preoperative antisepsis
pagesmh/3345>. with chlorhexidine versus povidone-iodone in clean con-
taminated surgery. British Journal of Surgery, 97, 1614–1620.
Operating Room Nurses Association of Canada (ORNAC).
(2015). Standards for perioperative nursing practice. Ontario: NSW Therapeutic Advisory Group. (2007). Indicators for
Author. quality use of medicines in Australian hospitals. Retrieved
from <www.ciap.health.nsw.gov.au/nswtag>.
Pelaez, T., Munoz, P., Guinea, J., Valero, M., Giannella, M.,
Klaassen, C., et al. (2012). Outbreak of invasive aspergillosis Ogg, M. J. (2011). First surgical hand scrub of the day. AORN
after major heart surgery caused by spores in the air of Journal, 93(3), 397–398.
the intensive care unit. Clinical Infectious Diseases, 54(3), Ogg, M. (2013). Types of acceptable eye protection. AORN
e24–e31. Journal, 98(2), 195–196.
Phillips, N. (2013). Berry & Kohn’s operating theatre technique Resar, R., Griffin, F. A., Haraden, C., & Nolan, T. W. (2012). Using
(12th ed.). St Louis: Mosby. care bundles to improve health care quality. IHI Innovation
Rothrock, J. (2015). Alexander’s care of the patient in surgery Series white paper. Cambridge, MA: Institute for Healthcare
(15th ed.). St Louis: Mosby. Improvement. Retrieved from <www.IHI.org>.
Schultz, L. (2015). Can efficient smoke evacuation limit aero- Spruce, L. (2014). Back to basics: Surgical attire and cleanli-
solization of bacteria? AORN Journal, 102(1), 7–14. ness. AORN Journal, 99(1), 139–146.
Silva, P. (2014). The right skin preparation technique: A lit- Van Wicklin, S. (2012). Surgical hand antisepsis using plain
erature review. Journal of Perioperative Practice, 24(12), soap. AORN Journal, 95(6), 818–819.
283–285. Van Wicklin, S. (2013a). Scrubbed personnel who are sneez-
Society for Healthcare Epidemiology of America (SHEA). ing. AORN Journal, 97(5), 592–593.
(2014). Strategies to prevent surgical site infections in acute Van Wicklin, S. (2013b). Length of time after which a surgical
care hospitals. Infection Control Hospital Epidemiology, 35(6), mask should be changed. AORN Journal, 97(5), 593–594.
605–627. doi:10.1086/676022. Widmer, A. F., Rotter, M., Voss, A., Nthumba, P., Allegranzi, B.,
Spry, C. (2015). Infection prevention and control. In J. Boyce, J., et al. (2010). Surgical hand preparation: State-
Rothrock & D. McEwen (Eds.), Alexander’s care of the patient of-the-art. Journal of Hospital Infection, 74(2), 112–122.
in surgery (15th ed., pp. 69–123). St Louis: Mosby. doi:10.1016/j.jhin.2009.06.020.
159
Chapter 7
ASSESSMENT AND PREPARATION
FOR SURGERY
CATIE McCULLAGH AND TRACEY LEE
EDITOR: MARILYN RICHARDSON-TENCH
LEARNING OUTCOMES
• Discuss the different pre-admission assessment processes employed, including at nurse-led clinics
• Explore the purpose of preoperative assessment for inpatients, day-of-surgery and day surgery patients
• Describe the components of preoperative assessment including patient education and investigations
• Discuss the need for cultural sensitivities in the care of perioperative patients
• Identify risk management procedures for patients who smoke and obese patients
• Discuss the admission process to the holding room
KEY TERMS
cultural sensitivity
holding area
patient education
preoperative assessment
preoperative preparation
requirements. The chapter then explores the effect

INTRODUCTION of preoperative smoking for surgical patients and
This chapter explores the importance of patient risk management procedures for obese patients.
education and pre-admission care for the periop- Discussion includes the importance of the preop-
erative patient. Specifically, the increasing role of erative check for surgical patients.
the pre-admission clinic and the critical elements Preoperative care of the patient once in the
of preoperative assessment are identified and dis- healthcare organisation starts in the preoperative
cussed, along with the development of nurse-led ward and continues into the preoperative holding
clinics. The importance of preoperative tests and area. It encompasses the unique holistic physical,
examinations is also discussed. The increasing psychological, emotional and spiritual preparation
cultural diversity of the population requires the of patients prior to their surgery. Adequate preop-
perioperative nurse to be sensitive to cultural erative preparation can lead to optimal outcomes
160
CHAPTER 7 | Assessment and preparation for surgery
for patients. Preoperative care is a complex and

• Preoperative assessment is required for surgery that
dynamic field; however, much of the literature and takes place in a variety of practice settings, both public
clinical guidelines lack evidence, leaving room for and private, including hospitals, day surgery clinics and
debate as to what constitutes optimal patient care doctors’ rooms.
• Assessment may take place in a pre-admission clinic or
(Richardson-Tench, Rabach, Kerr, Adams & Brown, by telephone.
2012). • Pre-admission clinics are more commonly situated in
general hospitals. However, not all patients come
PRE-ADMISSION through these; for example, some are assessed in the

surgeon’s rooms.
• The outcome of the patient’s preoperative assessment
The pre-admission stage of a patient’s surgical determines where the patient will be admitted for the
journey is critical in the patient’s preparation for surgical procedure.
surgery and prompt safe discharge. The require-
ment to increase the number of patients receiving
surgery (maximising theatre use) and reduce
waiting lists and waiting times has determined
the need for patients to be fully prepared, thus Day surgery Admission
23-hour short
procedure to a surgical
minimising the risk of cancellations or delays stay unit
ward
(Singhal, Warburton & Charalambous, 2014). The
need for increased efficiency has been driven largely FIGURE 7-1: Selection for surgery process
by government policies, such as the New Zealand
Health Strategy (Ryall, 2012) and those developed
by the Australian Department of Health and Ageing
(ADHA) (2008). The effectiveness of pre-admission are then used throughout the selection and assess-
clinics is demonstrated in an associated reduction ment process, enabling those patients who do not
in cancellation of cases, a shortened length of meet the criteria to be referred for treatment as an
hospital stay related to increased patient well- inpatient. Figure 7-1 demonstrates the selection
being and improved patient satisfaction (Mottram, process. The goals of preoperative assessment and
2012). Assessment of the patient for surgery is criti- thus the decision as to whether the patient will
cal in the pre-admission stage. Some of the assess- be a day patient or an inpatient are presented in
ment processes for day surgery patients may be Figure 7-2.
different from the processes for inpatients. Refer to
the Australian Day Surgery Nursing Association PREOPERATIVE ASSESSMENT
(ADSNA) guidelines at http://adsna.info/guidelines. Preoperative assessment (POA) is the clinical
investigation that precedes anaesthesia for surgical
PATIENT SELECTION AND ASSESSMENT or non-surgical procedures and that provides data
FOR SURGERY for the selection of an appropriate anaesthetic
PATIENT SELECTION strategy (Nicholson, Coldwell, Lewis & Smith, 2013).
Preparation of patients commences when they are Traditionally, patients were visited on the wards by
informed by their surgeon that surgery is needed. the anaesthetist the day before surgery. However, if
Careful selection and assessment are paramount to significant comorbidities were present, this could
successful surgery and many factors need to be result in cancellation of the surgery. A late cancel-
taken into account. A team approach is used to lation is distressing for the patient and results in
establish written criteria for patient assessment under-utilisation of the operating room as it may
and selection. This encompasses all who may be not be possible to schedule another patient (Singhal
involved in the care of the patient, so that all stake- et al., 2014). The provision of preoperative/pre-
holders take ownership of the criteria developed admission clinics has enabled the opportunity to
and consequently abide by them. The criteria should manage comorbidities, provide quality safe periop-
address, but not be limited to, the suitability of the erative care and reduce cancellations.
procedure, the significance of the medical history, A variety of models are available for preopera-
the minimal physical and anaesthetic assessments tive assessment. The most commonly used model
to be undertaken and how the evaluation of social internationally utilises a nurse who is experienced
circumstances will be determined. These criteria in all aspects of day surgery practice, and has a
161
The patient
agrees to be a
Informed consent day patient if the
is obtained for the procedure is
anaesthetic and suitable
Verbal and surgical procedure
written
information
covering all
The patient is aspects of the
medically fit for surgery
surgery and experience are
anaesthesia, given
and any
necessary
The patient investigations
understands the are carried out
procedure to be
performed and
the anaesthetic
to be given, as
well as the side
effects and
alternative
treatments
FIGURE 7-2: Goals of preoperative assessment
well-structured medical/health questionnaire, fol- This is particularly important if there are signifi-
lowing completion by the patient of a physical and cant comorbidities requiring management, special
social questionnaire at least 1 week prior to surgery. laboratory tests or procedures to be ordered, or
The ideal interview is a face-to-face meeting with planning/management of any anaesthetic concerns
the patient and carer (if possible), which also pro- required, and to allow time for patient education
vides the opportunity for physical assessment, pre- (Nicholson et al., 2013). Each patient is unique
operative diagnostic and other tests, and information and requires the opportunity to express concerns,
sharing and education (Richardson-Tench et al., ask questions and be supported in their decision
2012). An anaesthetist should be available for refer- making, even if that means changing their mind as
ral or advice as necessary. Where distance is a to the intended surgical procedure. Figure 7-2 out-
problem, the assessment may be carried out by tel- lines the goals of preoperative assessment.
ephone, followed by a mail-out of written informa- A number of different healthcare professionals
tion. This information enables identification of may be involved in the care and preparation of
those patients who are suitable for surgery, those the patient prior to surgery; for example, the
who may be suitable following further assessment pre-admission nurse, anaesthetist, dietician, physi-
and those who are unsuitable. Issues and concerns otherapist, pharmacist, social worker and occupa-
raised must be communicated to the multidiscipli- tional therapist. Assessment involves a two-way
nary team and referred for inpatient admission. pre-admission interview between the patient and
The principles of assessment include ensuring the health practitioner so that the patient is
that the consultation occurs at an appropriate time assessed physically, psychologically and socially
and place. The environment should provide ade- for surgery (White et al., 2012; Richardson-Tench
quate privacy for the patient, such as a single- et al., 2012). Even though most preoperative assess-
bed consulting room, and the consultation should ments are carried out in pre-admission clinics,
occur without interruption. Ideally, the consulta- some aspects are completed over the telephone
tion should take place several weeks before surgery. (see Research box 7-1). While more patients can be
162
RESEARCH BOX 7-1: Pre-Admission Telephone Screening versus Pre-Admission Clinic
Research undertaken by Richardson-Tench and colleagues (2012) compared the effectiveness of pre-
admission telephone screening with pre-admission clinics for improving care and patient satisfaction for
patients undergoing endoscopy procedures during day surgery. The participants were predominately
female (65%) and English-speaking (85%), with a median age of 52 years. The results demonstrated no
statistical difference between patients’ perception of preparedness for surgery by telephone screening or
face-to-face clinics.
SOURCE: RICHARDSON-TENCH ET AL. (2012).
assessed in a timely manner by telephone assess- to others within the multidisciplinary healthcare
ment, selection criteria are required to identify team. Nurse-led clinics can prevent inappropriate
patients who are suitable to be assessed in this way admission of unfit patients and reduce late cancel-
(White et al., 2012). Suggested criteria include: lations (Singhal et al., 2014); see Research box 7-2.
• no obvious medical condition The responsibilities and activities of the pre-
• diastolic blood pressure <95 mmHg admission nurse may vary between different health-
care agencies. A major responsibility is to ensure
• body mass index <35. that patients are available and prepared for their
The format, policy and protocol of the telephone allocated surgery. This includes communicating
assessment should be the same as for face-to-face with patients by telephone regarding preoperative
assessment. Consent must be obtained for tele- diagnostic tests and organising the preoperative
phone assessment and identification of the correct assessment consultation and detailed patient edu-
patient confirmed using approved patient identification so that the patient is prepared for the
ers, such as patient identity, site, procedure and planned surgery.
consent (Australian Commission on Safety and
Quality in Health Care [ACSQHC/the Commission], PATIENT EDUCATION AND
2012a; World Health Organization Surgical Safety
Checklist [WHOSSC], 2009). Following consulta-
INFORMATION
tion, a written summary is included in the patient’s Preoperative education supports patients by giving
health record. Documentation and communication a clear and consistent message of the impending
within the perioperative team ensure that the surgery from all members of the multidisciplinary
patient’s requirements are respected and should be health team. Patient education enables informed
as provided for in advance of their surgery, thereby decisions to be made, with time to reflect on infor-
decreasing the potential for confusion, cancellation mation already given, and provides patients with
or delay (Hartley, 2014). It is common practice for opportunities to ask questions. Providing preopera-
patients to complete a health assessment prior to tive information also helps decrease patient anxiety,
telephone or clinic assessment. Figure 7-3 shows a resulting in a reduction in postoperative (PO) pain,
pre-assessment health questionnaire used in New a reduced length of stay and increased patient sat-
Zealand, while Figure 7-4 illustrates a pre-procedure isfaction (Wilson et al., 2015). It is important to
screening tool used in Australia. assess patients’ current level of understanding on a
topic prior to education and then to assess that the
NURSE-LED CLINICS education provided has been understood by asking
Pre-admission clinics may be staffed by nurses patients to summarise their interpretation of the
whose role includes patient preoperative screening. information in their own words (Mulsow, Feeley &
This may detect medical or physical conditions that Tierney, 2012).
may generate a referral to the surgeon or anaes- Fear of the unknown and anxiety are common
thetist, as discussed above (Verma et al., 2011). feelings for many patients. This anxiety may be
Within nurse-led clinics, policies and protocols attributed to the forthcoming surgical procedure,
provide guidance as to when referral may be made Text continued on p. 170
163
SURNAME: NHI:
FIRST NAMES:
DATE OF BIRTH: / / SEX:

Please attach patient label here
Pre-Assessment Health Questionnaire
To be completed by patients
This information is important and confidential. Please complete both sides of this form fully.
If you need help to complete this form or need an interpreter, please ask a staff member.
Are the above name and details correct?

What would you like us to call you (i.e. Mr or Mrs or by your first name)?
Do you require an Interpreter? Yes No Language
Do you have any particular cultural/religious needs?
Do you have any difficulties with speech, hearing or vision?
What operation will you be having?
For Day Surgical patients only:

Will you have someone to take you home by car? Yes No
Will you have a responsible adult to look after you overnight? Yes No
Health Questionnaire Do you suffer from, or have you ever suffered from, the following:
Yes No Yes No Yes No
High blood pressure Persistent cough Stroke / TIA
Previous heart attack Shortness of breath Blackouts / Fainting
Heart murmur Obstructive Sleep Apnoea Medication for long term pain
Palpitations or unusual beating Cancer Recreational Drugs
Artificial heart valve or pacemaker Anaemia Steroids (e.g. Prednisone)
Chest pains / Tightness or angina Bleeding or excessive bruising Joint or metal implant
How often Blood clots in lungs/legs Arthritis
When did it last occur Blood transfusion Do you smoke
Hiatus hernia/Heartburn/Indigestion Hepatitis / Jaundice How many daily
Previous rheumatic fever Are HIV+ or have AIDS If you stopped, when
Asthma Kidney problems Do you drink alcohol Yes No
Tuberculosis Diabetes If yes, how much
Emphysema or bronchitis Epilepsy How often
I had surgery on my brain or spinal cord prior to 1992 Yes No

I received pituitary - derived hormones for infertility or short stature prior to 1985 Yes No
I was involved in a CJD surgical instrument contact incident. Yes No
Women Only. Are you or could you be pregnant? Yes No If yes, how many weeks
If you answered “yes” to any of the above, please give further details below:
Please list all previous admissions to hospital/Consultation with private specialist

Reason for admission Hospital Date
/ /
/ /
/ /
/ /
FIGURE 7-3: Patient pre-assessment health questionnaire

Source: Auckland District Health Board © Crown Copyright 2013.
164
SURNAME: NHI:
FIRST NAMES:

Pre-Assessment Health Questionnaire
Please list all current medications (including natural remedies / complementary therapies)
Drug name Dose Times of Day Taken
Do you have any allergies to medication, tablets, plasters, food, LATEX or any other substance Yes No
If “Yes”, please list
Substance Type of reaction
Do you have a problem opening your mouth? (e.g. previous jaw problems) Yes No
Have you been told of any difficulties during previous anaesthetics? Yes No
Do you have dentures, partial plate, capped or loose teeth? Yes No
Does lying flat make you breathless? Yes No
How many pillows do you sleep with at night?
What physical activities do you take part in on a regular basis? Please tick those that apply.
Walking Gym work Tennis Golf Other (specify)
How many flights of stairs can you climb without getting out of breath?
One flight Two flights Three flights or more
My activity is restricted by: Shortness of breath Chest pain Joint pain Muscle pain Not applicable
Are there any major illnesses, to your knowledge, among your blood relatives?
e.g. diabetes, muscular dystrophy, malignant hyperthermia Yes No If “Yes”, please list
Have you or any of your family had problems with an anaesthetic? Yes No If “Yes”, please outline
Do you suffer from any other conditions (including mental health) not already noted or do you wear a medic alert bracelet?
Yes No If “Yes”, please outline
Do you have any concerns or questions about your anaesthetic or surgery?
The details above have been completed by patient / guardian / relative / other (please circle)
Signed: Date: / /
Staff to complete
Height: cm Weight: Kg BMI: kg/m2
BP: HR: 02 Sats (air)
To see GP for blood pressure control: Peak flow l /min
FIGURE 7-3, cont’d
165
(Affix identification label here)

Queensland
Government URN:
Family name:
Adult Integrated Given name(s):
Pre-Procedure Screening Tool
Address:
Facility: Date of birth: Sex: M F I
Patient to complete this section
Please complete and return this form to avoid any unnecessary delays in booking your surgery
General Information
Interpreter required? No Yes If Yes, preferred
language:
Do you have any religious / cultural needs? No Yes
Are you of Aboriginal or Torres Strait Islander origin? No Yes, Aboriginal Yes, Torres Strait Islander
Do you have an Advance Health Directive? No Yes
Do you have an Enduring Power of Attorney? No Yes
Local doctor’s (GP) name: Phone (if known):

Medical centre name:
Do you have any allergies? (medicines,sticking plaster, iodine, latex, food etc.)
Nil known If yes, please detail:
Yes
Have you seen a specialist doctor (e.g. cardiologist) or had surgery in the last 5 years?
No Yes If yes, please provide details below
Date of Reason for seeing doctor/ type of surgery
Hospital/ clinic Name of doctor
last visit (e.g. heart/lung problems, diabetes)
Current Medications Taken Bring medications with you whenever you come to hospital
Please list all medications below. Include: over the counter medications, inhalers, topical, eye drops,
pain relievers, herbal medication. If you have a medication list, please attach it to this form.
Medication name: Dose: Reason (e.g. blood pressure):
1
2
3
4
5
6
7
8
9
10
FIGURE 7-4: Australian pre-procedure screening tool

Source: Queensland Health. © The State of Queensland (Queensland Health) 1996–2014.
166

Queensland
Government URN:
Family name:
Address:
Date of birth: Sex: M F I
√ Please complete the following sections to help us to plan your care for your hospital stay.
Health Questionnaire
1. Have you or any of your family No Yes Give details:
members ever had a problem with an
anaesthetic?
2. Do you have difficulty walking up more No Yes If yes, what stops you from walking further?
than two flights of stairs?
3. What is your weight? kg What is your height? cm
Do you have or have you ever had any of the following?
1. High blood pressure No Yes
2. Heart problems/chest pain/heart disease No Yes How often:
3. Heart attack No Yes When:
4. Blood clots in the legs or lungs No Yes When:
5. Heartburn or acid reflux No Yes
6. Heart valve surgery or stent No Yes When:
7. Pacemaker or defibrillator No Yes When:
8. Diabetes No Yes Diet controlled Tablets Insulin
9. Asthma No Yes
10. Chronic bronchitis/emphysema/COPD No Yes
11. Sleep apnoea No Yes CPAP Machine? Yes No
12. Stroke or TIA No Yes When:
13. Epilepsy or fits No Yes How often:
14. Rheumatoid arthritis No Yes
15 Bleeding / bruising disorder No Yes What:
16. Do you smoke cigarettes? No Yes How often:
17. Do you drink alcohol? No Yes How often:
18. Do you take recreational (party) drugs? No Yes Which ones and how often:
19. Could you be pregnant? No Yes How many weeks:
20. Do you suffer from anxiety, depression No Yes
or emotional disorders?
21. Are you unwell at the moment (e.g. No Yes

cough, cold, temperature)?
22. Have you had any recent blood tests / No Yes What:
heart tests /Iung tests?
Where:
23. Do you have any other medical No Yes Details:
conditions or disabilities not already
mentioned?

Continued
167

Queensland
Government URN:
Family name:
Address:
Planning For Your Care
Accommodation: House / Unit Hostel : Boarding
Retirement village Nursing home Other:
Number of stairs / steps – Front / back InternaI:
1. Do you live alone? No Yes
2. Do you have someone to look after you when you leave hospital? No Yes
3. Do you have dependants living with you? No Yes
4. Do you have care responsibilities for others? No Yes
5. Do you have difficulty Mobility Bathing
managing day to day activities? Dressing Other:
6. Do you have any special dietary requirements (list)? No Yes
7. Do you have any bowel or urine problems (e.g. bleeding or incontinence)? No Yes
8. Do you have Community Community nursing Home help Meals on wheels
support services? Other/name of provider:
9. Do you have difficulties with any of the following (tick all that apply)? Speech Hearing
Touch Vision
10. Will your occupation affect your recovery/or do you need a Medical Certificate? No Yes
11. How do you intend to arrive for your admission and discharge?
Skin Integrity
1. Do you have any skin problems such as sores, skin tears, bruises, blisters and rashes? No Yes
If yes, nurse to circle affected areas and describe below
Falls
1. Have you had any falls in the last 6 months? No Yes, nurse to complete full falls assessment
Nutrition
1. Have you lost weight in the last 6 No 0
months without trying? Unsure 2
Yes Nurse to complete
2. If yes, how much? 1–5 kg 1
Total score:
6–10 kg 2
11–15 kg 3 If score 2 or higher,
>15 kg 4 contact dietitian or refer
Unsure 2 to Malnutrition Action
Flowchart
3. Have you been eating poorly because No 0
of a decreased appetite? Yes 1
Patient's signature: Date:
168

Queensland
Government URN:
Family name:
Address:
Clinical staff to complete this section
Planned procedure:
Date of procedure: Consultant:

Is this form completed as a telephone consultation? No Yes
Observations
Weight: Height: BMI: Pulse: Blood pressure: Temp: Resps: O2 sats: BGL:
kg cm / °C % mmol/L
Infection Alert
Does the patient have an infection control alert? No Yes
If yes, for further information contact
infection control practitioner and give details:
Are swabs required? No Yes Date taken:
Is there clinical suspicion by a medical officer that the patient may have CJD? No Yes
Pre-Procedure Screen Outcomes

Schedule surgery (telephone review 2–4 weeks prior to surgery)
Schedule surgery Referral to clinic/service (please specify) Date referred Appointment date
(preadmission clinic
appointment required 2–4
weeks prior to surgery (e.g.
stable comorbidities)
Patient not ready for
care and needs further
assessment and
management by
multidisciplinary team
Plan:
Discharge carer and transport arranged (name: )

Procedural consent form signed
Anaesthetic info sheet given
Specific procedure education and information sheets given and discussed with patient
Post op pain education performed
TEDTM measurements: Thigh circumference: cm Calf circumference: cm Leg length: cm
Screen completed by (name): Designation: Signature: Date:
Reviewed by (name): Designation: Signature: Date:
169
RESEARCH BOX 7-2: Nurse-Led versus Doctor-Led Pre-Admission Service
A systematic review undertaken by Nicholson et al. (2013) examined whether a nurse-led service rather
than a doctor-led service affects the quality and outcome of POA for elective surgical participants of all
ages requiring regional or general anaesthesia. Outcomes considered by the authors were: cancellation
of the operation for clinical reasons; cancellation of the operation by the participant; participant satisfac-
tion with the POA; improvement in participant knowledge or information; perioperative complications
within 28 days of surgery, including mortality; and costs of POA. The authors concluded that currently
there is no evidence from randomised controlled trials to assess whether a nurse-led POA leads to an
increase or a decrease in cancellations or perioperative complications, knowledge or satisfaction in surgi-
cal patients. One study set in the UK indicated equivalent costs from economic models.
loss of autonomy or fear of the unknown (pain or requirements, such as fasting or specific surgical
death). It can present as abnormal haemodynamic preparation. Repeated education provided by the
readings such as hypertension or tachycardia multidisciplinary team provides the opportunity
(Pritchard, 2011). An anxious patient may present for relaying the same topic in a profession-specific
as an angry, hostile or attention-seeking individual manner, further enhancing the opportunity for
who appears not to comprehend or follow simple retention (King et al., 2014).
instructions (Pritchard, 2011). Personality charac- It is important that the education is provided at
teristics and underlying psychological comorbidi- an appropriate health literacy level for the patient.
ties are factors to be considered when assessing In other words, it is important to speak clearly
anxious patients. By identifying and managing the without the use of medical jargon, while using
effects of preoperative anxiety on a patient’s psy- active listening skills. Literacy and access to com-
chological status, we as health professionals are puters for web-based learning also need considera-
addressing our duty to care for people as individu- tion (Nicholson et al., 2013). A variety of media and
als (Pritchard, 2011). These fears may be elimi- tools may be used to provide patient information,
nated, or at least minimised, with patient education. including written pamphlets (provided in a variety
Familiarisation with the hospital environment, of languages), practical sessions with equipment,
equipment, procedures, anaesthesia, surgical talks, visits, videos, audio, mobile phone text mes-
routine and PO expectations provide a locus of saging and website instruction. A Cochrane proto-
control for patients (Nicholson et al., 2013). Patient col has been developed (Dumville, McFarlane,
involvement may also mean ensuring that caregiv- Edwards, Lipp & Holmes, 2013) to assess the differ-
ers and family members are briefed on what to ent types of formats or media used in preoperative
expect. This reduces vulnerability, increases confi- education and timing impacting on patients’
dence and provides an improved overall experience anxiety both prior to and following surgery. Reten-
and better outcomes. Much research into reducing tion of information from various formats differs
anxiety has been undertaken. Every patient’s risk between patients, meaning that multifaceted
perception is individual due to their differing approaches are needed (King et al., 2014). Coupled
assumptions and life experiences (Mottram, 2012). with verbal information provided prior to admis-
Patient education can take several forms; for sion, pamphlets can be a vital tool in the resources
example, from informally sitting down and con- available to empower patients.
versing with a patient at admission to the ward/ Some organisations have moved to developing
perioperative unit, to more formally structured electronic patient education materials, allowing
teaching/information sessions. Patient education staff to download and print this or email it to
can also take place in the surgeon’s rooms for patients. Web-based education provides the oppor-
private patients. Nursing staff play a vital role in tunity for patients to view information about the
the provision of patient education. Follow-up com- anaesthetic, surgery and PO care at their conven-
munication may be made by telephone to ensure ience. This has proven useful in particular for ambu-
that the patient understands all of the preparation latory patients who may have limited time allocated
170
for education in the clinical area and when innova- face-to-face or via telephone, several details spe-
tive approaches are required for delivery of infor- cific to surgery need to be ascertained.
mation (Nahm, Stevens, Scott & Gorman, 2012). • Medical history includes details of past surgical
To be successful, patient education should aim history, family medical history and current
to reduce anxiety, fear and uncertainty, enabling intake of medication. Many patients have
patients to feel empowered and secure, and provid- comorbidities such as cardiac disease, liver
ing time in an appropriate setting for trust and disease, pulmonary disease, hypertension,
understanding to be attained (Mottram, 2012). type 2 diabetes or latex allergy, thus requiring
complex medication regimens; for example,
PAEDIATRIC PATIENTS insulin-dependent diabetics and patients
Patient preparation and education for the paediat- taking anticoagulants. In these cases a specific
ric surgical patient should be age appropriate and clinical pathway should be initiated, indicating
provided in a form that is considered suitable. the necessary preoperative tests and patient
Studies have shown that providing information management throughout the surgical
about planned perioperative procedure reduces experience. Those patients with an artificial
anxiety and fear, whereas a lack of information may heart valve or other prosthesis may also
lead to an inconsistency between reality and the require prophylactic antibiotic therapy (White
patient’s own created beliefs. Multimedia with et al., 2012). Clear guidelines should be
interactive and educational elements is one effec- adhered to and provided to patients to ensure
tive method of providing age-related education patient safety and optimum outcome for their
(Fernandes, Arriaga & Esteves, 2014). Another surgery (Allison & George, 2014).
study has suggested that education is effective in • Demographic details, including confirming the
reducing anxiety in older children but that younger patient’s name, home address and other
children’s anxiety was negatively affected by similar relevant details, must be obtained.
education, suggesting that the education is best • The patient’s age should be confirmed, as some
aimed appropriately in the 4–6-years age range facilities may have upper and/or lower age
(Copanitsanou & Valkeapää, 2014). Educational limits.
programs for children that have been successful
• A consent form that indicates the correct
include play therapy, narrative information, inter-
procedure must be completed. An incomplete
active books, an orientation tour and video record-
consent form should not be accepted and steps
ings. Research has been undertaken to evaluate
must be taken to rectify this before the day of
whether preoperative anaesthetic education deliv-
surgery. If this is not possible, it must be
ered to children on the day of surgery reduces
rectified prior to the surgery or procedure.
anxiety behaviour during induction of anaesthesia.
Refer to Chapter 4 for information on consent.
The results showed that preoperative education
delivered on the day of surgery did not reduce • Recording of baseline observations should occur
anxiety behaviour in children during intravenous where possible.
induction of anaesthesia, but did reduce anxiety • Recording of weight and height should occur if
during subsequent inhalational induction (Hee, pertinent, and always for children as this
Lim, Tan, Bao & Loh, 2012). information is pertinent to the anaesthetic
and pain management. Obesity (along with
FACTORS AFFECTING SELECTION smoking and asthma) is a predictor of adverse
events in day surgery; specifically, respiratory
FOR SURGERY events (Joshi, Ahmad, Riad, Eckhert & Chung,
In some facilities a completed elective booking 2013).
form is required to gain a clear understanding of • The patient’s current medications should be
the surgeon’s instructions for the procedure. If identified. Some prescribed medications have
this form is completed fully and accurately by potential interactions with drugs used
the booking medical practitioner, it serves to mini- throughout the surgical procedure
mise delays and errors in the surgical pathway. (Kuwajerwala et al., 2013). See further
Whether patients are interviewed and/or assessed information on pp. 184–85 under
171
‘Premedication and medications’. Herbal and were directly, indirectly or even remotely related to
complementary medicines can cause adverse the planned surgery were ordered. While the tests
effects in patients undergoing anaesthesia and proved useful as baseline values for those caring
surgery. There is the potential for drug postoperatively for patients, in the current era of
interactions, and the side effects of herbal cost containment, such testing is not financially
medicines can result in unanticipated practical (Phoenix, Elliott, Chan & Das, 2012). Fur-
perioperative anaesthetic or surgical problems. thermore, current evidence supports the view that
The most important surgical interaction is changes in patient management rarely occur as a
unanticipated excessive bleeding associated result of routine testing (Phoenix et al., 2012).
with garlic, ginkgo biloba and ginger. The use Evidence-based guidelines have been developed
of non-steroidal anti-inflammatory drugs that rationalise the use of preoperative tests, leading
(NSAIDs) in a patient taking herbal medicines to a reduction in the number of tests ordered with
such as garlic, gingko or ginger may cause no subsequent compromise to patient safety, and
increased perioperative bleeding (Kuwajerwala the added benefit of reducing costs for both patients
et al., 2013). The American Society of and the healthcare system (Phoenix et al., 2012).
Anesthesiologists (ASA) recommends that Although some authors suggest that routine testing
patients cease taking herbal medicines at least can be eliminated completely, others propose that
2 weeks before surgery (Bajwa & Panda, 2012). testing should be based on the patient’s medical
An awareness of these over-the-counter condition (Kumar & Srivastava, 2011).
‘natural’ drugs and the risks they pose to
patients during their perioperative journey Investigations should be based on the findings
requires understanding, assessment and of the preoperative patient assessment and evalu-
patient education by the multidisciplinary ation (Phoenix et al., 2012). This assessment and
team. The use of recreational drugs can also evaluation may have already been conducted by the
impact on the anaesthetic and pain medical specialist prior to the day of the procedure
management. and the appropriate tests ordered as relevant to the
patient’s current medical history. It is therefore
• Anaesthetic evaluation is particularly important necessary to ascertain which, if any, tests have been
in patients identified as having previous or completed and to ensure that the results are made
family problems with anaesthesia and includes available once the patient arrives at the hospital/
patients who have a known (or possible) facility prior to the surgery or procedure.
difficult airway, a history of malignant
hyperthermia, a history of postoperative CHEST X-RAYS
nausea and vomiting (PONV), sleep apnoea
The benefit of chest X-ray examinations as part of
or drug/egg allergies. Recommendations
the preoperative examination is unproven; even
provided by the Australian and New Zealand
when abnormalities are detected, the information
College of Anaesthetists (ANZCA, 2008) on
is not necessarily useful. A preoperative chest X-ray
the pre-anaesthesia consultation indicate that
is, however, recommended for patients with new
all patients must be seen by an anaesthetist
or unstable cardiopulmonary signs or symptoms
prior to anaesthesia and surgery to ensure
(Kumar & Srivastava, 2011). The American Associa-
that they are in an optimal state of health
tion of Anaesthetists recommends that chest X-rays
and to facilitate the planning of anaesthesia
should be considered for smokers who have had a
along with appropriate discussion and
recent upper respiratory tract infection or who have
consent for the anaesthesia and related
chronic obstructive pulmonary disease and cardio-
procedures (Verma et al., 2011). The final
vascular disease (Breyer & Gropper, 2014).
decision on patient suitability for day surgery
is made by the anaesthetist (ANZCA, 2010). ELECTROCARDIOGRAPHY
ASA classification is presented in Table 7-1
(ASA, 2014). Abnormalities on preoperative ECGs in older
patients are common but are of limited value in
predicting PO cardiac complications (Greenland,
PREOPERATIVE INVESTIGATIONS 2012; Biteker, Duman & Tekkeşin, 2011). Obtaining
In the past, all patients received standard testing preoperative ECGs based on an age cut-off alone
regardless of their physical condition. Tests that may not be indicated because ECG abnormalities in
172
TABLE 7-1: ASA Physical Status Classification System
ASA GRADE DEFINITION EXAMPLES INCLUDE (BUT NOT LIMITED TO)

ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use.
ASA II A patient with mild disease Mild diseases only with substantive functional limitations. Examples
include (but not limited to): current smoker, social alcohol drinker,
pregnancy, obesity (30< BMI <40), well controlled DM (diabetes
mellitus) or HTN (hypertension), mild lung disease.
ASA III A patient with severe Sustainable functional limitations: one or more moderate to severe
systemic disease diseases. Examples include (but are not limited to): poorly controlled
DM or HTN, chronic obstructive pulmonary disease, morbid obesity
(BMI >40), active hepatitis, alcohol dependence or abuse, implanted
pacemaker, moderate reduction of ejection fraction, end stage renal
failure undergoing regular scheduled dialysis, premature infant PCA
<60 weeks, history (>3 months) of MI (myocardial infarction), CVA, TIA,
or CAD/stents.
ASA IV A patient with severe Examples include (but not limited to): recent (<3 months) MI, CVA, TIA,
systemic disease that is a or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction,
constant threat to life severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not
having regularly scheduled dialysis.
ASA V A moribund patient who is Generally, hospitalised, terminally ill patients.

not expected to survive Examples include (but are not limited to): ruptured abdominal/
without the operation thoracic aneurysm, massive trauma, intracranial bleed with massive
effect, ischemic bowel in the face of significant cardiac pathology or
multiple organ/system dysfunction.
ASA VI A declared brain-dead patient

whose organs are being
removed for donor purposes
SOURCE: ASA PHYSICAL STATUS CLASSIFICATION SYSTEM IS REPRINTED WITH PERMISSION OF THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS,
1061 AMERICAN LANE, SCHAUMBURG, ILLINOIS 60173-4973.
older people are prevalent but non-specific and are patient is an ASA III or higher or undergoing a
less useful than the presence and severity of comor- high-risk surgery (Breyer & Gropper, 2014).
bidities in predicting PO cardiac complications. To ensure appropriate ordering of tests, it is
However, in the elderly, silent myocardial infarction recommended that a detailed history and physical
is not uncommon and exposes the patient to the examination are performed. For major surgery, a
risk of cardiac arrest under anaesthesia—although blood group test and screen will also be required to
this is not always detectable on an ECG and may ensure the availability of blood should a transfu-
require further testing if suspected (Kim, Park, Ghil sion be required. Testing of patients’ International
& Choi, 2013). Normalised Ratio (INR) (clotting time) should be
carried out for those on anticoagulant therapy.
BLOOD INVESTIGATIONS Informed consent is required from patients for
Traditionally, routine blood tests were carried out authorisation of a blood transfusion prior to a sur-
prior to surgery for all patients. This included a full gical procedure. Documentation of such is recorded
blood count (FBC), urea, electrolytes and glucose. in the patient’s health record and/or on the surgical
This practice was expensive for individuals and consent/agreement to treatment form.
healthcare institutions and offered little advantage
to patients. In addition, when abnormalities were OTHER PERIOPERATIVE CONSIDERATIONS
detected, there was little change in patient man- It is necessary to check whether the patient has any
agement (Benarroch-Gampel et al., 2012). Routine special needs during the perioperative period (e.g.
blood testing is now not recommended unless a an interpreter or a carer or significant other).
173
Supporting patients’ unique needs protects their of ways. For example, the nurse should ensure that
dignity and allows them to maintain control over patients have appropriate support during any con-
what is happening to them. Also note the support sultations, on the day of surgery and for discharge.
systems available to the patient following surgery, An interpreter may be required. The nurse should
such as family, church or other community groups also ask patients if the care they are receiving is
(Verma et al., 2011). The patient’s social history appropriate to their beliefs. For example, permis-
must also be examined, noting alcohol intake, sion may need to be obtained before touching spe-
smoking habits, use of illicit drugs and use of non- cific parts of the patient’s body when undertaking
prescription medications and/or complementary the physical examination. Women of certain cul-
medications. tures, such as Muslim women, may have a prefer-
Patients who are scheduled for day surgery and ence to be cared for by female nurses. In some
who are unable to make satisfactory arrangements cultures the head area is deemed sacred and must
for travel and/or do not have a responsible carer to not be touched. The patient’s wishes must also be
take them home after surgery and provide care clearly documented in respect to the return of body
postoperatively are deemed unsuitable for day parts or tissue. In Māori culture body parts are
surgery. Alternative arrangements must be consid- revered; if a Māori patient’s body part is to be
ered when patients are the sole carer of another removed, the nurse needs to establish whether the
person; for example, those with a spouse who has patient requires it to be disposed of according to
dementia. It is important that these patients are practice or returned to them (Nursing Council of
given additional assistance to enable them to attend New Zealand, 2011).
hospital and then be supported while resuming The National Aboriginal and Torres Strait
their own role once they return home. Islander Health Plan 2013–2023 (ADHA, 2013)
Other perioperative considerations are a falls states that health services for Aboriginal and Torres
risk assessment for patients if appropriate and a Strait Islander peoples must be of high quality and
potential for infection assessment (ACSQHC/the be accessible and appropriate. Coordinated, cultur-
Commission, 2012b). ally appropriate services across the health system
will improve the patient journey and health out-
PREOPERATIVE VISITING comes for Aboriginal and Torres Strait Islander
peoples and their families. One goal of the plan that
The concept of preoperative visiting has been con-
is of relevance here is to ‘significantly improve the
sidered an important aspect of the perioperative
cultural and language competency of health serv-
nurse’s role and a way of articulating the patient-
ices and health care providers’ (ADHA, 2013).
centred focus. However, although the importance of
preoperative visiting is recognised, it is rarely, if Health professionals in Australia and New
ever, undertaken. Advancing technology, changes Zealand support the right of all individuals to
in the healthcare system, changing models of care have access to mental health, spiritual and reli-
and the predominance of day-of-surgery admission gious care during their surgical pathway. Specialist
have negated the opportunity for the perioperative professionals such as mental health specialists,
nurse to undertake a preoperative visit (Richardson- Indigenous support workers, interpreter services
Tench et al., 2012). and spiritual/pastoral carers are available to offer
appropriate support to individuals and their support
persons (Queensland Health, 2010). Recognition
CULTURAL SENSITIVITY and acknowledgement by the practitioner of these
The concept of cultural sensitivity has had a pow- sensitive issues is essential to ensure adequate pro-
erful ideological influence on health education and vision of the level of care required.
practice. It is important that the perioperative
nurse is culturally aware of the needs of patients
and demonstrates this awareness so that patients
SPECIAL POPULATION
feel that their beliefs and culture are valued and not CONSIDERATIONS
discounted. SMOKING
During the patient’s perioperative journey cul- An assessment of patient smoking habits is ascer-
tural sensitivity may be demonstrated in a number tained well before surgery and is undertaken by the
174
RESEARCH BOX 7-3: Effects of Smoking for Perioperative Patients
The results of a literature review of 25 studies indicated that timely cessation of smoking 4 weeks preop-
eratively decreases the risk of PO respiratory complications as well as the risk of PO complications with
wound healing. The optimal period of time for smoking cessation to reduce PO complications remains
unclear; however, interventions commenced 4–8 weeks prior to surgery had an impact on long-term ces-
sation as well as reducing PO complications. Interventions most successful were counselling and nicotine
replacement therapy (NRT).
SOURCE: WONG ET AL. (2013); THOMSEN, VILLEBRO & MOLLER (2014).
BOX 7-1 » SMOKING CESSATION FOR SURGERY: THE FIVE As

Ask about tobacco use Identify and document tobacco use status for every patient at every visit
Advise to quit In a clear, strong and personalised manner, urge every tobacco user
to quit
Assess willingness to make a quit attempt Is the tobacco user willing to make a quit attempt at this time?
Assist in quit attempt For the patient willing to make a quit attempt, offer medication and
provide/refer for counselling or additional treatment to help the
patient quit
For the patient unwilling to quit at the time, provide interventions
designed to increase future quit attempts
Arrange follow-up For the patient willing to make a quit attempt, arrange for follow-up
contacts, beginning within the first week after the quit date
For the patient unwilling to make a quit attempt at the time, address
tobacco dependence and willingness to quit at next clinic visit
SOURCE: ADAPTED FROM AVEYARD ET AL. (2012) AND AUSTRALIA AND NEW ZEALAND COLLEGE OF ANAESTHETISTS ( ANZCA ) (2014).
primary person making the surgical referral. of the medications (New Zealand Ministry of
Smoking is a risk factor for impaired bone healing, Health, 2014).
PO wound dehiscence, wound infections and
For patients about to undergo surgery, health-
delayed healing (Sørensen, 2012; Avila et al., 2012;
care professionals need to stress the importance of
Talbot & Palmer, 2013). Smoking also results in a
smoking cessation and provide an explanation of
higher incidence of perioperative respiratory and
the possible consequences of not stopping smoking.
cardiovascular complications compared to non-
Box 7-1 provides an example of a brief assessment
smoking (Talbot & Palmer, 2013). The optimum
suitable for use with patients preoperatively. Brief
length of time a smoker should cease smoking prior
counselling preoperatively, along with referral
to surgery remains unclear; times ranging from
information, has been shown to increase the likeli-
12 hours to 8 weeks have been suggested as having
hood of patients quitting preoperatively when com-
the optimal impact on perioperative complications,
pared with no advice at all (Aveyard, Begh, Parsons
such as rates of PO wound healing (Talbot & Palmer,
& West, 2012; Lee, Landry, Jones, Buhrmann &
2013; Thomsen, Villebro & Moller, 2014) (see
Morley-Forster, 2013; Stead et al., 2013).
Research box 7-3). Smoking also increases liver
enzyme numbers used to break down many medica- The New Zealand and Australian governments
tions, resulting in reduced blood concentrations have introduced strategies to reduce smoking in the
175
general population (Australian Ministerial Council equipment, extensions for bed sides, and position-
on Drug Strategy, 2011; New Zealand Ministry of ing equipment and its weight capabilities, as well
Health, 2014). Options for patients coming into the as extra staffing requirements for transfer and
hospital environment may include medicinal ther- considerations for emergency management of the
apies such as NRT (including lozenges and patches), patient. Obesity has an effect on anaesthesia induc-
bupropion, nortriptyline and varenicline as well tion, moving and positioning the patient, and the
as behavioural support (New Zealand Ministry of equipment and sterile supplies required for surgery,
Health, 2014). All healthcare organisations are as well as requiring more time in intraoperative
smoke-free. To assist patients who normally smoke, surgical exposure, all of which impact on the total
health professionals should check their local organ- operating room time required. This can be greatly
isation’s policies regarding the provision of free reduced through adequate planning and prepara-
nicotine patches to patients during their hospitali- tion prior to the patient’s arrival in the preopera-
sation. Advice available to patients may take the tive area (Kadry et al., 2014). Ideally this information
form of written materials or speaking with nurses should be communicated at the time of surgical
who specialise in smoking cessation. scheduling and following pre-admission assess-
ment. It also requires appropriate education of
OBESITY operating room staff and the development of poli-
Body mass index (BMI, kg/m2) is commonly used cies and guidelines at an organisational level to
to classify obesity: people with a BMI >25 and <30 support caring for obese patients throughout the
are classified as overweight, while those with a BMI perioperative period.
>30 are classified as obese (WHO, 2014). In New
Zealand, 31% of all adults and 11% of children aged DIABETES
2–14 years are considered as obese (Chai, 2013). The patient with diabetes is vulnerable to the
Obesity is a growing epidemic worldwide and in effects of both the anaesthetic and the surgery with
surgical patients its effects on organ function PO complications including infection, hypoglycae-
require consideration. It is believed that the techni- mia and hyperglycaemia. The type of diabetes and
cal knowledge and skills of the anaesthetic team in control of blood sugar levels will determine the
particular can reduce the risks for obese patients plan created by the surgeon or anaesthetist. Regular
perioperatively (Huschak, Busch & Kaisers, 2013). monitoring of blood sugar levels in the diabetic
Common health consequences for overweight fasted patient is necessary in the preoperative
and obese people include cardiovascular disease, period (Lewis et al., 2014).
diabetes, musculoskeletal disorders and endome- Leading up to the day of admission the diabetic
trial, breast and colon cancers (WHO, 2014). Each patient should be assessed to determine glycaemic
of these comorbidities increases with BMI score control and this should be optimised by establish-
and increases the risk for the surgical patient. ing an individualised management plan prior to
Effects on cardiac function include increased surgery (Auckland District Health Board, 2012).
cardiac output, increased sympathetic responses If the diabetes is uncontrolled, this should be
and increased circulating blood volume. Respira- weighed up against the urgency for surgery. This
tory problems associated with obesity have further also provides the opportunity for support from the
implications for anaesthesia such as obstructive diabetes specialist team where necessary. Compli-
sleep disorder, hypoxaemia, restrictive lung disease, cations from uncontrolled diabetes require con
chronic obstructive pulmonary disease and hyper- sideration and planning, such as patients with
capnia. For these patients extra preparations are neuropathy or peripheral vascular disease with
required for intraoperative positioning and respira- regards to venous thromboembolism assessment
tory support; ideally they should be identified and prevention interventions. The role and engage-
and organised during preoperative assessment ment of the patient in planning are essential. In an
by the anaesthetic and surgical teams (Graham, emergency situation where planning is not possi-
Faggionato & Timberlake, 2011). ble, blood glucose levels should be monitored regu-
In a practical sense, consideration and planning larly and an insulin infusion considered until the
are also required for obese surgical patients with patient is able to eat and drink postoperatively
regard to theatre bed weight capacity, transfer (Dhatariya et al., 2012).
176
Organisational policy should guide diabetes (Tokarski et al., 2014). Refer to Chapter 1 for more
management in surgical patients pre-/intra- and information.
postoperatively. Assessment and planning should
be completed and documented at the time of surgi- PREOPERATIVE HAIR REMOVAL
cal booking or the point of admission. This should The CDC and the World Health Organization
include all relevant preoperative testing such as strongly recommend that hair should not be
electrocardiograms, blood potassium levels and removed preoperatively unless it obscures the inci-
renal tests. Ideally, patients with diabetes should be sion site. The Health Quality and Safety Commis-
placed first on an elective list to prevent longer sion New Zealand (2014) recommends clipping and
than necessary fasting; see Figure 7-5. not shaving. Research box 7-4 presents recent
research on hair removal. See Chapter 6 for more
PREPARATION IN THE IMMEDIATE detail on perioperative hair removal.
PREOPERATIVE PERIOD SURGICAL SITE MARKING
Surgical site infection (SSI) is a serious complica- If the patient is to undergo surgery on a limb or any
tion of surgery and can be the cause of long illness other body part where the potential for operating
and, less frequently, death of surgical patients. Pre- on an incorrect site exists (such as a kidney, breast
venting a PO SSI through preoperative skin prepa- or digit), the patient may not proceed to the operat-
ration has a long history. Bathing with an antiseptic ing room unless the surgical site is clearly marked
solution and hair removal are two procedures cur- (ACORN, 2016; Association of periOperative Regis-
rently undertaken preoperatively to reduce or tered Nurses [AORN], 2016b; NSQHS, 2012). The
prevent an SSI. surgeon should mark the site with a single-use
indelible pen. Alternatively, a variety of commer-
PREOPERATIVE BATHING cially produced marking tools are available. The
The provision of an antiseptic solution to patients marking consists of an arrow close to, but not
for preoperative bathing is widely practised in the directly on, the site of the incision, which must
belief that it reduces the incidence of SSI. The remain visible to the OR staff when the patient has
Centers for Disease Control and Prevention (CDC) been draped. If the details of the intended proce-
(2015) recommends that patients shower or bathe dure differ between the operating list and the
with an antiseptic agent at least the night before consent/agreement to treatment form, the surgical
the operative day, as a reduction in skin microbial site marking on the patient or the patient’s opinion,
colony counts has been shown to result (Kamel the surgeon should be informed prior to transfer-
et al., 2012). However, a Cochrane Review con- ring the patient to the operating room. When the
ducted by Dumville and colleagues (2013) of 13 consent/agreement to treatment form has been
studies including more than 2623 patients did not completed prior to admission to hospital, the
show strong evidence of the benefit of using chlo- surgeon or delegated registrar should mark the sur-
rhexidine solution over other wash products in the gical site before the patient is moved to the operat-
prevention of SSIs. The CDC does not currently rec- ing room (AORN, 2016b; The Joint Commission,
ommend one product over another in reducing SSIs 2013; WHO, 2009). See further content in Chapter 3.
RESEARCH BOX 7-4: Hair Removal for Surgical Patients
A Cochrane Intervention Review conducted by Tanner, Norrie and Melen (2011) found that on the basis
of existing evidence it is not clear whether hair removal preoperatively affects rates of SSIs. However, if
hair has to be removed to facilitate surgery or the application of adhesive dressings, clipping rather than
shaving appears to result in fewer surgical site infections.
SOURCE: TANNER, NORRIE & MELEN (2011).
177
Avoid alterations of
Discontinue metformin
long-acting basal
prior to surgery in Avoid oral agents and non- insulin the day before
patients with renal insulin injectable the day of surgery unless there
dysfunction and who surgery is report of
will receive IV contrast
hypoglycaemia and in
patients on diet
restrictions
preoperatively
Reduce evening dose of

Withhold prandial intermediate-acting insulin
insulin while patient is (NPH) the day before The day of surgery,
fasting surgery to 75%; the day of may use 75% to 100%
surgery use 50% to 75% of of daily long-acting
morning dose insulin dose
Consider the level of Postpone surgery in Schedule patients with

preoperative patients with significant diabetes as the first
glycaemic control dehydration, case of the day when
when planning for ketoacidosis or possible to minimise
preoperative insulin hyperosmolar non- disruption to their
use ketotic states routine
Request patients to
Obtain blood glucose bring their insulin and
level on the patient’s hypoglycaemia
Instruct adequate
arrival before surgery treatment to the
preoperative hydration
and before discharge facility
home
Provide clear and

consistent instructions
regarding plans to
Suspect, prevent,
return to preoperative
Monitor intraoperative identify and manage
antidiabetic regimen
blood glucose every hypoglycaemia
and management of
1–2 hours depending on promptly
potential
the duration of the hypoglycaemia
procedure and type of postoperatively
insulin used
Instruct patient to
travel with
hypoglycaemia
treatment to and from
the surgical facility
FIGURE 7-5: Recommended preoperative planning and considerations for the day surgery diabetic patient
Source: Pichardo-Lowden & Gabbay (2012).
178
PREVENTION OF DEEP VEIN THROMBOSIS X-ray and ECG results) are reviewed. Detailed
Venous thromboembolism (VTE) is a blood clot that admission procedures are discussed below.
forms in a vein and migrates to another location
(Ortel et al., 2014). Typically the clot is a deep ADMISSION TO THE PREOPERATIVE
venous thrombosis (DVT) that becomes a pulmo- HOLDING AREA
nary embolism (PE); it often has serious health The preoperative holding area is an area specifi-
consequences. DVT can occur in surgical patients cally allocated for receiving patients. Characteristi-
as a result of their inability to move and change cally, the environment is quiet, provides privacy
position during anaesthesia and their reduced and is staffed by an appropriately qualified regis-
mobility during the PO period. A consequence of tered nurse (RN) with skills in patient assessment,
reduced mobility is the impaired physiological decision making and an understanding of peri
mechanisms for returning blood to the heart from operative processes and procedures. Some preop-
the peripheral circulation (Ortel et al., 2014). This erative areas may provide calm, quiet music to
can lead to stasis of blood in the deep leg veins and minimise patient anxiety. A reassessment of the
the potential development of a DVT. Fragment clots patient should take place, with time allowed for
can dislodge and lead to pulmonary or cerebral last-minute questions. A warm blanket, pillow or
emboli. These complications are associated with a position adjustment is provided if the patient is
high rate of morbidity and mortality and PE is con- uncomfortable (Edis, 2015).
sidered one of the leading causes of potentially pre- It is the responsibility of the RN, enrolled nurse
ventable hospital death (National Health and (EN) or registered anaesthetic technician (AT) (in
Medical Research Council, 2009). This led to Aus- New Zealand) to check in patients prior to surgical
tralia developing a clinical practice guideline for procedures. The perioperative nurse or AT should
the prevention of VTE in 2009 and New Zealand introduce themselves to the patient and receive
developing a national policy guideline for the pre- the handover from the ward nurse, systematically
vention of VTE in 2012 to support localised working through the preoperative checklist to
hospital-initiated guidelines and policy. ensure that the patient is ready for surgery.
Patients should be assessed individually for Figure 7-6 shows a patient being checked into an
their risk of VTE with preventive methods pre- operating suite. Figures 7-7 and 7-8 show examples
scribed by a medical professional prior to arrival in of a preoperative checklist. While these differ
the preoperative area. This might include antiem- between hospitals, their aim is the same: to ensure
bolism stockings applied to the patient’s legs pre- patient safety and timely care.
operatively to encourage venous return during Text continued on p. 184
the perioperative period, or pharmacological and
other mechanical prophylaxis. The intervention
will vary depending on the patient’s risk factors and
those associated with the planned procedure. See
Chapter 3 for further discussion on prevention and
management of VTE.
PREOPERATIVE CARE IN THE

OPERATING SUITE
Hospital policy designates the exact procedure that
should be followed when admitting the patient to
the holding area and the operating suite. A general
routine includes initial greeting, extension of
human contact and warmth, and proper patient
identification using unique patient identifiers as
per the NSQHS 2012. Accompanying documenta-
tion, such as the patient’s health record and diag-
nostic results (e.g. blood and urine testing, chest FIGURE 7-6: A patient being checked into an operating suite
179

Queensland
Government URN:
Family name:
Perioperative Given name(s):
Patient Record
Address:
Facility: Date of birth: Sex: M F I
Preoperative checklist Patient must not be transferred to operating suite unless Procedural Consent is completed
Date Temp: Pulse: Resps Blood pressure: O2 sats:
BGL: Check 1 Check 2 Check 3
Preoperative Patient Patient
mmol/L preparation handover/ handover/
/ / °C / Time : area transfer transfer
Beta Weight: Height: BMI: Pressure injury risk score Ward from Ward to
Checked
Variance
Checked
Variance
Checked
Variance
Adult Paediatric
N/A
N/A
N/A
HCG kg cm
1 Patient/parent/legal guardian to state full name and DOB; full name DOB and URN match ID band
and medical record Patient’s preferred name:
2 Procedural Consent Form completed
3 Patient/parent/legal guardian to state procedure in own words, procedure stated corresponds with
signed consent form Response:
4 Intended surgical site marked by surgeon

5 X-rays/Medical Imaging/PACS Queensland Health Private Number of packets:
6 Allergy status documented Yes (note on page 2) Nil known
7 Infection alert Contact Droplet Airborne MRO Contact operating theatre
8 Cytotoxic medication administered in the last 7 days Yes (note on page 2) No
ALERTS
9 Anticoagulant / antiplatelet agent / fish oil

administered within the last 7 days Yes (note on page 2) No
10 Pregnant Yes Suspected/Unknown (document as variance) No
11 Diabetic status NIDDM IDDM
12 Other alerts (e.g. falls, interpreter, aggression) (if yes, document as variance)
13 Fasted Last food intake: / / : hrs Last fluid intake: / / : hrs
14 Pre-medication administered Yes No
Other medication taken Yes (note on page 2) No
Other medication withheld Yes (note on page 2) No
15 Haematology documented Group and hold INR Blood cross-match Blood product refusal
16 Existing implants/prostheses Yes (note on page 2)
17 Caps/crowns/loose teeth or dentures documented
Caps Crowns Loose teeth Specify site(s):
Dentures: Upper Lower Partial Full Insitu Remain on ward
18 Preparation Pre-op shower Surgical attire
Removed/taped: jewellery, body jewellery, hair pins, make-up, nail polish
- Operation site prepared: Clip Bowel prep and return:
- Anti-embolic devices applied TEDsTM SCDs/lPCs Other:
19 Skin integrity assessed Rash Bruise Tears Pimples Pressure injury Other
Site:
20 Personal aides/items documented Specify:
Glasses: lnsitu Remain on ward Contact lenses: Removed
Hearing aid: lnsitu Remain on ward
21 Passed urine: hrs IDC insitu Nappy/Pad
22 Relevant documentation
Medical record Fluid order sheet Medication chart Fluid balance chart
Diabetic chart 3 sheets of patient labels Observation sheet ECG
23 Patient/parent/legal guardian agrees to clinicians discussing the procedure with the nominated
support person Yes No
Support person Name: Phone number
Ck1 Print name: Designation: Signature: Time: :

FIGURE 7-7: Australian checklist for admission into the OR

Source: Queensland Health. © The State of Queensland (Queensland Health) 1996–2014.
180

Queensland
Government URN:
Family name:
Perioperative Given name(s):
Patient Record
Address:
Allergies Existing implants and prostheses
Allergy Reaction Type Site
Variances / Other alerts / Additional notes

Date and time Actions and outcomes

Continued
181
Surgical Safety Checklist (Affix identification label here)

URN:
Family name:
Date: / / Given name(s):
Address:
Document variances on page 2
AII checks need to be read out loud at time of confirmation

Sign in - Before anaesthesia or equivalent
1. Patient has confirmed: 8. Prosthesis (or special equipment) has been
Identity AND checked and confirmed:
Site / Side AND Yes OR
Procedure AND Not applicable
Consent
9. Plan for antibiotic prophylaxis has been made:
2. Site marked: Yes OR
Yes OR Not applicable
Not applicable
10.Thromboprophylaxis:
3. Anaesthesia safety check completed: Mechanical:
Yes Implemented OR
4. Appropriate equipment / assistance available for Not indicated
managing a difficult airway / aspiration risk: Mechanical:
Yes Ordered OR
Not indicated
5. Known allergy(ies):
Yes OR 11. Essential imaging:
No Checked with patient ID AND
Available in theatre and viewed by operator AND
6. Known alert(s): Cross-checked against planned procedure OR
Yes OR Not applicable
No
7. Risk of blood loss of > 500mL (7mL/kg in
children):
Yes, and adequate planning for intravenous
access and fluids OR
No
Time out - Before operative procedure or equivalent commences
12.Confirm all team members have: 15.Pressure injury prevention plan implemented:
Introduced themselves by name and role OR Yes
Already know each other by name and role
16.Anticipated critical events:
13. Surgeon, Anaesthetist and Nurse confirm: Surgical team review:
Patient AND Confirm the critical or non-routine steps
Site / Side AND
Anaesthesia team review:
Procedure
Confirm any patient-specific concerns
14. Antibiotic prophylaxis has been given: Nursing team review:
Yes OR
Confirm sterility (including indicator results) AND
Not applicable Confirm all equipment available
Sign out - Before patient leaves operating room
17. Nurse confirms with the team: 19.Equipment problems to be addressed:
The name of the procedure documented AND Yes OR
Accountable items count correct Not applicable
18. Specimens are correctly labelled: 20.Specific concerns for post operative care
Yes OR including pressure injury prevention:
Not applicable Surgical team AND
Anaesthetic team AND
Nursing team
Based on the WHO Surgical Safety Checklist, URL http://www.who.int/patientsafety/safesurgery/en, © World Health Organization 2008 All rights reserved.
182
MUST ATTACH PATIENT LABEL HERE

SURNAME: NHI:
FIRST NAMES: DOB:
Pre-Operative Checklist Please ensure you attach the correct visit patient label
Attach patient label after checking that information matches the Visit Record Front Sheet (CR2685).
Important: Complete the checklist with either a ✓Yes or ✗ No or N/A and circle as appropriate
Parent or legal guardian present for consent
Escort person / overnight support
Currently nursed in isolation? Yes / No MRSA+ VRE+ ESBL+ TB+ Other
PATIENT PREPARATION
Ward Preop OR
Name verbally communicated by patient, if non verbal, identification verified by Caregiver / Power of Attorney
Identification band correct according to Front Sheet / Consent
Surgical / Procedural Consent Form signed and dated
Anaesthetic Consent Form signed and dated
Operation Site marked
Patient / Family requests return of body part / tissue (Form CR2547)
Interpreter required Language:
Interpreter: Phone number:
Patient is oriented / disoriented
Impairments: vision / hearing / speech / mobility Aids location: with patient / ward / support person
Last food (time and date): Last clear fluid (time and date):
Allergies / Adverse Reactions, Details
Medic Alert Bracelet Details

Regular medication given Withheld for valid medical reason
Premedication given
Diabetic / Metabolic disorder Blood sugar level- Time:
IV fluids / Infusions in progress / Meds due
Fluid Balance Chart, Medication Chart, 20 patient labels checked against front sheet
Old notes with patient / electronic X-Rays with patient / electronic
Pre-Operative investigations e.g ECG
Group and Screen / Cross Match Date:
Haematology Results electronic / paper Date:

Biochemistry Results electronic / paper Date:
Urine voided (time): Catheter insitu Bowel prep:
Last Menstrual Period: Pregnancy Test: Pos / Neg / N/A
Skin Integrity intact / broken / bruised / rashes
Pressure Area Assessment Completed, Details
Teeth own / chipped / crowns / caps / loose / dentures / full / partial
Jewellery / Taonga removed / taped (details):
Metalware / Implants / Pacemaker
Clean appropriate pyjamas / gown Compression Stockings Size:
Removed: hair pins / nail polish / make up / contact lenses
Patient property
Additional Information: Weight Temp
Height BP
HR
Sats
Resp Rate
WARD STAFF PRE-OPERATIVE STAFF INTRA-OPERATIVE STAFF
Name
Signature
Designation
Date / Time
FIGURE 7-8: New Zealand checklist for admission into the OR
183
PATIENT IDENTIFICATION PREOPERATIVE FASTING

The preoperative nurse is required to ensure the Preoperative fasting is an essential component of
correct identity of the patient. Preoperative nurses patient preparation. The rationale is to empty the
need to ensure that they are admitting the: stomach and therefore reduce the risk of the
• correct patient stomach contents being regurgitated and aspirated
into the lungs (ASA, 2015), which is a rare but dan-
• for the correct surgery gerous and potentially fatal complication of anaes-
• correctly prepared thesia. ANZCA (2015) recommendations for fasting
times in adults who are having day surgery are that
• at the correct time (Radford & Palmer,
limited solid food may be taken up to 6 hours prior
2012).
to anaesthesia and unsweetened clear fluids of not
In order to do this patients are asked to state: more than 200 mL may be taken up to 2 hours prior
• their name to anaesthesia.
• their date of birth Body fluid depletion due to excessive fasting
should be avoided. It is not unusual for patients
• the procedure they are having.
to be fasted from midnight before the surgery,
This information is checked against their patient regardless of whether they are first on the list or
identification bracelet, marked operative site and booked in for the afternoon. In a ‘healthy’ adult
consent form (NSQHS, 2012). having elective surgery, this is unnecessary and
may cause dehydration, headaches, irritability,
CONSENT electrolyte imbalance and malaise (Pimenta &
Informed consent is the process whereby the patient Aguilar-Nascimento, 2014). Unrestricted free fluids
is fully informed regarding his or her surgery and given 3 hours prior to surgery do not significantly
enters into a partnership with the healthcare team increase gastric volume or affect the stomach pH.
in order to receive healthcare (Royal Australian There is no indication that fluid permitted up to
College of Surgeons (2014). Informed consent is 2 hours prior to planned surgery during the preop-
discussed in Chapter 4. erative period has any adverse outcomes compared
with those participants that follow standard fasting
ALLERGIES AND SENSITIVITIES regimens (e.g. fasting from midnight) (Kulshrestha
Any allergies or sensitivities that a patient reveals et al., 2013). Flexible and suitable fasting times in
must be listed, with the type of reaction noted on relation to scheduled operating times have been
the preoperative check-in sheet. This should include identified as improving patients’ preoperative
non-drug as well as drug reactions/sensitivities. All comfort and PO recovery (Power et al., 2012).
care is taken during the perioperative continuum to On assessment, some people may be considered
avoid contact with or administration of these aller- to be more likely to regurgitate while under anaes-
gens. Patients with a history of any allergic respon- thetic, such as those who are pregnant, on opioids,
siveness have a greater potential for demonstrating are obese, have had lap band surgery, have a hiatus
hypersensitivity to drugs administered during hernia or abdominal disorder or have a neurological
anaesthesia (Dewachter, Mouton-Faivre, Castells & deficit (Kulshrestha et al., 2013). Also, patients who
Hepner, 2011). Previous unfavourable reactions to are acutely ill or have been involved in some unex-
anaesthesia, blood transfusions, iodine and tapes pected event, such as a car accident, requiring them
are noted. Formerly, patients would wear a second to have surgery, will be treated as though they have
ID band noting their specific allergy. Current prac- a full stomach. The assessment of risk to the patient
tice is for patients to wear a red ID band; the band is made by the anaesthetist, who needs to be fully
does not contain any information and the patient’s informed by the preoperative nurse of exactly what
history must be accessed to identify the specific the patient has recently had to eat and drink.
health issue. All patients coming to the operating
room are also assessed with purposeful questions PREMEDICATION AND MEDICATIONS
to identify the risk of latex allergy; see Chapter 5 While a premedication is now rarely given, special
for more information. consideration needs to be given to patients who
184
have been administered a premedication as they must be clearly documented on the preoperative
may need close observation and surveillance. In check form and tissue return form (see Fig. 7-9).
addition, if the patient is due other medications When patients choose to have a body part/tissue
while in the operating suite, this needs to be com- returned to them, laboratory staff will ensure that
municated to the OR staff to ensure timely admin- it is returned with written instructions if preserved
istration. Regular medications taken orally may in formalin. In the case of emergency surgery where
be continued unless documented by the anaesthet- no wishes have been noted, any body part/tissue
ist (Symons & McMurray, 2014; Allison & George, removed is retained for subsequent return to the
2014). patient (Canterbury District Health Board, 2014).
An assessment of all current medications and
their schedules is undertaken in the preoperative JEWELLERY AND PIERCINGS
area. Special attention is given to antihypertensive, The presence of body piercing and jewellery requires
anti-anginal, antiarrhythmic, anticoagulant, anti- attention from the perioperative nurse during the
convulsant and insulin medications (Allison & preoperative assessment and ideally should be
George, 2014). An assessment of when these medi- removed. This is to minimise the risk of infection,
cations were last given and next dose due is prudent traumatic removal or loss of the jewellery (AORN
and included in the handover to OR staff. 2016a; ACORN, 2016; West Coast District Health
Board [WCDHB], 2015). If the jewellery remains in
IMPLANTS place, such as a wedding band, it needs to be taped
All implants within the patient must be docu- to prevent its loss. All mouth, tongue, nasal and
mented on the preoperative form and highlighted facial jewellery must be removed as they create a
during handover. This ensures that the periopera- risk to patients undergoing anaesthetic and opera-
tive nurse is alerted to their presence when consid- tive procedures. Other body jewellery is removed if
ering electrosurgical unit (ESU) pad placement. it is within the operative field, is at risk of being
Some implants are large and will have scar tissue traumatically removed or causing pressure damage,
encircling them. Scar tissue is high in resistance or provides an alternative pathway for ESU current.
and placing a return electrode (diathermy plate) Genital piercing does not have to be removed if the
over this area may increase the temperature under- surgery is elsewhere on the body (AORN, 2016a;
neath the pad (AORN, 2016a). If the patient has an ACORN, 2016; WCDHB, 2015). If there are any
internal or external pacemaker, bipolar diathermy doubts, these should be discussed with the anaes-
may need to be used, as monopolar diathermy thetist and the surgeon. Removed jewellery is given
interferes with the pacemaker signals, potentially to a family member or labelled and locked away in
causing it to enter an asynchronous mode or block- the ward or hospital safe.
ing the pacemaker entirely. If the patient has an
internal cardiac defibrillator, the cardiologist may PREOPERATIVE PATIENT WARMING
need to be consulted (AORN, 2016a). Consideration Perioperative hypothermia is defined as a tempera-
is also required for patients with cochlear implants. ture below 36°C, which is estimated to occur unin-
Diathermy must never be used over the implant as tentionally in approximately half of all patients
this can cause tissue damage or permanent damage (Ousey et al., 2015). All patients have their tem-
to the implant. perature measured and recorded prior to admission
to the operating suite to act as a baseline. Preopera-
RETURN OF BODY PARTS OR HAIR tive management of normothermia involves assess-
Patients must give informed consent prior to the ing the patient for risk factors of unplanned
surgical removal of any body part/tissue. Although (inadvertent) perioperative hypothermia. The
not commonplace in Australia, it is routine in New highest risk factor reported by Billeter and col-
Zealand that in every case where hair, specimens or leagues (2014) is illness at admission; however, the
tissue is removed, patients are offered the opportu- elderly and infants are also population groups at
nity to have this returned to them on completion risk (Alderson et al., 2014). Day surgery patients
of the histology or other required testing. The should have a risk assessment at the time of the
patient’s wish to have a body part/tissue returned pre-admission interview as there are a number of
185
SURNAME: NHI:
FIRST NAMES:

Body Parts / Tissue Release
Important Information for Returns / Temporary Storage:

• Yellow body part sticker to be placed on patient's front sheet in Clinical Record, on specimen and all forms
• This form covers: Product of Pregnancy / Fetus (Baby under 20 weeks) / Placenta / Tissues / Body Parts
1 Return / Cremation
Please tick option below for each different body part / tissue.
Description Lab Registration
Cremation only (No testing) [TDIS]

Take immediately following delivery / surgery
Cremation following laboratory examination (Women's Health only)
Return following laboratory examination
Temporary storage then return (Pick up only from LabPlus)
2 Clinical Staff to complete
Staff Member's Name: Designation:

Staff Member's Signature: Date:
3 Patient to complete
Tissue is held for 28 days. Tissue that has not been collected after 28 days will be cremated,
unless alternative arrangements have been made with LabPlus.
Please complete section 3 for the following:
a) For all Products of Pregnancy / Fetus (Baby under 20 weeks) / Placenta or
b) If an Agreement to Treatment form (CR0111) is not completed
Patient / Guardian / Parent / Whanau Name:

Patient / Guardian / Parent / Whanau Signature: Date:
Current contact details: Phone: Mobile:
4 To complete at time of return
I have received instructions on the proper transport and disposal of body parts:
Patient / Guardian / Parent / Whanau Name:
Patient / Guardian / Parent / Whanau Signature: Date:
Staff Member's Name: Designation:

Staff Member's Signature: Date:
Date of Cremation if not collected:
YELLOW SHEET send with tissue to LabPlus, or if immediate return of tissue place sheet in clinical records
FIGURE 7-9: Document for completion of return of body parts

186
day procedures where preoperative warming may less effective than active warming devices. Active
not be considered necessary. All surgical patients warming refers to devices and processes that actively
whose temperature is above 36°C do not require transfer heat to the patient. Forced-air warming,
pre-warming. whereby the patient is covered by a resistive
Inadvertent hypothermia may have detrimental polymer-incorporated blanket, is current practice
effects on the patient undergoing surgery and has (Duff et al., 2014). Other methods include heated
been associated with: gel pads, warming intravenous fluids, warmed
cotton blankets, electric blankets, water mattresses
• poor clotting times and ambient temperature control, although these
• increased risk of wound infection are less effective in maintaining normothermia
(Ousey et al., 2015). These interventions should
• delayed healing
ideally be initiated in the ward and used continu-
• decreased drug metabolism and clearance ously until the patient has been anaesthetised.
• increased blood loss
• PO myocardial ischaemia CONCLUSION
• impaired immune function This chapter has explored the pre-admission and
• delayed postanaesthesia recovery preoperative care of the patient through the peri-
• lengthened hospital stay. operative continuum. Specifically, elements of pre-
operative assessment have been identified and
It also interferes with the perception of comfort discussed. Education of the patient has been pre-
during the patient’s perioperative experience sented. Discussion has included activities under-
(Sessler, 2014). taken in the preoperative period and the potential
The literature indicates that pre-warming for consequences for the patient. Management of
1–2 hours preoperatively has an initial effect on special populations such as people with diabetes
decreasing redistribution hypothermia resulting and patients who smoke has been addressed. Cul-
from anaesthetic agents and is more effective than tural issues have been explored. The preoperative
intraoperative warming alone in preventing hypo- phase becomes crucial in the provision of effective
thermia in the first 2 hours of surgery (Ousey et al., and efficient patient care within the environment
2015; Steelman & Graling, 2013; Horn et al., 2012). of shorter hospital stays, an increasing complexity
Warmed blankets and reflective ‘space’ blankets of surgery and comorbidities, longer waiting lists
are considered passive warming devices and are and budget constraints.

1. Assessment
Ninety-two-year-old Mrs James is accompanied by her daughter, Jayne, at a pre-admission consulta-
tion for cataract surgery. Jayne states that her mother has dementia and that she developed a VTE
following a hip replacement 2 years previously.
• What should you do with this information? Explain your decision.
• What interventions are required when Mrs James is admitted to the DSU for her surgery?
Explain your answer.
2. Medication use
Mrs Gianoulis, who is scheduled for a hysterectomy, reports using ginkgo biloba for well-being.
• Does this have a relevance to Mrs Gianoulis’ surgery? Explain your answer.
• What should you do with this information? Explain your decision.
Continued
187

3. Communicating issues with the multidisciplinary team
Mrs Smith presents for a nurse-led pre-admission assessment. She is an insulin-dependent diabetic
with a BMI >45.
• What tests and referrals would you recommend for Mrs Smith?
• What information is required to communicate with the multidisciplinary team?
4. Social issues
Mr Thomas informs the nurse at the pre-admission clinic that he has no support person available to
help him after his forthcoming day surgery under a general anaesthetic.
• Who do you need to communicate with to minimise the risk of the procedure being delayed or
cancelled due to lack of support issues? Explain your answer.
Allison, J., & George, M. (2014). Using preoperative assess-

RESOURCES ment and patient instruction to improve patient safety.
AORN Journal, 99(3), 364–375.
Ambulatory Surgery Journal of the International
Association for Ambulatory Surgery American Society of Anesthesiologists (ASA). (2014). Stand-
www.iaas-med.com/index.php/home ards & Guidelines Library. ASA physical status classification
system. Retrieved from <www.asahq.org/…/asa-physical-
status-classification-system/en/1>.
www.anzca.edu.au
American Society of Anesthesiologists (ASA). (2015). Prac-
Australian and New Zealand Working Party on the
tice guidelines for preoperative fasting and the use of phar-
Management and Prevention of Venous
macologic agents to reduce the risk of pulmonary aspiration:
Thromboembolism. (2007). Prevention of venous
Application to healthy patients undergoing elective proce-
thromboembolism: Best practice guidelines for Australia
dures. An updated report by the American Society of
and New Zealand (4th ed.). Sydney: Health Education &
Anesthesiologists Committee on Standards and Practice
Management Innovations.
Parameters. Anesthesiology, 114(3), 495–511. doi:10.1097/
www.surgeons.org/media/19372/VTE_Guidelines.pdf
ALN.0b013e3181fcbfd9.
Australian Day Surgery Nurses Association
www.adsna.info
(2016a). Recommended practices for electrosurgery. Periop-
Australian Day Surgery Nurses Association. (2013). Best erative Standards and Recommended Practices. Retrieved
practice guidelines for ambulatory surgery and from <http://aornstandards.org/content/1/SEC8.body>.
procedures. Osborne Park, WA: Cambridge Publishing.
Australian Department of Health and Ageing (2016b). Actions to prevent wrong-patient, wrong-site,
www.health.gov.au wrong-procedure events. Retrieved from <www.aorn.org/
British Association of Day Surgery Clinical_Practice/Sentinel_Events/Wrong_Site_Surgery
www.bads.co.uk .aspx>.
Joanna Briggs Institute Auckland District Health Board. (2012). Diabetes in adults
www.joannabriggs.edu.au (organisational policy). Auckland: Author.
National Institute for Health and Clinical Excellence Australian and New Zealand College of Anaesthetists
www.nice.org.uk (ANZCA). (2008). PS7. Recommendations for the Pre-
Anaesthesia Consultation. Retrieved from <www.anzca
New Zealand Health and Disability Commissioner .edu.au>.
www.hdc.org.nz
New Zealand Ministry of Health (ANZCA). (2010). PS15. Recommendations for the Perioperative
www.moh.govt.nz/moh.nsf/wpg_Index/Publications-Index Care of Patients Selected for Day Care Surgery. Retrieved from
<www.anzca.edu.au>.
REFERENCES Australian and New Zealand College of Anaesthetists
Alderson, P., Campbell, G., Smith, A. F., Warttig, S., Nicholson, (ANZCA). (2014). Guidelines on smoking as related to the
A., & Lewis, S. R. (2014). Thermal insulation for preventing perioperative period. Retrieved from <www.anzca.edu.au/
inadvertent perioperative hypothermia. Cochrane Database resources/professional-documents/pdfs/ps12-2013
of Systematic Reviews, (6), CD009908. doi:10.1002/14651858. -guidelines-on-smoking-as-related-to-the-perioperative
CD009908.pub2. -period.pdf>.
188
Australian and New Zealand College of Anaesthetists Canterbury District Health Board. (2014). Volume 11: Clinical
(ANZCA). (2015). Patient information on fasting. Retrieved return of tissue/body parts to patients. Retrieved from <www
from <www.anzca.edu.au/patients/frequently-aske questions/ .cdhb.health.nz/Hospitals-Services/Health-Professionals/
fasting.html/?searchterm=fasting>. CDHB-Policies/Clinical-Manual/Documents/4632-Return
Australian College of Operating Room Nurses (ACORN). -body-tissue-parts.pdf>.
(2016). ACORN standards for perioperative nursing. Adelaide: Centers for Disease Control and Prevention. (2015). Guide-
Author. lines for prevention of surgical site infection, 1999. Retrieved
Australian Commission on Safety and Quality in Health 2 March from <www.cdc.gov/hicpac/pdf/guidelines/SSI
Care (ACSQHC/the Commission). (2012a). National Safety _1999.pdf>.
and Quality Health Service Standards: Standard 5: Patient Chai, C. (2013). New Zealand Health Survey: Annual update of
identification and procedure matching. Retrieved from <www key findings, 2012/13. Wellington: Ministry of Health.
.safetyandquality.gov.au>. Copanitsanou, P., & Valkeapää, K. (2014). Effects of educa-
Australian Commission on Safety and Quality in Health tion of paediatric patients undergoing elective surgical
Care (ACSQHC/the Commission). (2012b). National Safety procedures on their anxiety: A systematic review. Journal of
and Quality Health Service Standards: Standard 10: Prevent- Clinical Nursing, 23(7–8), 940–954.
ing falls and harm from falls. Retrieved from <www Dewachter, P., Mouton-Faivre, C., Castells, M. C., & Hepner,
.safetyandquality.gov.au>. D. L. (2011). Anesthesia in the patient with multiple drug
Australian Department of Health and Aging. (2008). Hospital allergies: Are all allergies the same? Current Opinion in
and health workforce reform. Retrieved from <www.ahwo Anesthesiology, 24(3), 320–325.
.gov.au/documents/coag/nationalpartnershipagreementon Dhatariya, K., Levy, N., Kilvert, A., Watson, B., Cousins, D.,
hospitalandhealthworkforce reform.pdf>. Flanagan, D., et al. (2012). NHS diabetes guideline for the
Australian Department of Health and Ageing (ADHA). (2013). perioperative management of the adult patient with diabe-
National Aboriginal and Torres Strait Islander Health Plan, tes. Diabetic Medicine, 29(4), 420–433.
2013–2023. Canberra: Author. Duff, J., Walker, K., Edward, K. L., Williams, R., &
Australian Ministerial Council on Drug Strategy. (2011). Sutherland-Fraser, S. (2014). Incidence of perioperative
National tobacco strategy, 2010–2015: A framework for action inadvertent hypothermia and compliance with evidence-
on alcohol, tobacco and other drugs. Canberra: Author. based recommendations at four Australian hospitals: A
Aveyard, P., Begh, R., Parsons, A., & West, R. (2012). Brief retrospective chart audit. ACORN Journal, 27(3), 16–18,
opportunistic smoking cessation interventions: A systematic 20–23.
review and meta-analysis to compare advice to quit and Dumville, J. C., McFarlane, E., Edwards, P., Lipp, A., & Holmes,
offer of assistance. Addiction (Abingdon, England), 107(6), A. (2013). Preoperative skin antiseptics for preventing surgi-
1066–1073. cal wound infections after clean surgery. Cochrane Database
Avila, C., Bhangoo, R., Figueroa, R., Santorelli, J., Ogburn, P., of Systematic Reviews, (3), CD003949. doi:10.1002/14651858.
& Desan, P. H. (2012). Association of smoking with wound CD003949.pub3.
complications after cesarean delivery. Journal of Maternal- Edis, H. (2015). Enhanced recovery: The role of patient
Fetal and Neonatal Medicine, 25(8), 1250–1253. warming. British Journal of Healthcare Management, 21(8),
Bajwa, S. J. S., & Panda, A. (2012). Alternative medicine and 358–367.
anesthesia: Implications and considerations in daily prac- Fernandes, S., Arriaga, P., & Esteves, F. (2014). Using an
tice. Ayu, 33(4), 475–480. <http://doi.org/10.4103/0974 educational multimedia application to prepare children for
-8520.110515>. outpatient surgeries. Health Communication, (ahead-of-
Benarroch-Gampel, J., Sheffield, K. M., Duncan, C. B., print), 1–11.
Brown, K. M., Han, Y., Townsend, C. M., Jr., et al. (2012). Graham, D., Faggionato, E., & Timberlake, A. (2011). Prevent-
Preoperative laboratory testing in patients undergoing ing perioperative complications in the patient with high
elective, low-risk ambulatory surgery. Annals of Surgery, body mass index. AORN Journal, 94(4), 334–347.
256(3), 518. Greenland, P. (2012). Should the resting electrocardiogram
Billeter, A. T., Hohmann, S. F., Druen, D., Cannon, R., & Polk, be ordered as a routine risk assessment test in healthy
H. C. (2014). Unintentional perioperative hypothermia is asymptomatic adults? JAMA: The Journal of the American
associated with severe complications and high mortality in Medical Association, 307(14), 1530–1531. doi:10.1001/
elective operations. Surgery, 156(5), 1245–1252. jama.2012.441.
Biteker, M., Duman, D., & Tekkeşin, A. (2011). Predictive Hartley, B. (2014). Older patient perioperative care as
value of preoperative electrocardiography for perioperative experienced via transurethral resection of the prostate
cardiovascular outcomes in patients undergoing noncar- (TURP). Journal of Perioperative Practice, 24(6), 135–140.
diac, nonvascular surgery. Clinical Cardiology, 35(8), Health Quality and Safety Commission New Zealand.
494–499. (2014). Our programmes, surgical site infection improvement.
Breyer, K. E., & Gropper, M. A. (2014). Preoperative preparation Retrieved from <www.hqsc.govt.nz/our-programmes/
of the surgical patient. Current surgical therapy (11th ed., infection-prevention-and-control/projects/surgical-site
pp. 1163–1169). Philadelphia: Elsevier. -infection-improvement>.
189
Hee, H. I., Lim, E. H. L., Tan, Q. C., Bao, Z. Y., & Loh, K. W. T. (2012). Nahm, E. S., Stevens, L., Scott, P., & Gorman, K. (2012). Effects
Effect of preoperative education on behaviour of children of a web-based preoperative education program for patients
during induction of anaesthesia: A randomised clinical trial undergoing ambulatory surgery: A preliminary study. Journal
of efficacy. Anaesthesia and Intensive Care, 40(5), 795. of Hospital Administration, 1(1), 21.
Horn, E. P., Bein, B., Böhm, R., Steinfath, M., Sahili, N., & National Health and Medical Research Council. (2009). Clini-
Höcker, J. (2012). The effect of short time periods of pre- cal practice guideline for the prevention of venous thromboem-
operative warming in the prevention of peri-operative bolism (deep vein thrombosis and pulmonary embolism) in
hypothermia. Anaesthesia, 67(6), 612–617. patients admitted to Australian hospitals. Melbourne: Author.
Huschak, G., Busch, T., & Kaisers, U. X. (2013). Obesity in National Safety and Quality Health Service (NSQHS). (2012).
anesthesia and intensive care. Best Practice & Research Clini- Patient identification. Retrieved from <www.safetyandquality
cal Endocrinology & Metabolism, 27(2), 247–260. .gov.au/our-work/patient-identification>.
Joshi, G. P., Ahmad, S., Riad, W., Eckhert, S., & Chung, F. (2013). New Zealand Ministry of Health. (2014). Background and
Selection of obese patients undergoing ambulatory surgery: recommendations of the New Zealand guidelines for helping
A systematic review of the literature. Society for Ambulatory people to stop smoking. Wellington: Author.
Anaesthesiology, 117(5), 1082–1091. Nicholson, A., Coldwell, C. M., Lewis, S. R., & Smith, A. F.
Kadry, B., Press, C. D., Alosh, H., Opper, I., Orsini, J., Popov, I., (2013). Nurse-led versus doctor-led preoperative assess-
et al. (2014). Obesity increases operating room times in ment for elective surgical patients requiring regional or
patients undergoing primary hip arthroplasty: A retrospec- general anaesthesia. Cochrane Database of Systematic
tive cohort analysis. Peer J, 2, e530. Reviews, (11), CD010160. doi:10.1002/14651858.CD010160.
Kamel, C., McGahan, L., Polisena, J., Mierzwinski-Urban, M., pub2.
& Embil, J. M. (2012). Preoperative skin antiseptic prepara- Nursing Council of New Zealand. (2011). Guidelines for cul-
tions for preventing surgical site infections: A systematic tural safety, the Treaty of Waitangi and Māori health in nursing
review. Infection Control, 33(06), 608–617. education and practice. Retrieved from <www.nursingcouncil
Kim, S. Y., Park, W. Y., Ghil, J. S., & Choi, J. C. (2013). Cardiac .org.nz/…/Guidelinesforculturalsafety.pdf>.
arrest in the elderly with silent myocardial ischemia during Ortel, T. L., Beckman, M., Muhlbaier, L., Reyes, N., Grant, A.,
general anesthesia. Korean Journal of Anesthesiology, 64(1), Tcheng, J., et al. (2014). Venous thromboembolism (VTE) sur-
93–94. doi:10.4097/kjae.2013.64.1.93. veillance: Incidence, characteristics, and initial treatment of
King, J., Chamberland, P., Rawji, A., Ager, A., Léger, R., Michaels, VTE patients. Blood, 124(21), 4256.
R., et al. (2014). Patient educational needs of patients Ousey, K. J., Edward, K. L., Lui, S., Stephenson, J., Duff, J.,
undergoing surgery for lung cancer. Journal of Cancer Educa- Walker, K. N., et al. (2015). Perioperative warming therapy
tion, 29(4), 802–807. for preventing surgical site infection in adults undergoing
Kulshrestha, M., Mathews, J. J., Kapadia, M., & Sanwatsarkar, surgery. The Cochrane Library.
S. (2013). Breaking the midnight fast: An observational Phoenix, G. K., Elliott, J., Chan, K., & Das, S. K. (2012). Preop-
cross-sectional audit of preoperative fasting policies and erative blood tests in elective general surgery: Cost and
practices at a tertiary care hospital. Indian Journal of Anaes- clinical implications. Journal of Perioperative Practice, 22(9),
thesia, 57, 414–417. 282–288.
Kumar, A., & Srivastava, U. (2011). Role of routine laboratory Pichardo-Lowden, A., & Gabbay, R. A. (2012). Management
investigations in preoperative evaluation. Journal of Anaes- of hyperglycemia during the perioperative period. Current
thesiology, Clinical Pharmacology, 27(2), 174–179. Diabetes Reports, 12(1), 108–118.
Kuwajerwala, N. K., Schwer, W. A., Reddy, R. C., Kanthimathi- Pimenta, G. P., & de Aguilar-Nascimento, J. E. (2014). Pro-
nathan, V. S., Siddiqui, R. A., Villalba, P., et al. (2013). Periop- longed preoperative fasting in elective surgical patients:
erative medication management. Retrieved from <http:// Why should we reduce it? Nutrition in Clinical Practice, 29(1),
emedicine.medscape.com/article/284801-overview>. 22–28.
Lee, S. M., Landry, J., Jones, P. M., Buhrmann, O., & Morley- Power, S., Kavanagh, D. O., McConnell, G., Cronin, K., Corish,
Forster, P. (2013). The effectiveness of a perioperative C., Leonard, M., et al. (2012). Reducing preoperative fasting
smoking cessation program: A randomized clinical trial. in elective adult surgical patients: A case–control study.
Anesthesia & Analgesia, 117(3), 605–613. Irish Journal of Medical Science, 181(1), 99–104.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. Pritchard, M. J. (2011). Using the hospital anxiety and depres-
(2014). Medical-surgical nursing: Assessment and manage- sion scale in surgical patients. Nursing Standard, 25(34),
ment of clinical problems. Sydney: Elsevier. 35–41.
Mottram, A. (2012). Day surgery patients’ perception of risk: Queensland Health. (2010). Aboriginal and Torres Strait
A qualitative research study. International Association for Islander Cultural capability framework, 2010–2033. Brisbane:
Ambulatory Surgery, 17(4), 69–73. Author.
Mulsow, J. J., Feeley, T. M., & Tierney, S. (2012). Beyond Radford, M., & Palmer, R. (2012). Preoperative care. In K.
consent—improving understanding in surgical patients. The Woodhead & L. Fudge (Eds.), Manual of perioperative care.
American Journal of Surgery, 203(1), 112–120. Chichester: John Wiley & Sons.
190
Richardson-Tench, M., Rabach, J., Kerr, D., Adams, W., & Brown, of the Association of Anaesthetists of Great Britain and Ireland,
S. (2012). Comparison of preparedness after preadmission 66, 417–434.
telephone screening or clinic assessment in patients under- West Coast District Health Board (WCDHB). (2015). Removal
going endoscopic surgery by day surgery procedures: A pilot of jewellery and body piercings prior to transfer to operating
study. International Association for Ambulatory Surgery, 17(4), theatre procedure. Retrieved from <www.westcoastdhb
74–78. .org.nz>.
Royal Australian College of Surgeons. (2014). Informed White, P. F., White, L. M., Monk, T., Jakobsson, J., Raeder, J.,
consent position paper. Professional Standards. Retrieved from Mulroy, M. F., et al. (2012). Perioperative care for the older
<www.surgeons.org/media/312206/2014-08-29_pos_fes outpatient undergoing ambulatory surgery. Society for
-pst-042_informed_consent.pdf>. Ambulatory Anaesthesiology, 114(6), 1190–1215.
Ryall, T. (2012). Implementing the New Zealand Health Strat- Wilson, C. J., Mitchelson, A. J., Tzeng, T. H., El-Othmani, M. H.,
egy 2012. Wellington: Ministry of Health. Retrieved from Saleh, J., Vasev, S., et al. (2015). Caring for the surgically
<www.health.govt.nz/publication/implementing-new anxious patient: A review of the interventions and a guide
-zealand-health-strategy-2012>. to optimizing surgical outcomes. The American Journal of
Sessler, D. I. (2014). Temperature monitoring: The conse- Surgery, pii: S0002-9610(15)00291-3. doi:10.1016/j.amjsurg.
quences and prevention of mild perioperative hypothermia. 2015.03.023.
Southern African Journal of Anaesthesia and Analgesia, 20(1), Wong, J., Abrishami, A., Yang, Y., Zaki, A., Friedman, Z., Selby,
25–31. P., et al. (2013). A perioperative smoking cessation interven-
Singhal, R., Warburton, T., & Charalambous, C. P. (2014). tion with varenicline: A double-blind, randomized, placebo-
Reducing same day cancellations due to patient related controlled trial. Survey of Anesthesiology, 57(3), 149–150.
factors in elective orthopaedic surgery: Experience of a World Health Organization (WHO). (2009). Surgical Safety
centre in the UK. Journal of Perioperative Practice, 24(4), Checklist. Retrieved from <www.who.int/patientsafety/
70–74. safesurgery/checklist/en>.
Sørensen, L. T. (2012). Wound healing and infection in World Health Organization (WHO). (2014). Obesity and over-
surgery: The pathophysiological impact of smoking, smoking weight. Fact sheet no. 311. Retrieved from <www.who.int/
cessation, and nicotine replacement therapy. A systematic mediacentre/factsheets/fs311/en>.
review. Annals of Surgery, 255(6), 1069–1079.
Stead, L. F., Buitrago, D., Preciado, N., Sanchez, G., Hartmann- FURTHER READING
Boyce, J., & Lancaster, T. (2013). Physician advice for smoking
Al-Benna, S. (2011). Perioperative management of morbid
cessation. Cochrane Database of Systematic Reviews, (5),
obesity. Journal of Perioperative Practice, 21(7), 225–233.
CD000165. doi:10.1002/14651858.CD000165.pub4.
Steelman, V. M., & Graling, P. R. (2013). Top 10 patient safety
(ANZCA). (2008). PS7. Recommendations for the Pre-
issues: What more can we do? AORN Journal, 97(6), 679–701.
Anaesthesia Consultation. Retrieved from <www.anzca
Symons, V. C., & McMurray, A. (2014). Factors influencing .edu.au>.
nurses to withhold surgical patients’ oral medications
pre-and postoperatively. Collegian (Royal College of Nursing,
(ANZCA). (2010). PS15: Recommendations for the perioperative
Australia), 21(4), 267–274.
care of patients selected for day care surgery. Retrieved from
Talbot, L., & Palmer, J. (2013). Effects of smoking on health <www.anzca.edu.au/resources/professional-documents>.
and anaesthesia. Anaesthesia & Intensive Care Medicine,
14(3), 107–109.
(ANZCA). (2014). PS09: Guidelines on sedation and/or analge-
Tanner, J., Norrie, P., & Melen, K. (2011). Preoperative hair sia for diagnostic and interventional medical, dental or surgical
removal to reduce surgical site infection. The Cochrane procedures. Retrieved from <www.anzca.edu.au/resources/
Library. Retrieved from <www.bibliotecacochrane.com/pdf/ professional-documents>.
CD004122.pdf>.
Daabiss, M. (2010). American Society of Anaesthesiologists
The Joint Commission. (2013). Solutions for a process reduc- physical status classification. Indian Journal of Anaesthesia,
ing the risk of wrong site surgery. Retrieved from <www 55(2), 111–115.
.centerfortransforminghealthcare.org/assets/4/6/CTH_WSS
Grauer, R. P., Thomas, R. D., Tronson, M. D., Heard, G. C., &
_Storyboard_final_2011.pdf>.
Diacon, M. (2004). Preoperative use of herbal medicines and
Thomsen, T., Villebro, N., & Moller, A. M. (2014). Interventions vitamin supplements. Anaesthesia and Intensive Care, 32(2),
for preoperative smoking cessation. Cochrane Database of 173–177.
Systematic Reviews, (7), CD002294.
Griffiths, P., Bridges, J., Sheldon, H., & Thompson, R. (2014).
Tokarski, A. T., Blaha, D., Mont, M. A., Sancheti, P., Cardona, L., The role of the dementia specialist nurse in acute care: A
Cotacio, G. L., et al. (2014). Perioperative skin preparation. scoping review. Journal of Clinical Nursing, 23(3–4), 1394–
The Journal of Arthroplasty, 29(2), 26–28. 1405. doi:10.1111/jocn.12717.
Verma, R., Alladi, R., Jackson, I., Johnston, I., Kumar, C., Page, Leary, C. (2013). Streamlining day surgery using information
R., et al. (2011). Day case and short stay surgery: 2. Journal technology [online]. Day Surgery Australia, 12(2), 16–18.
191
NSW Health. (2011). Extended day only admission policy, Rudra, A., Chatterjee, S., Sengupta, S., Kumar, P., Das, T.,
PD2011_045. Retrieved from <www.health.nsw.gov.au/ Wankhede, R., et al. (2008). Herbal medications and their
policies/pd/2011/PD2011_045.html>. anaesthetic implications. The Internet Journal of Anesthesiol-
NSW Health. (2012). High volume short stay surgical model ogy, 19(1), 1394–1405.
toolkit. Retrieved from <www.health.nsw.gov.au/ Thurairatnam, R. R., Mathew, G. S., Montgomery, J., & Stocker,
Performance/Publications/hi-vol-short-stay-surgery.pdf>. M. (2014). The role of patient satisfaction surveys to improve
Rice, A. N., Muckler, V. C., Miller, W. R., & Vacchianp, C. A. patient care in day surgery [online]. Day Surgery Australia,
(2015). Fast-tracking ambulatory surgery patients following 13(3), 6–8.
anesthesia. Journal of Perianesthesia Nursing, 30(2), 124–133. Webster, J., & Osborne, S. (2012). Preoperative bathing or
doi:10.1016/j.jopan.2014.01.006. showering with skin antiseptics to prevent surgical site
Rowen, L., Hunt, D., & Johnson, K. L. (2012). Managing obese infection. Cochrane Review, (5), 1–39. doi:10.1002/14651858.
patients in the OR. OR Nurse, 6(2), 26–35. doi:10.1097/01. CD004985.pub5.
ORN.0000412324.97287.aa.
192
Chapter 8
PATIENT CARE DURING ANAESTHESIA
JULIE WALTERS AND ZOE KUMAR

LEARNING OUTCOMES
• Examine the role of the nurse when caring for the patient during anaesthesia
• Explore the different modalities of anaesthesia
• Describe the physiological changes that occur during anaesthesia
• Identify the drugs commonly used in anaesthesia
• Describe equipment used for management of the patient during anaesthesia
• Explain airway management strategies
• Discuss the fluid and electrolyte requirements of a patient undergoing anaesthesia
• Highlight complications that may arise during anaesthesia and their management
• Explore the management of paediatric, elderly and bariatric patients
KEY TERMS
airway management
anaesthetic emergencies
central neural blockade
epidural anaesthesia
fluid and electrolyte balance
general anaesthesia
haemodynamic monitoring
regional anaesthesia
spinal anaesthesia
193
description of the physical state of the patient,

INTRODUCTION along with an indication of whether the patient’s
This chapter presents the concepts of perianaes- surgery is elective or an emergency (see Chapter 7
thesia care of the patient, with an emphasis on the for more information). This classification influ-
nurse’s role, including the different types of anaes- ences the anaesthetist’s decisions about anaes-
thesia commonly used, management of the patient’s thetic care and postoperative (PO) management.
airway and the monitoring required during the These decisions include whether the patient
perianaesthesia period. Anaesthesia has a physio- requires PO care in the day surgery unit, an inpa-
logical impact on all body systems and these are tient bed, a high-dependency unit or an adult
described, together with discussion on anaesthetic intensive care unit (Langton, 2013).
complications and their management. The chapter Prior to the patient undergoing an anaesthetic,
also discusses fluid and electrolyte management, a full medical assessment must be carried out by a
including blood replacement. Finally, it examines member of the anaesthetic team. This assessment,
management of geriatric, bariatric and paediatric which often takes place in a pre-admission clinic,
patients, although detailed information on paedi- must take into consideration the patient’s:
atric anaesthesia is beyond the scope of this text.
• baseline physiological state
The complexity of surgery and advances in
surgery require the anaesthetist to be supported by • current and past medical and surgical
an assistant, who may be a nurse or an anaesthetic history
technician (depending on the healthcare facility’s • family history
protocol). The assistant must be educated and com- • social history (e.g. smoking, alcohol, illicit
petent in the range of anaesthetic procedures drugs)
carried out within the local healthcare facility in
order to provide safe and effective support to both • planned procedure
the anaesthetist and the patient. Anaesthetic • drug sensitivities or allergies
nurses are guided in their practice by Australian
• current medications, including herbal dietary
College of Operating Room Nurses (ACORN) Stand-
supplements
ards (2016) and the New Zealand Nurses Organisa-
tion (NZNO) Knowledge and Skills Framework • past anaesthetic experience
(2014). Anaesthetic practice is supported by a range • psychological make-up (Marley, Calabrese &
of policies published by the Australian and New Thompson, 2014).
Zealand College of Anaesthetists (ANZCA), which
See Chapter 7 for more information on preoperative
guide the care of the patient during the perianaes-
patient assessment and preparation.
thesia period (ANZCA, 2015).
After the patient’s history, examination and rel-
General anaesthesia dates back to William T.
evant investigations have been collated, the anaes-
Morton, an American dentist who was credited as
thetist can plan the patient’s care more accurately.
being the first to use ether as a surgical anaesthetic
The decisions being considered regarding anaes-
in 1846. This discovery revolutionised surgery,
thetic care, pain management and possible blood
making it possible for more complex procedures to
transfusions should be discussed with the patient
be undertaken because patients could now be ren-
and opportunities should be made available for
dered unconscious with anaesthesia. Since then,
the patient to ask questions. Nurses in the pre-
anaesthesia has seen many advances and anaes-
admission clinic or on the ward will inform patients
thetists are now able to use a wide range of drugs,
about fasting times and whether regular medica-
techniques and sophisticated equipment to provide
tions should be taken or omitted on the day of
patients with safe and pain-free surgery.
surgery.
MEDICAL PRE-ANAESTHETIC ASSESSMENT OF THE AIRWAY

ASSESSMENT OF THE PATIENT As part of the pre-anaesthetic assessment, it is
The American Society of Anesthesiologists (ASA) essential that the anaesthetist predicts airway
grading system was introduced in the 1960s as a and intubation difficulties and plans airway
194
CHAPTER 8 | Patient care during anaesthesia
management accordingly. Assessment criteria ascertain any special requirements for the patient’s
include the following: anaesthetic management. This will help the anaes-
• length of incisors—this may impede the thetic nurse to plan nursing care and prepare
introduction of a laryngoscope blade into equipment to ensure safe patient outcomes.
the mouth Verification of all patient details must comply
• mobility of cervical spine, and length and with the National Safety and Quality Health Service
thickness of neck—to facilitate neck (NSQHS) Standards (the National Standards) on
movement during intubation patient identification and procedure matching
(Australian Commission for Safety and Quality
• the ability to see the soft palate and uvula in Healthcare [ACSQHC/the Commission], 2012).
with the mouth open and tongue protruded, Correct patient identification continues through-
known as the Mallampati score out each stage of the patient’s journey to reduce the
• the ability to sublux lift the mandible forwards risk of mismatch between the patient and the
and upwards at the temporomandibular joint intended procedure (see Chapters 3 and 7 for further
(subluxation) information). When the patient is accompanied to
the operating suite by a nurse from the ward, a
• the thyromental distance (less than three
clinical handover is completed by both nurses and
fingers)—this is measured from the thyroid
the patient using a preoperative patient checklist.
notch to the inner border of the mandible
When the patient arrives unaccompanied (i.e. from
when the patient’s head is extended (Cook &
the day surgery ward), the perioperative nurse
Simpson, 2013).
will use the checklist to verify details with the
patient. This checklist may vary according to hos-
MALLAMPATI ASSESSMENT
pital policy, but will include asking the patient to
The Mallampati test is used to examine the patient’s confirm:
oral cavity and soft palate visually, in order to
predict any possible difficulties with tracheal intu- • his or her name
bation. It is conducted during the pre-anaesthetic • date of birth
assessment. Figure 8-1 shows the four classifica- • fasting times—when the patient last ate or
tions. Classes III and VI, which indicate that viewing drank
of the soft palate is difficult or impossible, suggest
a higher degree of difficulty with intubation in these • allergies
patients (Fell & Kirkbride, 2013). • his or her consent—the patient confirms the
procedure, the site and the side of surgery; in
NURSING ASSESSMENT AND PREPARATION OF most hospitals the site of surgery should
THE PATIENT already be marked by the surgeon, although
It is important that the anaesthetic nurse, in con- this may be carried out following admission to
sultation with the anaesthetic team, is familiar with the operating suite
the patient’s history and assessment, in order to • any preoperative medications given.
Class I Class II Class III Class IV
FIGURE 8-1: Classification of the pharyngeal view when performing the Mallampati test
Source: Fell & Kirkbride (2013).
195
This information is checked against the patient

identification bracelet, marked operative site and
TYPES OF ANAESTHETICS
consent form (the Commission, 2012). (See Chapter It is important that the anaesthetic nurse has an
7 for further information on patient admission to understanding of the different types of anaesthet-
the operating suite.) ics in order to provide support to the anaesthetist
In addition, the anaesthetic nurse should ensure and the patient in the safe administration of anaes-
that the anaesthetic assessment documentation is thesia, as well as provide effective assistance during
present and complete. Any discrepancies that the critical anaesthetic situations (ACORN, 2016).
perioperative nurse notes on admission must be Anaesthesia is defined as the ‘loss of the sensations
reported to the anaesthetic and surgical teams and of pain, pressure, temperature and touch in a part
rectified before commencement of anaesthesia or the whole of the body’ (Bryant & Knights, 2015).
(ACORN, 2016). The main categories of anaesthesia are:
Prior to the induction of anaesthesia, the anaes- • general

thetic nurse should take and document the patient’s • local infiltration
pulse, temperature and blood pressure as baseline • regional—spinal and epidural—these
observations. The nurse should also attach electro- can be continued in the immediate PO
cardiograph (ECG) leads and other monitoring period, to provide the patient with pain
devices as well as instituting active warming meas- relief
ures, if required (ANZCA, 2015). In addition, the
nurse may prepare for intravenous (IV) access or • sedation/analgesia.
ensure that lines present are secured and labelled in
compliance with the national recommendations for GENERAL ANAESTHESIA
user-applied labelling of injectable medicines, fluids General anaesthesia is a reversible, unconscious
and lines (the Commission, 2012) (see Fig. 8-2). state characterised by amnesia, analgesia and sup-
The period just before induction of anaesthesia pression of reflexes. The drugs and gaseous agents
can be a highly anxious time for the patient and the used to induce and maintain anaesthesia have a
anaesthetic nurse plays an important role in reduc- profound physiological effect on body systems,
ing the patient’s anxiety by demonstrating good notably the central nervous system (CNS). The area
communication skills to explain to the patient what in the CNS that is most affected is the sensory
is happening and providing quiet reassurance. pathway from the thalamus to the cortex, thus
Therapeutic touch and other anxiety-reduction depressing conscious thought, motor control, per-
measures (e.g. music) may be used or an anxiolytic ception, memory and sensation. The medullary
medication such as midazolam and a narcotic may centres are the final cerebral area to be affected
be given, depending on the surgery. by anaesthesia and unconsciousness then occurs,
FIGURE 8-2: IV line label placed on the patient side close to the injection port
Source: ACSQHC/the Commission (2011).
196
TABLE 8-1: Stages of Anaesthesia (Modified from Guedel)
UPPER RESPIRATORY TRACT

STAGE RESPIRATION PUPILS EYE REFLEXES AND RESPIRATORY REFLEXES
1. Analgesia Regular, small volume
2. Excitement Irregular Eyelash absent
3. Anaesthesia
Plane I Regular, large volume Eyelid absent, Pharyngeal and vomiting

conjunctival reflex reflexes depressed
depressed
Plane II Regular, large volume Corneal reflex

depressed
Plane III Regular, becoming Laryngeal reflex depressed

diaphragmatic, small volume
Plane IV Irregular, diaphragmatic, Carinal reflex depressed

small volume
4. Overdose Apnoea
SOURCE: FELL & KIRKBRIDE (2013).
with both respiratory and cardiovascular centres intravenous anaesthesia (TIVA) and the use of
temporarily depressed. The stages of anaesthesia target-controlled infusion (TCI) devices enables the
were first described by the American anaesthetist theoretical concentration of propofol in the plasma
Arthur Guedel and are outlined in Table 8-1. These to be continuously controlled, as well as adminis-
stages can be observed by the anaesthetic team; tered (Fell & Kirkbride, 2013).
for example, checking eyelash reflex, altered pupil Propofol is known to cause allergic reactions in
size—signs that assist in assessing when anaesthe- patients who are allergic to eggs, so an alternative
sia has been achieved. induction agent, such as thiopental sodium (pen-
tothal), can be used. As well as being used for induc-
PHARMACOLOGICAL AGENTS USED IN tion of general anaesthesia, thiopental sodium has
GENERAL ANAESTHESIA several other clinical uses:
IV induction agents
• as supplementation to other drugs
IV induction agents, such as short-acting propofol,
are commonly used to induce general anaesthesia • in conjunction with regional anaesthesia
because they provide a smoother and more rapid • to treat status epilepticus
induction than most inhalational agents. Anaes- • as a sedative
thesia is maintained for the duration of the surgical
procedure by using a combination of oxygen, nitrous • for cerebral protection with raised intracranial
oxide and volatile inhalational agents (e.g. sevoflu- pressure (Fell & Kirkbride, 2013).
rane). Some anaesthetists may use an IV induction
agent as a continuous infusion to maintain anaes- Inhalational agents
thesia, eliminating the need for inhalational agents Volatile and gaseous inhalational anaesthetic
(Fell & Kirkbride, 2013). This is known as total agents remain popular for the maintenance of
197
anaesthesia and may be used to induce anaesthe- care unit (PACU). Opioid is a term used to refer to a
sia in paediatrics to avoid the need to insert IV group of drugs, both naturally occurring and syn-
cannulae, which can be traumatic for a child. Inha- thetically produced, that possess the properties of
lational agents include nitrous oxide, which is opium or morphine. The anaesthetic nurse can
colourless, essentially odourless and the only inor- monitor the patient’s pain response by observing
ganic anaesthetic gas in clinical use. Although it for physiological changes or reactions to surgical
possesses some analgesic properties, it will not interventions and alerting the anaesthetist.
maintain narcosis; however, it does reduce the
amount of other narcotic medications needed. The MUSCLE RELAXANTS
addition of a volatile inhalational agent (e.g. The discovery of curare, a naturally occurring
sevoflurane) is required to maintain the patient in muscle relaxant, by Harold Griffith and Enid
an unconscious state. Johnson in 1942 was a milestone in anaesthesia.
Volatile agents are liquid at room temperature Curare greatly facilitated endotracheal intubation
and administered through a specialised vaporiser and provided excellent relaxation for abdominal
attached to the anaesthetic machine. Oxygen, surgery. For the first time, surgery could be per-
which must be used in all general anaesthesia, formed on patients without having to administer
passes through the vaporiser and mixes with the large doses of anaesthetic agents, which was neces-
liquid agent, changing the volatile agent into a gas. sary to produce the muscle relaxation required to
The mixture is administered to the patient via the incise through muscles and enter the abdominal
airway and delivery equipment attached to the cavity. A wide range of muscle relaxant agents have
anaesthetic machine. The percentage of inhala- been developed since then, giving today’s anaes-
tional agents delivered to the patient is adjusted by thetist a variety of drugs for use in clinical practice
the anaesthetist depending on the depth of anaes- (Hunter, 2013).
thesia required (Kossick, 2014a). Muscle relaxation is achieved by blocking neu-
Table 8-2 provides a summary of the IV and romuscular activity at the motor end plate of skel-
inhalational agents used in general anaesthesia. etal muscles where the receptors for acetylcholine
are located. Acetylcholine, a naturally occurring
ADJUNCTS TO GENERAL ANAESTHESIA neurotransmitter, plays an important role in facili-
There are a variety of drugs that are used as adjuncts tating the transmission of nerve impulses. Interfer-
to anaesthesia and they include analgesics, seda- ence with the transmission of nerve impulses
tives, antiemetics and neuromuscular blocking results in paralysis of skeletal muscle, which
agents (muscle relaxants). Table 8-3 provides a includes the muscles of respiration. There are two
summary of the adjuncts most commonly used in types of neuromuscular blocking agents: depolaris-
general anaesthesia. As can be seen from Tables 8-2 ing and non-depolarising agents (Naguib, Lien &
and 8-3, many of the agents used to induce anaes- Mistelman, 2015).
thesia and as adjuncts have a powerful effect on the
patient’s cardiovascular and respiratory systems. Depolarising neuromuscular blockers
This requires the anaesthetist and the anaesthetic Suxamethonium is a short-acting depolarising
nurse to monitor the patient closely using their muscle relaxant that acts in 30–60 seconds and
observational skills and a variety of invasive and lasts 3–5 minutes before it is metabolised by plasma
non-invasive haemodynamic monitoring tech- cholinesterase, a naturally occurring enzyme. It is
niques described later in the chapter. the only agent that creates good conditions for tra-
cheal intubation in emergency airway management
ANALGESICS situations or when rapid sequence induction is
In addition to the drugs designed to keep the required. Its onset of action is characterised by
patient under general anaesthesia, it is important facial twitching or fasciculations. However, the
to provide pain relief during the procedure. Opioid effect wears off rapidly due to the build-up of
analgesic drugs (e.g. fentanyl) are given intraopera- plasma cholinesterase (Naguib et al., 2015). It is the
tively and in the immediate PO period when further only example of a depolarising muscle relaxant
pain protocols are initiated in the postanaesthesia (Bryant & Knights, 2015).
198
TABLE 8-2: IV and Inhalational Anaesthetic Agents
DRUGS ADVANTAGES DISADVANTAGES NURSING INTERVENTIONS

IV agents
Barbiturates
Thiopentone Rapid induction, duration of Adverse cardiac effects, Usually have minimal PO
action less than 5 minutes hypotension, tachycardia, effects due to extremely
respiratory depression short duration
Repeated doses may lead to
‘hangover effect’
Non-barbiturate hypnotics
Propofol Ideal for short outpatient May cause bradycardia and Short action leads to minimal
procedures because of rapid other dysrhythmias, PO effects; monitor injection
onset of action, rapid hypotension, apnoea, phlebitis, site for phlebitis; cardiac
distribution and high metabolic nausea and vomiting, hiccups monitoring if unstable
clearance; may be used for May cause hypertriglyceridaemia Monitor serum triglycerides
maintenance of anaesthesia as every 24 hours for sedation
well as induction greater than 24 hours
Inhalational agents
Volatile liquids
Isoflurane All volatile liquids: muscle All volatile liquids: myocardial Assess and treat pain during
Desflurane relaxation, low incidence of depression, early onset of pain early anaesthesia recovery;
Sevoflurane nausea and vomiting because of rapid elimination assess for adverse reactions
Isoflurane: less cardiac Sevoflurane: may be associated such as cardiopulmonary
depression, devoid of toxicity with emergence delirium depression with
to body organs hypotension and prolonged
Desflurane: rapid induction and respiratory depression;
emergence, widely used monitor for nausea and
volatile agent vomiting
Sevoflurane: predictable effects
on cardiovascular and
respiratory systems, rapid
acting, non- irritating to
respiratory system
Gaseous agents
Nitrous Potentiates volatile agents, Weak anaesthetic, rarely used Produces little or no toxicity at
oxide allowing a reduction in their alone; must be administered therapeutic concentrations;
dosage and their negative side with oxygen to prevent monitor for effects of
effects and increases the rate hypoxaemia; nausea and volatile liquids when nitrous
of induction; has high vomiting more common than oxide used as an adjunct
analgesic potency with other inhaled
anaesthetics
Dissociative anaesthetics
Ketamine Can be administered May cause hallucinations and Anticipate administration of a

intravenously or nightmares, increased benzodiazepine if agitation
intramuscularly; potent intracranial and intraocular and hallucinations occur;
analgesic and amnesic pressure, increased heart rate, calm quiet environment is
hypertension essential in PO care
SOURCE: TIZIANI (2013).
199
TABLE 8-3: Adjuncts to General Anaesthesia
USES DURING NURSING

AGENTS ANAESTHESIA ADVERSE EFFECTS INTERVENTIONS
Opioids
Fentanyl Induce and maintain Respiratory depression, Assess respiratory status,

Sufentanil anaesthesia, reduce stimuli stimulation of vomiting monitor pulse oximetry
Morphine sulfate from sensory nerve centre, possible bradycardia (for a late sign of
Alfentanil endings, provide analgesia and peripheral vasodilation hypoxaemia), protect
Remifentanil during surgery and (when combined with airway in anticipation of
Methadone anaesthetic recovery anaesthetics), high incidence vomiting, use standing
of pruritus with both orders for antipruritics,
regional and intravenous such as diphenhydramine
administration
Benzodiazepines
Midazolam Induce and maintain Potentiation of the effects of Monitor cardiopulmonary

Diazepam anaesthesia opioids, increasing the status, level of
Lorazepam potential for respiratory consciousness
depression, hypotension and
tachycardia
Neuromuscular blocking agents
Depolarising agent: Facilitate endotracheal Apnoea related to paralysis of Monitor respiratory rate and
Suxamethonium intubation, promote respiratory muscles, pattern until the patient
Non-depolarising skeletal muscle relaxation prolonged muscle relaxation is able to cough and
agents: (paralysis) to enhance due to longer action of return to previous levels
Vecuronium access to surgical sites; non-depolarising agents of muscle strength;
Atracurium effects of non-depolarising than reversal agents, cardiac maintain patent airway;
Pancuronium agents are usually reversed alterations; recurrence of ensure availability of
Rocuronium towards the end of surgery muscle weakness with non-depolarising reversal
Mivacurium by the administration of correction of hypothermia agents and respiratory
anticholinesterase agents support equipment,
(e.g. neostigmine, monitor temperature and
pyridostigmine, levels of muscle strength
edrophonium) with temperature changes
Antiemetics
Droperidol Prevention of vomiting with Droperidol: dysrhythmias, Monitor cardiopulmonary

Ondansetron aspiration during surgery, laryngospasm, status, level of
Dolasetron counteract the emetic bronchospasm, tachycardia, consciousness and ability
Metoclopramide effects of inhalation hypotension, central nervous to move limbs
Prochlorperazine agents and opioids; system alterations, Droperidol: administer with
Promethazine droperidol often used extrapyramidal reactions; caution in patients with
during surgery; others contraindicated in patients heart disease
more often used with Parkinson’s disease or
postoperatively hypomagnesaemia
Other antiemetics: headache,
dizziness, sedation, malaise,
fatigue, musculoskeletal
pain, shivers, diarrhoea,
acute dystonic reactions,
cardiovascular alterations;
contraindicated in patients
with hypomagnesaemia
SOURCE: TIZIANI (2013).
200
Non-depolarising neuromuscular blockers PROCEDURE FOR GENERAL

To maintain muscle paralysis for the duration of
the vast majority surgical procedures, a longer
ANAESTHESIA
acting muscle relaxant is required. These agents are PREPARATION AND EQUIPMENT
known as non-depolarising muscle relaxants (e.g. Anaesthetic machines deliver gases and volatile
rocuronium) and they have a different mode of agents to the patient via delivery tubing that
action to depolarising agents. Non-depolarising attaches to the patient’s airway management
muscle relaxants compete with naturally occurring equipment (e.g. endotracheal tube [ETT], laryngeal
acetylcholine for receptors at the motor end plate mask airway [LMA]). Oxygen, nitrous oxide and air
of skeletal muscles, thus causing paralysis. are delivered into the operating room via a network
To terminate the action of non-depolarising of pipes from a central bulk store of gases within
muscle relaxants, a reversal drug, such as neostig- the hospital. A pendant attached to the ceiling
mine, is administered towards the end of the pro- delivers the gases to the anaesthetic machine
cedure. This allows acetylcholine to build up to through colour-coded tubes, which are standard-
normal levels and enables normal muscle contrac- ised and internationally recognised (white for
tion to return. This results in the patient commenc- oxygen, blue for nitrous oxide). The fixtures for
ing unassisted respiration once all other anaesthetic each gas outlet are gas specific, an important safety
agents have been stopped. A side effect of neostig- feature ensuring that oxygen tubing cannot be
mine is bradycardia, which is counteracted by the attached to the nitrous oxide outlet, and vice versa.
simultaneous administration of an antimuscarinic Similarly, the gas cylinders attached to the anaes-
drug (e.g. atropine, glycopyrrolate), which blocks thetic machines are pin-index yoked, to ensure that
parasympathetic stimuli and increases pulse rate cylinders cannot be interchanged (Thompson,
(Bryant & Knights, 2015). 2012). These cylinders provide back-up gases if the
pipeline supplies fail, although in smaller facilities
Anaesthetists may select an alternative muscle they may be the main source of gas supply. Another
relaxant for patients with renal impairment; for safety feature of anaesthetic machines is that they
example, cisatracuruim, which is metabolised in a are fitted with gas analysers to monitor gas outflow
manner that does not compromise renal function from the pipeline system.
(Nagelhout, 2014a).
The anaesthetic machine is more than a gas
The anaesthetic team must be alert to the pos- delivery unit. It also contains a range of sophisti-
sibility of administering insufficient inhalation cated equipment necessary to monitor the patient’s
agents or TIVA, which can lead to the patient suf- condition throughout the perianaesthesia period
fering awareness of the procedure. Feature box 8-1 (e.g. ECG, pulse oximetry and capnography) and the
provides information about this distressing condi- means to provide various types of ventilation inclu-
tion and how it can be avoided. sive of paediatrics and neonates. Prior to the com-
mencement of the operating list, it is important
ANTIEMETICS that the anaesthetist and the anaesthetic nurse
Nausea and vomiting can be an unpleasant side check the anaesthetic machine in accordance with
effect of general anaesthesia and cause patients dis- ANZCA and the manufacturer’s guidelines (ANZCA,
tress and discomfort. In order to minimise nausea, 2014a). Figure 8-4 is an example of an anaesthetic
vomiting and possible aspiration of stomach con- machine and its components.
tents into the lungs, which can cause serious com- Other preoperative equipment checks include
plications of pneumonitis, the anaesthetist may suction, airway equipment, drugs and additional
administer an antiemetic drug intraoperatively. The equipment such as infusion pumps, warming
effects of antiemetic drugs should continue into the devices and monitoring equipment. These must be
immediate PO period, providing the patient with a available and in working order prior to the patient’s
more comfortable recovery period. Examples of arrival in order to ensure a smooth and safe anaes-
antiemetic drugs can be seen in Table 8-3. thesia process for the patient.
201
FEATURE BOX 8-1 » AWARENESS UNDER GENERAL ANAESTHESIA
Awareness occurs when the patient is paralysed with muscle relaxants but has been given insuf-
ficient doses of anaesthetic agents to maintain an unconscious state. Paralysed patients have no
way of indicating their awareness to the anaesthetic team. The possibility of patients remaining
aware during general anaesthesia is a concern for both the anaesthetic team and patients.
Accounts in the media of patients experiencing awareness during anaesthesia have heightened
patient fears. A 2014 report published by the Royal College of Anaesthetists in the United Kingdom
found that awareness under anaesthesia occurs in approximately 1 in 19,000 cases of general
anaesthesia. Sensations reported by patients who remain aware included tugging, stitching, pain,
paralysis, choking, feelings of dissociation, panic, extreme fear, suffocation and even feeling that
they may be dying. Longer term psychological harm often includes features of posttraumatic stress
disorder (Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and
Ireland, 2014). Although rare, awareness under general anaesthesia is distressing for those who
experience it.
To reduce the possibility of patients remaining aware during general anaesthesia, constant obser-
vation is required and this can be achieved using bispectral index (BIS) monitoring or entropy. A
sensor strip attached externally to the patient’s forehead monitors the patient’s brain waves rela-
tive to the depth of anaesthesia and relays this information to a monitor, which can alert the
anaesthetic team if the patient’s level of awareness is increasing (see Fig. 8-3). The numerical
reading is shown on the monitor: a BIS value of 0 indicates electroencephalograph (EEG) silence,
whereas a value near 100 is the expected value in a fully awake adult; between 40 and 60 is the
recommended reading for general anaesthesia (Pandit & Cook, 2014).
FIGURE 8-3: BIS monitoring electrodes.

Source: Brain Monitoring System™. All rights reserved. Used with the permission of Covidien, a Medtronic company.
AIRWAY MANAGEMENT EQUIPMENT cartilage (Heiner & Gabot, 2014). Figure 8-5 illus-
AND TECHNIQUES trates the anatomy of the upper airway.
To understand how artificial airways are used, it is
important to review the anatomy of the airway. The ARTIFICIAL AIRWAYS
airway is divided into two sections, upper and lower, When the patient loses consciousness, muscle tone
which are separated at the level of the cricoid of the upper airway is also lost, causing the tongue
202
and epiglottis to fall back against the posterior wall

of the pharynx, obstructing the airway. An artificial
airway (e.g. Guedel’s airway) is inserted into the
patient’s mouth to prevent airway obstruction.
Manoeuvres such as chin lift and jaw thrust may
also be required in conjunction with Guedel’s
A
airway to maintain a clear airway. Nasopharyngeal
airways are also available to prevent PO trauma
to the mouth following oral or dental surgery.
Nasopharyngeal airways require lubrication before
insertion via the patient’s nose; they are well toler-
ated during light anaesthesia or during emergence
B
from anaesthesia (Cook, 2012).
FACE MASKS
C F Face masks used in anaesthesia are made of silicone
E
D or polyvinyl chloride (PVC) and are designed to fit
firmly over the nose and mouth, following the con-
G tours of the face, as this will assist in providing
H effective ventilation of an unconscious patient.
Several types of face mask are available, including
I
J
transparent masks, which allow observation of
exhaled gas and immediate recognition of vomit-
ing, and cushioned masks, which allow for contour-
K
L
ing to facial bone structures (Cook, 2012).
Holding face masks in situ requires correct
technique to maintain a patent airway. The tech-
nique involves holding the mask with a downward
pressure using the thumb and index finger, while
the middle and ring fingers grasp the mandible
to extend the atlantomaxillary joint. The little
finger slides under the angle of the jaw and pulls
FIGURE 8-4: Anaesthetic machine and monitoring devices
it anteriorly (see Fig. 8-6). Poor technique when
A Monitor and ventilator controls
B Unit to monitor expired carbon dioxide and anaesthetic agents
applying a face mask can result in pressure on the
C Ventilator bellows soft tissues of the face and neck, which can lead to
D Auxiliary oxygen supply obstruction and excessive bag pressure, causing
E Inhalational cartridge in use sevoflurane inflation of the stomach.
F Machine and suction on/off switch Difficulties in obtaining an effective seal with
G Oxygen flush button
face masks may be experienced in edentulous
H Storage for other inhalational agents not in use
patients (without teeth) and those patients with
I Carbon dioxide absorber
J Circle breathing circuit
congenital abnormalities, facial and eye trauma,
K Suction tumours, infections or limited neck extension.
L Reservoir breathing bag
LARYNGEAL MASK AIRWAY
A laryngeal mask airway provides an alternative to
face masks or ETTs (see next section). It consists of
a silicone or PVC tube that is slightly shorter than
an ETT, with an inflatable elliptical cuff at the distal
end, which resembles a miniature face mask. When
this cuff is inflated the LMA is designed to provide
a relatively airtight seal around the perimeter of the
203
Nasopharynx Nares
Hard palate
Soft palate
Oral cavity
Uvula
Tongue
Oropharynx
Epiglottis
Larynx
Thyroid
cartilage
Oesophagus Cricoid
cartilage
Trachea
FIGURE 8-5: Anatomy of the upper airway
As the LMA does not pass through the vocal

cords and thus provide the same security from aspi-
ration as ETTs, it is not suitable for all patients,
especially those who are at high risk of aspiration.
Contraindications to use of the LMA include:
• a full stomach—or unknown fasting status
• pregnancy
• hiatus hernia
• high airway resistance
• pharyngeal abscess
• low pulmonary compliance, such as obesity
FIGURE 8-6: Technique for holding a face mask with one hand (Campbell, 2015).
Source: Knoop, Storrow, Stack & Thurman (2010).
ENDOTRACHEAL TUBES
larynx, but it does so without passing through the Endotracheal tubes are designed to deliver gases
vocal cords. LMAs are inserted by hand without directly into the trachea and onwards into the
the aid of a laryngoscope (see Figs 8-7 and 8-8). lungs. They are disposable and made of PVC or
LMAs are available in sizes for both paediatric and silicone, with the distal end bevelled to aid visuali-
adult patients. Indications for their use include: sation and insertion through the vocal cords. The
Murphy eye is an additional hole at the distal end
• patients who do not require tracheal and is designed to lessen the risk of obstruction by
intubation to facilitate their surgical procedure secretions, blood or other matter. Resistance to air
and are breathing spontaneously flow depends primarily on the tube diameter, but is
• providing a clear airway without the need for also affected by tube length and curvature. ETTs
the anaesthetist’s hands to support a mask. may have an inflatable cuff at the distal end that
204
A B C
D E F
FIGURE 8-7: Insertion of laryngeal mask airway
Source: Campbell (2015).
A B C
FIGURE 8-8: Laryngeal mask airway in situ
Source: Adapted from Campbell (2015).
when inflated with air provides a seal, permitting designed to reduce obstruction when the patient
positive pressure ventilation and decreasing the is in the prone position. Ring-Adair-Elwyn (RAE)
risk of aspiration. tubes are used in orofacial surgery as they are
ETTs have been modified for a variety of spe- angled to avoid encroaching on the surgical site
cialised applications. Reinforced ETTs have been (e.g. during ear, nose and throat surgery, plastic
205
FIGURE 8-9: Intubation equipment 10 Temperature probe

1 Filter on anaesthetic delivery tubing 11 Bougie
2 Face mask 12 Introducer
3 LMA 13 Linen tape for securing ETT
4 Guedel airway 14 Tapes
5 Air syringe for inflating cuff on endotracheal tube (ETT) 15 Yankauer sucker
6 Lubricating gel 16 Nasogastric tube
7 ETT tube 17 Y-suction catheter
8 MAC Blade 3 Laryngoscope Source: Courtesy Zoe Kumar.
9 MAC Blade 4 Laryngoscope
surgery and ophthalmology). Nasal RAE tubes are • patients with significant comorbidities (Fell &
also used for oral and faciomaxillary surgery. Indi- Kirkbride, 2013).
cations for intubation include:
• patients who are at risk of aspiration and INTUBATION EQUIPMENT
require the airway to be protected, as The anaesthetic nurse must be aware of the require-
discussed later in the section on rapid ments for intubation in order to provide effective
sequence induction assistance to the anaesthetist and a safe outcome
• patient positioning, where the airway is at a for the patient (ACORN, 2016). The equipment
greater risk of being compromised (e.g. when required includes the following (see also Fig. 8-9):
it must be protected from blood loss at the • laryngoscope handle and blades in working
operative site during ear, nose and throat, order (the anaesthetic nurse should ensure
facial, plastic or dental surgery) and to that the blade fits and locks onto the handle,
facilitate access to the surgical site confirm the light-source strength by opening
• abdominal surgery requiring muscle relaxation the blade and viewing the light, and be aware
and mechanical ventilation that brands are generally not interchangeable)
• thoracic surgery that requires specific control • appropriately sized tubes, plus lubricant
of ventilation and sometimes one lung • 10-mL syringe for cuff inflation
ventilation • tape to secure tube in place (this may depend
• patients with a Mallampati score of class III or on anaesthetist preference, e.g. linen tape,
IV, where a difficult airway is anticipated Elastoplast)
206
• suction equipment, including Yankauer and • gastrointestinal bleeding

Y-suction catheters. • gastric reflux
Additional requirements that should be available • trauma sustained after eating.
include:
The technique involves the anaesthetic nurse
• a malleable introducer using her or his fingers to apply pressure on the
• Magill forceps cricoid cartilage, pressing it firmly backwards onto
• intubating bougie (for difficult or awkward the cervical vertebral bodies behind it and occlud-
airways). ing the upper end of the oesophagus, thus prevent-
ing aspiration of gastric contents. This is known as
a Sellick’s manoeuvre and was first described in
COMPLICATIONS OF INTUBATION 1961 (Tasch & Langeron, 2013). The sequence of
The anaesthetic nurse must be aware of and alert the technique is as follows:
to complications that may arise during intubation
• locate appropriate equipment (e.g. ETT,
in order to provide effective and prompt assistance
laryngoscope and suction)
to the anaesthetist, such as obtaining additional
equipment. Complications include: • secure IV access
• oesophageal intubation or endobronchial • apply haemodynamic monitoring
intubation, as neither will provide effective • preoxygenate the patient using a face mask
ventilation and could be fatal as the patient
• locate the cricoid cartilage and apply pressure
will receive little or no oxygen
using two fingers when instructed to do so by
• complications when in situ, such as the anaesthetist, usually as the induction
malposition due to changes in patient agent is being administered (see Fig. 8-10)
position, unintentional extubation or ignition
• administer IV induction agent and short-
of anaesthetic gases resulting in fire during
acting muscle relaxant (e.g. suxamethonium)
use of lasers
• observe for muscle twitching or fasiculations,
• obstruction of the Murphy eye with secretions,
which indicates the muscle relaxant is taking
which could compromise the ability to
effect
ventilate the patient
• intubate, inflate cuff and ventilate patient
• airway trauma, such as damage to the teeth,
lip and mucosal laceration, sore throat or • confirm correct position of ETT (i.e. equal
dislocation of the mandible chest inflation and end-tidal carbon dioxide
displayed waveform)
• tube malfunction or cuff perforation
• release cricoid pressure only on the advice of
• laryngospasm.
the anaesthetist once the position of the ETT
has been confirmed (Nagelhout, 2014c).
RAPID SEQUENCE INDUCTION
On occasions it is necessary to secure the airway
rapidly in order to reduce the risk of pulmonary
aspiration of the acid stomach contents. The tech-
nique to achieve this is called a rapid sequence
induction. Aspiration can result in severe pneumo-
nitis, which is known as Mendelson’s syndrome and
is often fatal (Hagberg & Artime, 2015). The indica- Cricoid
tions for rapid sequence induction include patients cartilage
who are at risk of aspiration due to: Oesophagus
• unknown fasting time

• pregnancy
• hiatus hernia
FIGURE 8-10: Applying cricoid pressure
• bowel obstruction Source: Nagelhout (2014a).
207
It is important that patients are warned that they • the height of the patient trolley or the
will feel pressure on their neck as their anaesthetic operating table, which should be adjusted to
is being induced. facilitate access by the anaesthetist.
Note that Sellicks’s manoeuvre is different from
the application of external laryngeal pressure,
DIRECT LARYNGOSCOPY AND INTUBATION
which the anaesthetist may ask the anaesthetic It is important that the anaesthetic nurse has
assistant to perform, in order to facilitate a view of assembled and prepared all the equipment ready
the larynx for routine intubation. This is known as for intubation prior to induction of anaesthesia.
BURP, an acronym for backwards, upwards, right- Any delay in intubating the patient could compro-
wards pressure. mise the patient’s airway. The anaesthetic nurse
should be positioned preferably to the right side of
SEQUENCE OF GENERAL ANAESTHESIA the patient’s head. This allows for the intubation
Once the anaesthetic equipment has been assem- equipment to be handed to the anaesthetist without
bled and checked, the anaesthetic team is ready and obstructing her or his view of the patient’s airway.
the patient has been prepared, the sequence of The procedure for intubation is as follows:
general anaesthesia can commence. Table 8-4 illus- • The laryngoscope is designed to be used in the
trates this sequence and the rationale for each step. anaesthetist’s left hand and is handed to him or
NURSING CONSIDERATIONS DURING her so that the blade is inserted into the right
GENERAL ANAESTHESIA side of the patient’s mouth and the tongue is
swept to the left, locating the epiglottis.
In addition to the information contained in Table
8-4, the anaesthetic nurse must be aware of other • The blade is inserted into the vallecula
considerations during the patient’s anaesthesia. (posterior oropharynx) and the patient’s head
is lifted perpendicular to the patient’s
INDUCTION OF ANAESTHESIA mandible to expose the vocal cords.
Induction of anaesthesia is a critical time during • The anaesthetic nurse holds the ETT so that it
the patient’s perioperative care and the anaesthetic can be taken by the anaesthetist’s right hand
nurse must ensure that all equipment is prepared and inserted so that the cuff is just below the
prior to induction. Any delay due to lack of equip- vocal cords, noting the level on the tube and
ment can compromise patient safety. As mentioned at the lips.
earlier, this is an anxious time for the patient and
the nurse should seek assistance from the other • The ETT is then connected to the anaesthetic
members of the surgical team to provide an envi- delivery tubing; see Figures 8-12 and 8-13.
ronment that is as quiet as possible to facilitate a
MAINTENANCE OF ANAESTHESIA
smooth induction. Noise from music, people talking
or the instrument and circulating nurses setting Once the airway is established, the patient will be
up equipment should be reduced (Fell & Kirkbride, positioned ready for surgery. The anaesthetic nurse
2013). The anaesthetic nurse must have knowledge may assist with positioning, ensuring that the
of the indications for intubation (as discussed patient remains covered with a sheet or blanket to
earlier) in order to ensure that the appropriate maintain privacy and dignity and reduce the inci-
equipment is prepared. dence of inadvertent perioperative hypothermia
(IPH). The nurse will also assist with the placement
ESTABLISHMENT OF THE AIRWAY of additional equipment, such as warming devices
Once anaesthesia is induced, the patient will and further monitoring equipment. During mainte-
proceed through the stages of anaesthesia shown nance of anaesthesia, when the operative proce-
in Table 8-1. The establishment of an airway now dure is taking place, there are a variety of activities
becomes a priority. As well as ensuring that the the anaesthetic nurse may undertake:
intubation equipment is readily available the • obtaining further narcotic drugs
anaesthetic team will ensure:
• cleaning up used equipment
• correct patient positioning, head extension
and flexion (the patient appears to be ‘sniffing • priming further IV fluids
the morning air’) (see Fig. 8-11) • documenting fluid balance
208
TABLE 8-4: Sequence of General Anaesthesia
SEQUENCE RATIONALE
Induction
Preoxygenation Provides a reserve supply of oxygen in the patient’s lungs during

induction and prior to intubation
Administration of midazolam and narcotic Provides sedation and commences pain management
Administration of propofol Induces anaesthesia
Ventilation with bag/mask and oxygen Manages apnoea caused by propofol and muscle relaxant drug
Administration of long-acting muscle relaxant Facilitates intubation and the surgical procedure; it takes 1–2 minutes
e.g. rocuronium to act, hence bag/mask ventilation, which provides airway support
Intubation with ETT Facilitates ventilation for surgical procedure
Inflation of ETT cuff Seals airway and facilitates positive pressure ventilation
ETT secured using tape of anaesthetist’s choice Prevents ETT being dislodged and resultant airway compromise
Confirmation of correct location of ETT using Ensures equal inflation of each lung and that the ETT is not located
stethoscope and monitoring of C02 in the right main bronchus or in the oesophagus
Attachment of ETT to ventilator on anaesthetic As the patient is paralysed and unable to breathe unassisted, they
machine and delivery of appropriate levels of must be attached to the mechanical ventilator; and anaesthesia must
oxygen, nitrous oxide and volatile agent be maintained using a combination of agents
Maintenance
Delivery of oxygen, nitrous oxide and volatile Provides continuing anaesthesia

agent (e.g. sevoflurane) or continuous TIVA
Further muscle relaxant drug may required Provides continuing muscle relaxation for surgical procedure
Haemodynamic monitoring, including Provides data on the patient’s physiological status, alerting the
temperature monitoring; continued IV access anaesthetic team to potential problems
maintained Provides access to circulation for administration of drugs (e.g.
analgesia) and IV fluids, if required
Ongoing analgesia will be administered Provides continuing pain relief
Emergence
Reversal of residual muscle relaxants using Non-depolarising muscle relaxants require reversing to allow return
neostigmine and atropine of spontaneous respiration
Switching off of inhalation agents and Cessation of inhalation agents assists the patient to emerge from
administration of 100% oxygen; cessation of general anaesthesia; delivery of 100% oxygen ‘washes out’ residual
TIVA if in use anaesthetic agents
Suction of oropharynx Removes secretions and prevents aspiration and laryngospasm
Removal of ETT when the patient is breathing Demonstrates successful emergence from general anaesthesia and
spontaneously, responding to verbal commands maintenance of airway with minimal support
and is haemodynamically stable
Continual monitoring until transfer to PACU; Monitoring facilitates management of potential relapse in the
suction and oxygen must be available for patient’s condition
transfer Availability of suction ensures the patient’s airway can be kept clear
Oxygen administration maintains optimal oxygen saturation of the
patient’s blood during transfer
SOURCE: FELL & KIRKBRIDE (2013) AND CAMPBELL (2015).
209
Head extended
Pillow to raise
head and flex neck
FIGURE 8-11: Head position for laryngoscopy

Source: Fell & Kirkbride (2013).
FIGURE 8-13: ETT in correct position

Source: Pfenninger & Fowler (2011). © 2011, 2003, 1994 by Mosby.
Curved blade
Epiglottis It is important that anaesthetic nurses demon-

strate good situational awareness (as discussed in
Trachea Chapter 2) by watching the progress of the surgery
and listening to the conversations of the nursing
and surgical team, so that they are aware of any
possible changes in the patient’s condition or in the
progress of the procedure that may require action
on the part of the anaesthetic team.
A
EMERGENCE FROM GENERAL ANAESTHESIA
Emergence from anaesthesia is a crucial time in the
care of the patient and the anaesthetic team must
be prepared with the extubation equipment, includ-
Straight blade ing suction and oxygen delivery equipment, ready
for post-intubation care of the patient and transfer
to the PACU. Prior to transferring the patient to the
bed/trolley, the nursing team, assisted by the anaes-
thetist and the surgical team, should carry out a
check of the patient’s skin integrity and record their
observations on the perioperative nursing record
(see Chapter 9 for further information). If any pres-
sure injuries are evident, in addition to informing
the PACU staff, these injuries must be treated as an
B adverse event and an incident form should be com-
FIGURE 8-12: Using a laryngoscope pleted, in line with the National Standards (the
Source: Fell & Kirkbride (2013). Commission, 2012). The patient’s skin should be
clean and dry—that is, any blood or skin preparation
• checking readiness of PO bed solution must be removed—and the patient should
be dressed in a gown and placed on a clean sheet
• preparing for the next patient ready for transfer. The lateral position (recovery
• collaborating with the anaesthetist for any position) may be adopted to assist in maintaining
additional patient requirements such as PO an unobstructed airway, unless the anaesthetist
orders. is satisfied that this is unnecessary or the nature
210
of the surgery prohibits it. The recovery position satisfied that the patient is in a stable condition
involves flexing the patient’s upper leg and extend- before both the anaesthetist and the instrument or
ing the lower leg, and positioning the patient’s head circulating nurse leave the PACU.
on one side so that the tongue falls forwards under
gravity, thus avoiding airway obstruction and/or AIRWAY EMERGENCIES AND
inhalation of secretions (Fell & Kirkbride, 2013).
MANAGEMENT
CLINICAL HANDOVER AIRWAY COMPLICATIONS
When the anaesthetist is satisfied that the patient’s Management of the patient’s airway usually occurs
condition is stable, the patient will be transferred without incident but occasionally, due to unantici-
to the PACU accompanied by the anaesthetist and, pated circumstances, the anaesthetic team may be
depending on local policy, either the instrument faced with a patient whose airway is difficult to
nurse or the circulating nurse. An anaesthetic and secure. This requires urgent management and the
nursing clinical handover to PACU nursing staff is whole team acting quickly and decisively to secure
important to ensure continuity of care. the patient’s airway.
On arrival in PACU, the anaesthetist will stay Difficulties with airway management contribute
with the patient until a PACU nurse is available to to a large number of situations that are collectively
care for the patient and carry out an initial assess- known as ‘can’t intubate, can’t oxygenate’ (CICO)
ment of airway, breathing and circulation, includ- (see Feature box 8-2) and according to Cook and
ing noting the patient’s skin colour. A pulse Simpson (2013), these account for more than 25%
oximeter, non-invasive blood pressure cuff and, of all anaesthesia-related deaths. Some patients
frequently, ECG electrodes will be attached to the will experience difficulties with tracheal intubation
patient and the readings noted. Often while this due to congenital abnormalities or acquired condi-
is occurring, the anaesthetist will commence the tions, such as trauma to the head, neck and cervical
formal handover to the PACU nurse. This is fol- spine, or tumours in the mouth (among many).
lowed by the nursing handover provided by the Several options are available for the anaesthetic
instrument or circulating nurse. The handover pro- team to achieve control of the airway depending on
cedures are covered in detail in Chapter 12. Follow- the patient’s presenting condition. These include
ing both handovers, the PACU nurse should seek different sizes and designs of laryngoscopes, intu-
clarification of any PO management issues and be bating LMAs, video laryngoscopes such as the
FEATURE BOX 8-2 » CICO: AN ANAESTHETIC EMERGENCY
CICO occurs when an obstruction exists in the upper airway that cannot be overcome by routine
airway management techniques such as use of LMA or ETT. As a result the anaesthetist is unable
to ventilate the patient, leading to low oxygen saturation. Emergency action is required to maintain
the patient’s airway and the anaesthetic nurse must be able to provide immediate assistance by
initiating emergency protocols and locating the difficult intubation trolley, which contains emer-
gency airway equipment and drugs. It may be necessary to quickly reverse the effects of the muscle
relaxant drugs in order to facilitate alternative airway management options. In this life-threatening
situation, sugammadex PIH (Biridion) is used to reverse the neuromuscular blockade induced by
rocuronium or vecuronium. Sugammadex can also be used when operations terminate prematurely,
in intubated patients who are not adequately reversed and in patients who have contraindications
to other reversal agents (Nagelhout, 2014a). The surgical and nursing team should be informed
that surgical airway intervention (e.g. crycothyroidotomy or tracheostomy) may be required and
an equipment set-up made available. In the United Kingdom, Elaine Bromiley, a fit and healthy
woman undergoing sinus surgery, suffered an incident of ‘can’t intubate, can’t oxygenate’ with a
tragic outcome. See Chapter 2 for further information (Heard, 2013).
211
FIGURE 8-14: Intubating LMA

Source: Courtesy Teleflex Medical Australia & New Zealand. FIGURE 8-16: Glidescope
Source: Courtesy Zoe Kumar.
insertion of a fine-bore tracheostomy tube in order

to ventilate the patient.
LARYNGOSPASM
Laryngospasm is irritation of the vocal cords leading
to an involuntary spasm of the superior laryngeal
nerve, which can result in complete or partial
obstruction of the vocal cords. This can occur during
a light plane of anaesthesia (e.g. Stage 3, Plane I)
and can be caused by: the presence of secretions,
vomitus, blood or inhalation agents; placement of
oropharyngeal or nasopharyngeal airways or the
laryngoscope blade; or painful stimuli. The larynx
can become completely closed by a reflex closure
of the cords and the anaesthetist will not be able
to ventilate the patient. A less severe reaction that
occurs when the cords only partially close is char-
acterised by a ‘crowing’ sound or stridor and by a
‘rocking’ obstructed pattern of breathing. If left
untreated, hypoxia, hypercarbia and acidosis will
result, leading to hypertension and tachycardia
FIGURE 8-15: C-MAC video laryngoscope and, finally, to cardiac arrest (Heiner & Gabot,
Source: © Karl Storz Endoscopy.
2014).
C-MAC and Glidescope, and fibreoptic intubating MANAGEMENT

bronchoscopes (see Figs 8-14 to 8-16). Failure to Initially, deepening the anaesthetic and removing
secure an airway using this equipment will require the stimulus (e.g. suctioning any blood or mucus
performing an emergency crycothyroidotomy using from the airway) will remove the irritant and relieve
a specialised needle to puncture the trachea and the laryngospasm. Positive end-expiratory pressure
212
FIGURE 8-17: Flowchart for the management of laryngospasm

Source: Gavel & Walker (2012).
(PEEP) is used to force 100% oxygen into the level of inhalational agent will frequently overcome
lungs. If this is ineffective, suxamethonium may bronchospasm. Bronchodilators such as salbutamol
be given, which will relax the vocal cords so that can be administered intravenously and other
intubation can take place. The anaesthetic nurse drugs—such as steroids, ketamine and adrenaline—
must be alert to this condition and have drugs can also be used.
and intubation equipment immediately available.
Figure 8-17 shows a flowchart for the management ASPIRATION
of laryngospasm. Patients who are at risk of aspiration are most likely
to undergo a rapid sequence induction, as noted
BRONCHOSPASM earlier. A patient’s airway reflexes are depressed by
General anaesthesia can alter airway resistance and general anaesthesia, which increases the risk of
cause reactions within the bronchial tree, which aspiration of gastric contents into the lungs. The
may result in bronchospasm. This is characterised occurrence of vomiting and regurgitation when the
by an expiratory wheeze, which, if the patient is airway is unprotected can lead to bronchospasm,
intubated, can make ventilation difficult. Bron- hypoxaemia, atelectasis, tachypnoea, tachycardia
chospasm can be caused by local airway irritation and hypotension. The severity of the symptoms
due to the presence of secretions, airway equip- depends on the volume and pH of the gastric con-
ment, pulmonary aspiration or drug hypersensitiv- tents. Patients who have aspirated may require
ity. Bronchospasm can also be precipitated by the ventilatory support in the intensive care unit for a
rapid introduction of volatile anaesthetic agents. period of time depending on the severity of the
Patients who smoke, have a history of asthma or condition (Heiner & Gabot, 2014).
have suffered a recent respiratory tract infection With at-risk patients, local and regional anaes-
are more susceptible to bronchospasm. thetic modalities may be an option, negating the
need for a general anaesthetic and airway manage-
MANAGEMENT ment. Thorough preoperative assessment is essen-
If the patient is intubated, repositioning the ETT tial to prepare a care plan for such patients and
may reduce the physical irritation to the bronchial ensure that all necessary equipment is available.
tree. Deepening the anaesthetic by increasing the Many operating suites have a difficult intubation
213
trolley that contains a range of anaesthetic equip- LOCAL ANAESTHETIC TECHNIQUES

ment that the anaesthetist may require when man- Local anaesthesia refers to a group of anaesthetic
aging a patient with a difficult airway. The role techniques that involve the use of local anaesthetic
of the anaesthetic nurse is vital to ensure safe drugs (e.g. lignocaine, bupivacaine, ropivacaine)
patient outcomes and the nurse must have a good to block sensory nerve pathways, thus allowing
understanding of the equipment and proposed pro- surgery to proceed without pain and without loss
cedures (ANZCA, 2014b). of consciousness. These techniques include periph-
eral nerve blocks, eye blocks, local infiltration at the
OTHER TYPES OF ANAESTHESIA site of surgery, local anaesthetic sprays to the vocal
cords prior to intubation and topical anaesthetic
SEDATION/ANALGESIA gels, which are often used prior to cannulation in
Sedation/analgesia refers to the administration paediatric patients. These techniques are particu-
of sedatives (e.g. midazolam) and analgesia (e.g. larly useful for patients who may have comorbidi-
fentanyl) to produce a depressed level of con ties that may contraindicate the use of general
sciousness, but patients retain the ability to anaesthesia. In many cases, they may be used in
maintain their own airway. ANZCA (2014b) guide- combination with general anaesthesia, providing a
lines on sedation/analgesia note that ‘the patient degree of PO pain relief for the patient. Other
is in a state of drug-induced tolerance of uncom- advantages for the patient include:
fortable or painful diagnostic or interventional • minimal respiratory impairment
medical, dental or surgical procedures’; however,
they should be rousable. Patients may also be • less nausea and vomiting
able to respond to commands or physical stimuli • being able to eat and drink sooner
(Williams, 2014). • more rapid mobilisation and discharge
Sedation/anaesthesia can range from a pleas- • simplicity of administration
ant, relaxed feeling to deepening levels of uncon-
sciousness depending on the drug and amount • sympathetic blockade (Coventry, 2013).
administered. With increasing dosage, the areas of
CENTRAL NEURAL BLOCKADE
the brain controlling cardiac and respiratory func-
tion will be depressed to the point where breathing Central neural blockade refers to the administra-
and blood pressure are adversely affected (NSW tion of local anaesthetic drugs into the spinal (sub-
Agency for Clinical Innovation [ACI], 2013). It is arachnoid) or epidural space, thus blocking nerves
therefore a minimum requirement that all patients as they exit the spinal cord and causing large areas
are assessed for suitability for sedation, that a of the lower body to lose sensation (hence the term
trained clinician is present to monitor and manage ‘block’). These techniques are particularly useful
the patient’s airway and that the person is trained for surgery of the abdomen and lower limbs.
in bag/mask ventilation (ACI, 2013). Spinal (subarachnoid) anaesthesia refers to a
This method is often used for endoscopy proce- single administration of local anaesthetic directly
dures such as colonoscopy because it facilitates into the subarachnoid space at the level of lumbar
a rapid recovery and return to normal activities, vertebrae L3–4 or L5–6, thus blocking the spinal
although patients must be warned not to drive or nerve roots and producing a loss of sensation to the
operate machinery for 24 hours post-sedation. areas supplied by the nerves from this level of the
These procedures often take place outside the peri- spinal cord. The anaesthetist advances a hollow
operative environment in dedicated endoscopy spinal needle through the intervertebral space into
units (see Chapter 13 for more information). In the subarachnoid space until drops of cerebrospinal
countries such as the United Kingdom and the fluid (CSF) appear. The local anaesthetic, which can
United States, sedation anaesthesia is often admin- be combined with opioids such as fentanyl, can be
istered by non-medical clinicians such as nurses injected into the subarachnoid space and the needle
who have undergone specialised training for the is then removed (Marley et al., 2014).
role (Jones, Long & Zeitz, 2011). Such a role is being The patient must be closely observed by the
trialled in Australia. See Chapter 1 for further infor- anaesthetic nurse in the immediate post-injection
mation about the role of the nurse sedationist. period as local anaesthesia injected into the CSF
214
can cause complications such as hypotension. This

occurs as a result of blocking the sympathetic
nerves that control vasomotor tone, thus producing
vasodilation. This effect can be managed by rapid
infusion of IV fluids and the administration of
adrenaline. If the local anaesthetic agent inadvert-
ently reaches the nerves controlling respiration,
the patient may require ventilator support and the Spinal cord
nurse must be alert to any changes in the patient’s
respiratory function.
Postoperatively, some patients may complain of L3 Epidural space
a severe headache, which is caused by the hole in
the dura and the leakage of CSF. The patient may
have to remain supine for 24 hours and receive
additional IV fluids until the headache subsides. L4
Occasionally, the anaesthetist may perform a ‘blood
patch’, which involves injecting 5–20 mL of blood Subarachnoid space
into the epidural space at the puncture site to seal
up the hole in the dura (Marley et al., 2014).
Epidural anaesthesia involves the intermit-
tent or continuous injection of local anaesthesia
through a catheter that is inserted between the ver- FIGURE 8-18: Location of the spinal cord and epidural space
Source: Gurch, https://commons.wikimedia.org/wiki/File:Epidural_blood_patch.svg.
tebrae at the L3–4 or L5–6 level into the epidural
space. The epidural space is not really a space but
an area of loose adipose tissue, lymphatic and blood
vessels that lies between the dura mater and the Postoperative backache and urinary retention have
ligamentum flavum (Bryant & Knights, 2015). The also been reported as a complication of epidural
anaesthetist uses a hollow Tuohy needle attached anaesthesia (Marley et al., 2014).
to an empty syringe, which is marked at 1 cm inter-
Figure 8-18 shows the location of the spinal
vals and has a Huber point that allows the fine
cord and epidural space. Table 8-5 outlines the dif-
catheter to be directed along the axis of the epi-
ferences between spinal and epidural anaesthesia.
dural space. When the needle penetrates the liga-
mentum flavum, there is a sudden loss of resistance It may not be possible for some patients to
to pressure on the plunger of the syringe, indicating receive either spinal or epidural anaesthesia.
to the anaesthetist that the correct location has Patients for whom these are contraindicated include
been reached. Advancing the needle further would patients with:
result in the dura being penetrated. A fine catheter
• no consent given
is then inserted via the needle into the epidural
space and local anaesthetic is injected (Coventry, • hypovolaemia—increased risk of
2013). The catheter is secured to the patient and is hypotension
available to provide ‘top-up’ doses of local anaes- • local sepsis—danger of septicaemia and
thetic drugs at intervals to maintain effectiveness meningitis
of the block. This may continue during the PO
period as part of the patient’s pain management. • raised intracranial pressure—both blocks
can dangerously alter intracranial
As with spinal anaesthesia, epidural anaesthe- pressure
sia can also cause hypotension, although onset is
usually slower. However, if a blood vessel in the • previous spinal surgery—anatomy may be
epidural space is inadvertently punctured and altered
the local anaesthetic agent is released into the • coagulopathies—if a blood vessel is
bloodstream, sudden and profound hypotension, accidentally punctured, there is a risk of
convulsions and respiratory compromise can occur. haemorrhage (Coventry, 2013).
215
TABLE 8-5: Differences in the Effect of Spinal and Epidural Anaesthetics
SPINAL ANAESTHESIA EPIDURAL ANAESTHESIA

Dose of drug Small: minimal risk of systemic toxicity Large: possibility of systemic toxicity after
used (accidental) intravascular injection or total
spinal blockade after subarachnoid injection
Rate of onset Fast: 2 minutes for initial effect; 20 minutes for Slow: 5–15 minutes for initial effect;
maximum effect 30–45 minutes for maximum effect
Intensity of block Usually complete anaesthesia Often incomplete anaesthesia for some
segments
Pattern of block May be dermatomal for first few minutes but Dermatomal
rapidly develops appearance of cord transection
Addition of Reliably prolongs block when used with Reliably prolongs block when used with
vasoconstrictor tetracaine (ametheocaine) but not with other lignocaine; may prolong block with bupivacaine
drugs but not in all patients
SOURCE: COVENTRY (2013).
L3
T5 High point
A Low point
Female
Crest of L3
Male ilium L4
L5
B C
FIGURE 8-19: Spinal curvature for insertion of central neural blockade
Source: Coventry (2013).
Management of the patient undergoing spinal or The position is similar to that used for a lumbar
epidural anaesthesia puncture. For those patients with physical disabili-
With both spinal and epidural anaesthesia, patients ties this position is difficult and they can be sat
are positioned with their back arched into the shape upright, a position that some anaesthetists also
of a C in order to maximise the space between the favour (Coventry, 2013).
spinous processes and to facilitate access for posi- Prior to administration of either block, the
tioning the spinal/epidural needles (see Fig. 8-19). routine checks of the anaesthetic machine and
216
FEATURE BOX 8-3 » EPIDURAL ERROR
In 2010 a patient in a large Sydney teaching hospital went into labour with her first child. During
administration of an epidural anaesthetic, chlorhexidine (an antiseptic skin preparation) was mis-
takenly injected into the patient’s epidural space instead of normal saline (used to check the
position of the epidural needle). This had a catastrophic effect on the patient’s nervous system,
causing her excruciating pain and leaving her virtually paralysed. How did such a mistake occur?
It appears from reports on the incident that both normal saline and the chlorhexidine 0.5% in
alcohol solution were placed in separate unlabelled gallipots on the aseptic field. The anaesthetist
drew up 8 mL chlorhexidine in a syringe by mistake and injected the substance via a Tuohy’s
needle into the patient’s epidural space (Bogod, 2012).
Afterwards, NSW Health issued a safety notice outlining steps to be taken to avoid a repeat of
such an incident. These include:
• skin preparation must precede preparation of any medication for the procedure
• receptacles containing skin preparation solutions must be removed from the aseptic field
following preparation of the skin
• medications must be carefully checked by two people, one of whom is the proceduralist
(NSW Health, 2010).
In addition, syringes containing medication must be labelled in accordance with national recom-
mendations for user-applied labelling of injectable medicines, fluids and lines (the Commission,
2012).
equipment must be carried out, because if the block closely monitored for any of the complications
should fail or resuscitation is required, all resusci- discussed earlier. The effectiveness of the block
tation equipment must be available and in working must also be assessed prior to surgery taking place.
order. Monitoring, IV access and baseline observa- This may be accomplished by using ice to test
tions are obtained to determine variations during numbness in the required (specific dermatome)
the administration of the block (ANZCA, 2014c). area and by asking the patient for feedback as to
In many instances, patients receive a combina- any sensations.
tion of a central block and general anaesthesia, par- The anaesthetic nurse should provide the
ticularly for complex abdominal surgery where the patient with explanations and reassurance at all
central block can provide PO pain relief, or it is used times and sit at the patient’s head during the pro-
as an adjunct to reduce the other drugs required cedure, using verbal and non-verbal communica-
during anaesthesia. However, the administration of tion to reduce the patient’s anxiety. Patients must
central neural blockades is not without risk, as can understand that although this type of anaesthesia
be seen in Feature box 8-3. will block painful stimuli, they may still be aware
The procedure to insert both spinal and epi- of pressure in the area of the surgical procedure. To
dural anaesthesia must be undertaken using sur alleviate anxiety they will also receive drugs (e.g.
gical aseptic non-touch technique to prevent midazolam) to make them drowsy. Haemodynamic
microorganisms from entering the spinal canal or monitoring by the anaesthetic team is important to
epidural space, which could lead to infection detect any complications or unwanted effects of the
(ANZCA, 2013a). The anaesthetic nurse assists the central block. Oxygen may be applied by a Hudson
anaesthetist by assembling the necessary equip- mask or nasal prongs. It is important that the surgi-
ment and by providing physical and emotional cal and anaesthetic team are aware that they should
support to the patient, who is likely to be awake not make unnecessary noise, especially conversa-
during the administration of the block. Once the tions, as the patient may still be semi-conscious
block has been administered, the patient must be and able to hear.
217
FEATURE BOX 8-4 » LOCAL ANAESTHETIC TOXICITY
A young woman undergoing cosmetic breast surgery in a Sydney clinic suffered a cardiac arrest,
the cause of which was suspected to have been an overdose of a local anaesthetic. She was treated
with Intralipid infusion and transferred to hospital where she made a full recovery (Patty, 2015).
LOCAL INFILTRATION Prior to performing a regional anaesthesia tech-

Infiltration of local anaesthetic agent facilitates nique, the procedure must be discussed with the
minor surgery (e.g. removal of skin cancer or sutur- patient and, prior to the block, the skin must be
ing of lacerations) or the insertion of invasive moni- marked close enough to the block site to be visible
toring devices and may be the only anaesthetic while performing the block. These form part of the
agent required for the procedure. This involves Sign In section of the WHO Surgical Safety Check-
direct injection into tissues to block sensory nerve list (SSC), which should be performed to ensure
pathways, thus resulting in an absence of pain, the correct side and site for insertion of the block
which may continue post-procedure to provide the (see Chapter 9 for more information on SSC). Veri-
patient with pain relief for a period of time. Patients fication with another clinician (i.e. nurse, assistant
remain conscious and aware of their surroundings, or medical officer) is required and must be docu-
although mild sedation may also be given depend- mented appropriately.
ing on the patient’s condition (Bryant & Knights, To assist with the safe and accurate placement
2015). Adrenaline may be added to local anaesthetic of the block and administration of local anaes-
agents for vasoconstriction properties in the area to thetic, ANZCA recommends that ultrasound equip-
be injected. However, this combination should not ment is made available for visualising the nerve and
be used when infiltrating digits (e.g. nail-bed repair surrounding vessels to be blocked. Alternatively, a
or laceration) due to possible necrosis of tissue peripheral nerve stimulator may be required to
caused by the effects of vasoconstriction (Campbell, assist in the identification of the nerves to be
2015). Examples of drugs used in local infiltration blocked (ANZCA, 2014c).
are lignocaine, bupivacaine and ropivacaine.
LOCAL ANAESTHETIC TOXICITY
REGIONAL ANAESTHESIA Toxicity can occur when an accidental overdose of
Techniques of regional anaesthesia involve inject- local anaesthetic is administered during a regional
ing local anaesthetics anywhere along a pathway or local anaesthetic block or is accidentally injected
of a nerve, resulting in anaesthesia to a region into the bloodstream. The result is life-threatening
of the body. Regional anaesthesia may be used circulatory collapse, convulsions, agitation and loss
alone or in combination with a general anaesthetic of consciousness. This situation requires immedi-
(Coventry, 2013). Regional anaesthesia may be ate cessation of the local anaesthetic injection and
administered by: resuscitation measures to support circulation and
breathing. The administration of lipid emulsion
• a single dose
(Intralipid) is also recommended as a treatment for
• intermittent bolus—repeated injections or local toxicity (Association of Anaesthetists of Great
indwelling catheter for repeat administration Britain and Ireland [AAGBI], 2010: Australian and
• continuous infusion via a catheter. New Zealand Anaesthetic Allergy Group [ANZAAG],
2013). Feature box 8-4 provides an example of local
Regional blocks, which are available using local
anaesthetic toxicity.
anaesthetics (e.g. bupivacaine, lignocaine, ropi-
vacaine), include:
• upper limb—axillary nerve blocks for elbow,
HAEMODYNAMIC MONITORING
forearm and hand surgery DURING ANAESTHESIA
• lower limb—femoral nerve blocks for femoral Regardless of the type of anaesthesia or sedation
fractures and knee and foot surgery (Coventry, the patient receives, haemodynamic monitoring
2013). is a vital component of the patient’s management
218
and safety. Advances in haemodynamic monitoring

have greatly decreased the mortality and morbidity
of patients undergoing anaesthesia. Both ANZCA
(2013b) and ACORN (2016) stipulate the minimum
standards for monitoring to be provided. The anaes-
1
thetic nurse should consult with the anaesthetist
regarding the type of monitoring equipment appro-
priate for the patient and the procedure being 2
undertaken (see Fig. 8-20). Monitoring equipment
available includes:
• oxygen supply failure alarm 3
• oxygen analyser
• pulse oximeter
7 6 5 4
• breathing system disconnection or ventilator
failure alarm
• electrocardiograph
• intermittent non-invasive blood pressure
monitor FIGURE 8-20: Monitor showing vital signs
• continuous invasive blood pressure 1 ECG
monitor 2 Oxygen saturation
3 Expired CO2
• temperature monitor 4 O2, C02 and volatile agent analyser
• carbon dioxide monitor 5 Inhalational agents, patient values
6 Temperature
• neuromuscular monitor 7 Non-invasive blood pressure
• volatile anaesthetic agent monitor
• BIS monitoring
• cardiac output, spirometry, central venous
pressure (CVP) or transoesophageal (Marley et al., 2014). When using a three-lead ECG,
echocardiogram (TOE) when clinically the electrodes can be placed one on each shoulder
indicated (ANZCA, 2013b). and one on the left side of the rib cage.
CIRCULATION BLOOD PRESSURE

ELECTROCARDIOGRAPH Indirect blood pressure monitoring is a minimum
Monitoring of the patient’s cardiovascular system requirement for all patients. Changes in systolic
involves observation of the patient’s blood pressure blood pressure correlate with changes in myocar-
and continuous ECG analysis. The ECG will detect dial oxygen requirements, and changes in diastolic
arrhythmias, myocardial ischaemia, electrolyte blood pressure reflect coronary perfusion pressure.
imbalance and pacemaker dysfunction. The anaes- Care must be taken to ensure that the blood pres-
thetic nurse must ensure that ECG monitoring sure cuff is the correct size. The cuff must be neither
electrodes are not placed close to the proposed sur- too tight nor too loose, as either will affect the
gical site. Electrode placement requires a minimum readings, giving false results (Kossick, 2014b).
of two sensing electrodes and a third reference Direct blood pressure monitoring involves can-
(grounding) lead. The lead that displays the most nulation of an artery to provide continuous meas-
prominent P waves on the ECG monitor is the pre- urement of arterial blood pressure. This invasive
ferred option because it follows the direction of the method is required when the patient is at risk of
normal electrical impulse. Five-lead ECG monitor- haemodynamic instability due to the nature of the
ing provides more precise recording, with more surgery or has comorbidities that require close
accurate detection of myocardial ischaemia, and is observation. Indicators for invasive blood pressure
used if the patient has a history of cardiac disease monitoring are listed in Box 8-1.
219
BOX 8-1 » INDICATORS FOR INVASIVE BLOOD PRESSURE MONITORING

• Patient-dependent factors
– Haemodynamic instability (shock)
– Cardiac disease
– Respiratory insufficiency
– Increased intracranial pressure
– Polytrauma
• Type of surgery
– Cardiac surgery
– Craniotomy
– Major thoracic surgery
– Major abdominal surgery (Nagelhout, 2014a)
CENTRAL VENOUS PRESSURE Complications of CVP catheter placement

A central venous pressure (CVP) catheter is often include:
inserted prior to commencement of anaesthesia. • arrhythmias (atrial and ventricular)
The purpose of CVP monitoring is to:
• carotid or subclavian artery puncture
• measure right heart filling pressure as a guide (subclavian vein cannulation is
to intravascular volume contraindicated in patients on anticoagulants
• administer drugs due to the inability to compress the vessel)
• provide IV access in patients with poor • pneumothorax, hydrothorax, infection or air
peripheral veins. embolism (Scott, 2013).
Additional reasons for CVP insertion include to: RESPIRATION
• provide a route for long-term parenteral Monitoring the patient’s respiratory function
nutrition during anaesthesia involves the mandatory use of
• inject dye for diagnostic purposes pulse oximetry and capnography.
• remove air emboli. PULSE OXIMETRY

Sites used for CVP catheter insertion include Pulse oximetry is a non-invasive measurement
the internal jugular, subclavian, external jugular, of haemoglobin oxygen saturation (SaO2) at the
cephalic, axillary and femoral veins. The anaes- arteriole level that measures changes in the light
thetic nurse will provide assistance to the anaes- absorbed by an extremity (Al-Shaikh & Stacey,
thetist in preparing the required equipment using 2013). It works by detecting the differences in
a surgical non-touch aseptic technique. The CVP absorption of oxygenated and deoxygenated blood.
catheter is inserted using the Seldinger technique, Normal values are 95% or above and the anaes-
which involves insertion of a needle and use of a thetic nurse should monitor the patient’s SaO2. If
guide wire to thread the CVP catheter over the the patient’s saturation level drops below 95%, the
guide wire. Chest X-ray is carried out post-insertion anaesthetic team should consider increasing the
to check the catheter position and to exclude oxygen concentration in the patient’s anaesthesia
pneumothorax. Documentation of insertion of the and/or check the equipment and placement of the
CVP must be completed by the anaesthetist and probe. The pulse oximeter probe is usually placed
kept in the patient’s medical record (NSW Health, on the fingers or toes and the reading is displayed
2011). on a monitor as a percentage. Cold or poorly
220
perfused extremities can affect the accuracy of the relation to providing perioperative patient warming
pulse oximeter, and newer technologies using fore- (Duff et al., 2014). See Chapter 9 for more informa-
head oximetry may be more effective, providing tion on the intraoperative management of IPH.
more accurate readings (Nagelhout, 2014a). Neonates are more prone to hypothermia due to
CAPNOGRAPHY their immature temperature regulation centres, as
are elderly patients owing to their lower metabolic
Capnography is a graphical representation of rates. Particular care should be taken to prevent
expired carbon dioxide (CO2) and is termed end- IPH in these special populations and strategies are
tidal CO2 (Odom- Forren, 2012). Monitoring end- discussed later in the chapter.
tidal CO2 assists the anaesthetic team in the early
detection of either technical catastrophes (e.g. inad- Planned hypothermia may be required and
vertent oesophageal intubation, breathing circuit deliberately induced to reduce oxygen requirements
leaks) or changes in the patient’s respiratory, circu- and create optimum operating conditions in spe-
latory or metabolic condition. It is usually the initial cific surgery (e.g. neurosurgery and cardiac surgery).
indicator of malignant hyperthermia, which can be Maintenance of normothermia should com-
an anaesthetic emergency. The normal value of end- mence in the preoperative period, with nursing
tidal CO2 is 35–45 mmHg. CO2 is collected by an staff in the pre-admission area monitoring the
adapter that is placed in the breathing circuit close patient’s temperature and applying additional bed
to the airway so that the CO2 collected will approxi- coverings or clothing or using forced-air warming
mate the alveolar concentration. The expired CO2 is devices if the patient’s temperature drops below
then analysed using an infrared ray, which converts 36°C (ANZCA, 2014d) (see Chapter 7 for more infor-
it to a waveform displayed on a monitor. mation). Specialised gowns incorporating forced-
air warming capabilities are commercially available,
TEMPERATURE as are devices that use a disposable warming blanket
Inadvertent perioperative hypothermia (IPH) is connected to a hose and warming unit. The warm
defined as a core temperature below 36°C (Duff air inflates the blanket and the temperature can be
et al., 2014). IPH is a preventable consequence of regulated as required. The blankets are available
surgery and anaesthesia; during major surgery, a in various configurations (e.g. full length or half
temperature probe placed orally, nasally or in the length) to facilitate warming while allowing access
bladder (incorporated as part of a urinary catheter) to the surgical site for the surgeon. The anaesthetic
is used to measure core temperature. If IPH is not nurse prepares the appropriately-sized warming
addressed during the perioperative period, it can blanket and assists in positioning it on the patient
lead to a variety of complications, including: as soon as practicable in the anaesthetic bay or
• increased recovery time due to increased immediately prior to the commencement of surgery.
demand for oxygen consumption Other methods of maintaining normothermia
• increased wound infections due to suppression include:
of the immune system • controlling the operating room temperature
• impaired cardiac function • warming IV fluids
• coagulopathy • using overhead heating lamps for paediatric
• increased morbidity and mortality (ANZCA, patients
2014d; Duff et al., 2014). • using forced-air warming devices
In addition, maintaining normothermia (36°C) • avoiding unnecessary exposure of the patient’s
provides the patient with a feeling of wellbeing and body
comfort (Duff et al., 2014). Despite extensive evi-
• pre-warming the patient.
dence demonstrating the importance of providing
intraoperative warming, a retrospective chart audit
of 400 patients in four Australian hospitals revealed
that almost one-third experienced IPH: this study
FLUID AND ELECTROLYTE BALANCE
highlights poor compliance by staff with estab- The average adult requires water to replace
lished recommended evidence-based practice in gastrointestinal losses (100–200 mL/day), losses
221
through respiration and perspiration (500– the anaesthetist will monitor the suction canisters
1000 mL/day) and excretion of urine (1000 mL/ for blood that has been suctioned from the surgical
day). Adults need to consume about 2500 mL of site. The instrument nurse will be able to provide
fluids per day to ensure their renal function is ade- the amount of intraoperative irrigation fluid used.
quate (Lynn & Winner, 2014). The anaesthetist may also use invasive monitoring
such as CVP in a patient with potential blood loss
ELECTROLYTE BALANCE to clinically manage the loss.
When electrolyte values are abnormal, this affects A patient who is adequately hydrated before,
the fluid and electrolyte balance and acid– during and after surgery will have a better outcome.
base balance, resulting in renal, neuromuscular, Therefore, all patients undergoing surgery or any
endocrine or skeletal dysfunction. The levels of procedure requiring an anaesthetic or sedation
serum electrolytes affect the movement of fluid must have some form of venous access, not only
between the body compartments. The major extra- to facilitate induction and maintenance of anaes-
cellular electrolytes are sodium, calcium, chloride thesia but also to enable provision of fluids during
and bicarbonate (see Table 8-6). Sodium is the most and after the procedure. There is increasing evi-
common cation and chloride the most common dence that intraoperative fluid therapy may influ-
anion. Potassium, magnesium and phosphate are ence PO outcomes. Both too little and too much
the major intracellular electrolytes, potassium fluid can adversely affect patient outcomes, and
being the most common cation and phosphate the fluid therapy guided by flow-based haemodynamic
most common anion. An imbalance in the serum monitors improves perioperative outcomes (Lynn
electrolyte levels has ramifications for metabolic & Winner, 2014). The anaesthetic nurse should
activity (Lynn & Winner, 2014). ensure that a wide range of cannulae and IV admin-
istration sets, as well as a variety of IV fluids, are
FLUID AND BLOOD LOSS available. The usual practice for most general
When patients arrive in the operating room, they anaesthetic procedures is to prepare a litre of IV
have usually been fasting for some hours. Fre- fluid on an administration set ready for the begin-
quently, they also endure some loss of blood and ning of the surgery. The ability to warm the IV fluid
other fluids during the surgical procedure. This can is also required, as well as a rapid infuser if there is
put them at risk of hypovolaemia, which can lead a risk of severe haemorrhage. The anaesthetist
to other complications such as tachycardia, hypo- determines the site of placement of the IV cannulae
tension and reduced urine output. after considering the type of surgery, the IV fluid
The fluid requirements of a patient undergoing requirements and the surgeon and patient’s prefer-
major surgery where considerable blood loss may ences, and the anaesthetic nurse assists with insert-
occur can be difficult to estimate; patients may ing, securing and labelling the IV lines.
experience losses of up to 20 mL/kg/hour. The cir- IV solutions available include the following:
culating nurse may be asked to provide the anaes- • Crystalloid solutions. These fluids (e.g. normal
thetist with an estimate of blood loss. In addition, saline, Ringer’s lactate solution, Plasmalyte)
are isotonic and are equivalent to plasma in
osmolarity. They are used to maintain normal
TABLE 8-6: Normal Electrolyte Values fluid requirements and replace evaporative
and third space losses (Lynn & Winner, 2014).
Sodium 137–145 mmol/L
• Colloid solutions. These fluids (e.g. albumin)
Potassium 3.2–5.0 mmol/L are hypotonic and are greater in osmolarity
than plasma. This causes the solutes to move
Chloride 98–108 mmol/L
from the bloodstream into the cells, causing
Calcium 2.2–2.7 mmol/L the cells to swell. They are used to replace
blood loss or restore intravascular volume.
Bicarbonate 22–31 mmol/L
• Blood transfusions. These are used to replace
Magnesium 0.75–1 mmol/L
lost blood volume or a specific component
SOURCE: ADAPTED FROM MURPHY (2015). (e.g. red cells, platelets or coagulation factors).
222
BLOOD TRANSFUSIONS management in order to provide effective support

If the patient’s hypovolaemia is moderate and due to the anaesthetic and possibly the surgical teams.
to loss of blood, the anaesthetist may decide to
give a blood transfusion, which, in these patients, ANAPHYLAXIS
will improve oxygen-carrying capacity. There are Anaphylaxis is an antibody-mediated reaction to
numerous potential complications with massive an antigen that can cause a sudden life-threatening
blood transfusion, including transfusion reactions, response involving the skin, respiratory and cardio-
development of coagulopathies, hypothermia and vascular systems. Anaphylaxis is a rare occurrence
sepsis (Doherty & Buggy, 2012). One of the most during anaesthesia and depends on the antigen
common causes of a transfusion reaction is the involved; for example, adverse reactions to muscle
administration of the wrong blood type. Therefore, relaxants occur in 1 in 5000 to 1 in 10,000 cases
local protocols for the checking of blood, based on (Aitkenhead, 2013). Other causes are the adminis-
national guidelines (addressed later) must be fol- tration of opioids, antibiotics, dextrans, haemaccel,
lowed. Signs and symptoms of an acute transfusion mannitol, blood and blood products or contrast
reaction include: media. More than 90% of these reactions usually
occur within 3 minutes of administration of the
• mild allergic reaction—localised urticaria,
agent and it is vital for the anaesthetic nurse to
pruritus and rash
remain with the anaesthetist at the beginning of
• severe allergic reaction—flushing, wheezing, the anaesthetic to assist in resuscitating the patient
hypotension, anaphylaxis should a reaction occur.
• febrile reaction—unexpected fever (e.g. a Treatment of anaphylaxis includes:
temperature rise >1°C; may have
• if the causative agent is known, stopping
accompanying chills and rigors).
administration immediately
Management of a suspected transfusion reac-
• administering 100% oxygen while maintaining
tion includes the following:
the airway
• Stop the transfusion immediately. • ceasing all anaesthetic drugs
• Check vital signs. • commencing fluid replacement with colloid or
• Maintain IV access. crystalloid
• Check the right pack has been given to the • treating bronchospasm with salbutamol
right patient. • administering adrenaline—bolus IV
• Notify the medical officer and transfusion 0.001 mg/kg.
service provider. Adrenaline is the drug of choice for anaphylac-
• Send freshly collected blood and urine samples tic reactions. It is a direct-acting sympathomimetic
along with the blood pack and IV line as agent that exerts its effect on alpha and beta
required by the transfusion service provider adrenoreceptors. It is a powerful cardiac stimulant
(National Blood Authority, 2011). with vasopressor and antihistamine actions. It is
Australia and New Zealand have blood transfu- also an excellent bronchodilator and has a rapid
sion services that provide guidelines for the man- onset. Once the patient has been stabilised, an
agement of patients undergoing blood transfusions adrenaline infusion may be commenced and other
(New Zealand Blood Service, 2008; National Blood drugs, such as hydrocortisone, administered. It is
Authority, 2011). recommended that the patient be followed-up once
this episode is resolved to determine the cause of
the reaction (ANZAAG, 2013; Aitkenhead, 2013).
ANAESTHETIC EMERGENCIES
Despite patients being closely monitored while MALIGNANT HYPERTHERMIA
under anaesthesia, emergencies still occur that Malignant hyperthermia (MH) is a rare, autosomal-
require prompt and effective action. The anaes- dominant muscle disorder. It is a life-threatening
thetic nurse must have knowledge of the commonly disease that is regarded as one of the true emergen-
occurring anaesthetic emergencies and their cies within the perioperative environment. The
223
condition can be triggered by any of the commonly malformations. Anaesthetic nurses must receive
used inhalational anaesthetic agents or muscle education in the anaesthetic management of pae-
relaxants, particularly suxamethonium. If left diatric patients, given the specialised equipment
untreated, MH can result in death. MH has very clear, and pharmacology requirements.
discernible clinical manifestations. These include:
• a sudden unexplained increase in end-tidal PREOPERATIVE ASSESSMENT
CO2 levels AND PREPARATION
The preoperative assessment and preparation of
• unexplained tachycardia, tachypnoea, labile
the child for surgery are important considerations,
blood pressure and arrhythmias
as it is during this time that the anaesthetist will
• hypercarbia in the spontaneously breathing evaluate the child’s medical condition, the needs of
patient the planned surgical procedure and the psychologi-
• acidosis, hypoxaemia, hyperkalaemia cal make-up of the child and family. The anaesthet-
ist also formulates the approach to induction of
• muscle rigidity, in particular of the masseter
anaesthesia, explains the possibilities regarding
(jaw) muscle
induction and, together with the anaesthetic nurse,
• fever, which is described as a late sign and helps soothe family concerns. In many operating
occurs in only 30% of MH cases suites, a parent or carer will accompany the child
• myoglobinuria, with dark-coloured urine (usually under 6 years of age) and provide comfort
to the child during induction of anaesthesia.
• mottled cyanotic skin (Marley & Calabrese,
2014). Fasting guidelines vary between healthcare
facilities and anaesthetists, but Box 8-2 lists some
TREATMENT general recommendations made by ANZCA.
Prompt diagnosis and treatment of MH can reduce
EQUIPMENT
mortality and morbidity and, even though the con-
dition is rare, knowledge of the condition and treat- The equipment used for paediatric patients (e.g.
ment is vital. Dantrolene sodium for injection is the face masks, ETTs, laryngoscopes and anaesthetic
only effective treatment for MH and functions by delivery systems) is scaled down to match the size
inhibiting calcium uptake. The anaesthetic nurse and differing anatomy of paediatric patients. It is
plays an important role in the management of an also modified to manage the different ventilator
acute episode of MH by being aware of the location pressures required.
of the MH emergency equipment and the need for • Laryngoscope. Curved or straight blades can be
it to be checked daily to ensure the availability of used, although the straight blade laryngoscope
at least 36 ampoules of dantrolene sodium for injec- is recommended in young children, because it
tion and drawing-up equipment (Nagelhout, 2014c); is designed to lift the epiglottis (which is
see Chapter 3. comparatively large and floppy in children)
under the tip of the blade, allowing a better
view of the vocal cords (see Figs 8-21 and 8-22).
PAEDIATRIC CONSIDERATIONS
• Endotracheal tubes. Traditionally, uncuffed
IN ANAESTHESIA endotracheal tubes have been preferred for use
It is beyond the scope of this text to provide detailed in children up to 8 years of age to reduce the
content on paediatric anaesthesia as it is an anaes- risk of trauma and oedema to the trachea at
thetic specialty in its own right; however, a brief the cricoid ring, which is the narrowest part of
summary of some of the key paediatric anaesthesia the airway (see Fig. 8-23). However, it is
considerations follow. becoming more common to use adjusted-size
The physiological, pharmacological and psy- cuffed ETTs to ensure adequate tidal volume
chological differences between children and adults delivery (Rieker, 2014).
must be understood in order to provide a safe • LMA. Scaled down versions of adult LMAs are
outcome, and special considerations must be given available for use in children under 5 kg in
to preterm infants and those with congenital weight.
224
BOX 8-2 » GUIDELINES FOR FASTING

Food and fluids are withheld prior to surgery as follows:
6 hours
• Solids foods
• Cow’s milk and formula
• Breast milk (children >6 months of age)
4 hours
• Breast milk (children <6 months of age)
2 hours
• Clear fluids such as water/apple juice (10 mL/kg to a maximum of 200 mL may be given)
• Medications can be administered on medical advice only
Tongue
B Vallecula
FIGURE 8-21: Laryngoscope blades used in paediatrics Epiglottis

A Seward blade
B Macintosh blade
C Miller blade
FIGURE 8-22: Position of the laryngoscope blade for paediatric intubation

ANAESTHETIC INDUCTION Source: Matsumoto & de Carvalho (2007).
Induction is usually carried out using inhalational
agents via a face mask (see Fig. 8-24) and with a
parent present, supported by the anaesthetic nurse, overhead heating devices can be used, providing
to provide comfort to the child. Face masks are radiant heating during the procedure when forced-
available with a pleasant fruity smell to provide air warming devices cannot be placed over the child.
further comfort to the child. IV access is usually Alternatively, as can be seen in Figure 8-25, a
secured following induction to reduce distress. forced-air warming device can be placed under-
neath the child (De Melo, 2013).
TEMPERATURE
Maintaining normothermia is extremely important DRUGS AND IV FLUIDS
in babies and neonates as their capacity to regulate Drugs and IV fluids are titrated according to the
temperature is not well developed. This is accom- child’s weight and are delivered through micro IV
plished by the use of warming devices similar to burettes to prevent fluid overload. Careful checking
those described earlier in the chapter. In addition, and documentation of medications used is vital, as
225
FIGURE 8-23: Uncuffed endotracheal tube

A Cuffed
B Uncuffed
Source: Julie Waters.
FIGURE 8-25: Infant underbody body blanket
Source: Reproduced with permission of 3M. Bair Hugger is a trademark of 3M.
ANAESTHETIC CONSIDERATIONS
FOR THE BARIATRIC PATIENT
The term bariatric originates from the Greek words
baros meaning weight and iatrics meaning medical
treatment. Worldwide, obesity is one of the greatest
health challenges facing Western medicine and yet
it is preventable (WHO, 2015). Recent figures indi-
cate that, based on body mass index (BMI), 3 out of
5 Australians are either overweight (BMI 25–29.9)
or obese (BMI 30–34.9 Class 1). Furthermore, 1 in
4 children are classified as obese or overweight
(Australian Institute of Health and Welfare, 2014;
FIGURE 8-24: Paediatric face masks WHO, 2015).
Source: Hagberg (2013).
PREOPERATIVE ASSESSMENT
As the world’s population increases and along with
drug calculations are often complex in neonates it the number of people who are obese, it is likely
(NSW Health, 2014). that increasing numbers of obese patients will
present to hospitals for surgery. Chapter 7 discusses
ANAESTHETIC CONSIDERATIONS some of the general issues to be considered when
managing bariatric patients in the perioperative
FOR THE ELDERLY PATIENT environment, including the importance of preop-
The ageing process brings with it physiological erative assessment for possible underlying cardiac
changes affecting all body systems that require con- and pulmonary conditions that could lead to peri-
sideration when planning anaesthetic management operative complications. In addition, patients who
of the elderly surgical patient. The anaesthetic are obese may face other complications in surgery
nurse must be cognisant of these changes in order and procedures. For example, there may difficulty
to plan the care of the patient and their special with intubation due to increased adipose tissue
needs; see Table 8-7. around the face and pharynx with secondary
226
TABLE 8-7: Patient Care Considerations and the Ageing Process
SYSTEM PATIENT CARE CONSIDERATIONS AND ACTIONS

Respiratory/airway • Narcotics and other anaesthetic agents may cause respiratory depression
Action: close observation following administration of narcotics in immediate pre- and
postoperative period
• Missing teeth or removed dentures may hinder ability to maintain bag/mask ventilation
Action: maintaining bag/mask ventilation may need additional care or dentures to remain in situ
until intubation; consider use of regional anaesthesia
Cardiovascular • Comorbidities of hypertension and ischaemic heart disease may be adversely affected by
adrenaline release during stress response
Action: awareness of current medications and interactions with anaesthetic agents, especially
anticoagulant therapy; monitor during surgery for any evidence of cardiovascular episodes;
maintain normothermia to reduce workload on the heart; consider PO care in high-dependency unit
Renal • Slower elimination of anaesthetic agents may increase recovery time from anaesthesia
Action: titration of drug dosage; monitor for respiratory depression in immediate PO period; if
renal impairment present, consider alternative anaesthetic agents
• Higher incidence of PO delirium/confusion
Action: awareness of preoperative cognitive impairment; reassure patient to time and place to
reduce effect of delirium/confusion; ensure bedrails are raised to prevent injury (see Chapters 9,
12 and 13 for further information)
Integumentary • Lack of body fat increases risk of pressure injuries and hypothermia
Action: ensure additional pressure injury management devices are used; prevent shearing forces
when transferring and positioning patient; monitor core temperature and use active warming
devices
Musculoskeletal • Osteoarthritis may affect mobility of joints and cervical spine, affecting patient positioning
and airway management
Action: pre-assessment of cervical spine to plan appropriate airway management; additional care/
equipment may be required to facilitate positioning/transfer; assess and document skin integrity
pre- and postoperatively and at handover to PACU staff
Other • Hearing deficit

Action: ensure hearing aid is present; remove mask when speaking to patient to allow lip reading
• Sight deficit
Action: patient may wish to retain glasses until induction to allow for awareness of surroundings
and aid in effective communication
• Immune system not as effective and greater susceptibility to infection
Action: strict adherence to aseptic practices; administration of antibiotics
SOURCE: ANCZA (nd) AND DODDS, FOO, JONES, KUMAR SINGH & WALDMANN (2013).
displacement of the larynx and enlarged tongue prior to any anaesthetic agents being administered
(Brammer & Forrest, 2014). Table 8-8 summarises to ensure that all appropriate difficult intubation
the main conditions associated with obesity, which equipment is available (see the discussion on dif-
require consideration when planning surgical and ficult intubation earlier in the chapter).
anaesthetic interventions.
Prior to the induction of anaesthesia, it is
AIRWAY AND VENTILATION advisable to pre-oxygenate the patient with 100%
Patients must be assessed preoperatively for the oxygen via a Hudson mask and apply positive
possibility of a difficult intubation. In the likeli- end-expiratory pressure (PEEP) (up to 10 cm H2O),
hood of a difficult intubation, it is important for to reduce the incidence of dependent atelectasis
the anaesthetic team to discuss the plan of action (partial or complete collapse of the lung).
227
TABLE 8-8: Conditions Associated with the

Pathophysiology of Obesity
SYSTEM CONDITIONS
Airway • Increased incidence of difficulty in
bag/valve mask ventilation due to
increased adipose tissue in the
pharyngeal wall
Respiratory • Decreased lung compliance due to

increased pulmonary blood flow
• Decreased chest wall compliance
due to presence of adipose tissue
• Decreased functional residual
capacity (FRC), leading to possible
hypoxia at rest, worse when
supine
• Obstructive sleep apnoea
• Obesity hyperventilation syndrome
Cardiovascular • Increased blood volume FIGURE 8-26: Hovermatt adjustable positioning device
• Cardiomyopathy Source: Courtesy Statina Healthcare.
• Hypertension
• Increased O2 consumption and
CO2 production that the ear canal is level with the sternal notch.
• Ischaemic heart disease This is typically referred to as ‘sniffing the morning
• Pulmonary hypertension air’ (see Chapter 9 for further information). An
(secondary to obstructive sleep intubation wedge or pillow can be useful to ensure
apnoea/obesity hyperventilation
syndrome) correct positioning. An example of this is the Hov-
• Thromboembolic disease ermatt intubation wedge, which can be positioned
deflated under the patient’s head and shoulders
Other • Increased risk of gastric aspiration and then inflated by the anaesthetist to the required
secondary to reflux hiatus hernia
height and position (see Fig. 8-26).
• Altered drug kinetics
• Diabetes
• Fatty liver disease
INTRAOPERATIVE CARE
• Dyslipidaemia As with any unconscious patient, caution must be
• Metabolic syndrome taken to ensure optimal patient positioning and
• Osteoarthritis protection of pressure areas. Nerve injuries can
occur more frequently in obese patients (Sabharwal
SOURCE: BRAMMER & FOREST (2014).
& Christelis, 2010). Patients placed in a steep Tren-
delenburg position are at greater risk of slipping
down the table, so placement of safety straps
Symptoms of obstructive sleep apnoea and (usually two) across the patient is advised. Operat-
obesity hyperventilation syndrome can become ing tables can generally accommodate patients up
worse in the supine position and induction of to 250 kg, although some tables can take much
anaesthesia can be particularly problematic due to greater weight. Side supports can also be fitted to
patients being unable to lie flat. Neck flexion and accommodate patients too wide for regular operat-
movement can also be hindered in an obese patient ing tables. Other equipment to be considered
and correct positioning is vital to ensure visualisa- includes extra-large calf compression stockings to
tion of the vocal cords. This can be achieved by prevent venous thromboembolism (VTE) and extra-
using extra pillows or blankets to ‘ramp’ the patient long blood pressure cuffs to ensure accurate blood
up, ensuring that their head, upper body and shoul- pressure monitoring. Transfer devices such as a
ders are substantially higher than the chest and Hovermatt should be positioned prior to the patient
228
arriving in the operating suite to facilitate safe members of the surgical team to ensure patient
transfer and positioning during the perioperative safety during all phases of anaesthetic manage-
period (Nagelhout, 2014b). ment. An in-depth knowledge of anaesthetic
modalities and agents commonly used, together
with haemodynamic monitoring and specialised
CONCLUSION anaesthetic equipment across different age groups
It is important that perianaesthesia nurses work and patients with comorbidities, can contribute to
in collaboration with the anaesthetist and other a smooth and safe anaesthetic for the patient.

1. Liver resection—monitoring
George Pocock, 63 years old, is admitted for liver resection. He had been well up until presenting to
hospital 1 month ago. His haemoglobin is 111 mmol/L.
• What are the considerations for this type of surgery and what tests need to be completed prior
to surgery? Provide rationales for your answers.
• What monitoring may be implemented and why is this important? Provide rationales for your
answers.
• During the surgery the patient loses 1500 mL of blood. What impact does this have on the
patient? How do you prepare for a blood transfusion and what checks need to be carried out?
Provide rationales for your answers.
2. Emergency laparotomy—airway management
Mrs Angela Stoop is about to arrive in the operating theatre from the emergency department to
undergo an emergency laparotomy. She last ate only 2 hours ago.
• Describe how you will prepare for this patient. Provide rationales for your answers.
• What special considerations will Mrs Stoop require during intubation? Provide rationales for
your answers.
Aitkenhead, A. (2013). Intravenous anaesthetic agents. In A.
Australian and New Zealand College of Anaesthetists Aitkenhead, I. Moppett, & J. Thompson (Eds.), (2013). Smith
www.anzca.edu.au & Aitkenhead textbook of anaesthesia (6th ed., pp. 37–55).
Australian College of Critical Care Nurses Edinburgh: Churchill Livingstone.
www.acccn.com.au Al-Shaikh, B., & Stacey, S. (2013). Essentials of anaesthetic
Australian Society of Post Anaesthesia and Anaesthesia equipment (4th ed.). Edinburgh: Churchill Livingstone.
Nurses Association of Anaesthetists of Great Britain and Ireland
www.aspaan.org.au (AAGBI). (2010). Safety guideline: Management of severe local
Difficult Airway Society anaesthetic toxicity. Retrieved from <www.aagbi.org/sites/
www.das.uk.com default/files/la_toxicity_2010_0.pdf>.
Lipid Rescue Resuscitation Australian and New Zealand Anaesthetic Allergy Group
www.lipidrescue.org (ANZAAG). (2013). Anaphylaxis management guidelines.
Retrieved from <www.anzaag.com/Mgmt%20Resources
Malignant hyperthermia .aspx>.
www.anaesthesia.mh.org.au/malignant-hyperthermia/w1/
i1001286/
(ANZCA). (2013a). PS28 Guidelines on infection control in
National Blood Authority Australia anaesthesia. Melbourne: Author.
www.blood.gov.au
New Zealand Blood Service (ANZCA). (2013b). PS18 Recommendations on monitoring
www.nzblood.co.nz during anaesthesia. Melbourne: Author.
229
Australian and New Zealand College of Anaesthetists textbook of anaesthesia (6th ed., p. 736). Edinburgh: Churchill
(ANZCA). (2014a). PS31 Guidelines on checking anaesthesia Livingstone.
delivery systems. Melbourne: Author. Dodds, C., Foo, I., Jones, K., Kumar Singh, S., & Waldmann, C.
Australian and New Zealand College of Anaesthetists (2013). Peri-operative care of elderly patients: An urgent
(ANZCA). (2014b). PS09 Guidelines on sedation and/or anal- need for change. A consensus statement to provide guid-
gesia for diagnostic and interventional, medical, dental or surance for specialist and non-specialist anaesthetists. Periop-
gical procedures. Melbourne: Author. erative Medicine, 2, 6. doi:10.1186/2047-0525-2-6.
Australian and New Zealand College of Anaesthetists Doherty, M., & Buggy, D. (2012). Intraoperative fluids: How
(ANZCA). (2014c). PS03 Guidelines for the management of much is too much? British Journal of Anaesthesia, 109, 69–79.
major regional analgesia. Melbourne: Author.
Duff, J., Walker, K., Edward, K., Williams, R., & Sutherland-
Australian and New Zealand College of Anaesthetists Fraser, S. (2014). Incidence of perioperative inadvertent
(ANZCA). (2014d). Clinical audit guide for perioperative nor- hypothermia and compliance with evidence-based recom-
mothermia. Retrieved from <www.anzca.edu.au>. mendations at four Australian hospitals: A retrospective
Australian and New Zealand College of Anaesthetists chart audit. ACORN Journal, 27(3), 16–23.
(ANZCA). (2015). PS08 Statement on the assistant for the
anaesthetist. Melbourne: Author. Fell, D., & Kirkbride, D. (2013). The practical conduct of
anaesthesia. In A. Aitkenhead, I. Moppett, & J. Thompson
Australian and New Zealand College of Anaesthetists (Eds.), Smith & Aitkenhead textbook of anaesthesia (6th ed.,
(ANZCA). (nd). Anaesthesia for the elderly. Retrieved from pp. 462–496). Edinburgh: Churchill Livingstone.
<www.anzca.edu.au/patients/frequently-asked-questions/
anaesthesia-and-the-elderly.html>. Gavel, G., & Walker, R. (2012). Algorithm for management of
laryngospasm. Royal Manchester Children’s Hospital Man-
Australian College of Operating Room Nurses (ACORN). chester, UK.
(2016). ACORN standards for perioperative nursing including
nursing roles, guidelines, position statements and competency Hagberg, C. Benumof and Hagberg’s airway management
standards. Adelaide: Author. (3rd ed., pp. 324–339). Philadelphia: Saunders.
Australian Commission on Safety and Quality in Health Care Hagberg, C., & Artime, C. (2015). Airway management in the
(ACSQHC/the Commission). (2011). National recommenda- adult. In R. Miller (Ed.), Miller’s anesthesia (8th ed., pp. 1647–
tions for user-applied labelling of injectable medicines, fluids 1683). San Francisco: Elsevier.
and lines. Retrieved from <www.safetyandquality.gov.au/ Heard, A. (2013). Appendix 12. Standards for can’t intubate
wp-content/uploads/2012/02/38766-IVlines.pdf>. can’t oxygenate (CICO). Retrieved from <http://www.anzca
Australian Commission on Safety and Quality in Health .edu.au/fellows/continuing-professional-development/
Care (ACSQHC/the Commission). (2012). National Safety and pdfs/Appendix_12_CICO_Standard_131210.pdf>.
Quality Health Service Standards. Retrieved from <www
Heiner, J., & Gabot, S. (2014). Airway management. In
.safetyandquality.gov.au>.
J. Nagelhout & K. Plaus (Eds.), Nurse anesthesia (5th ed.,
Australian Institute of Health and Welfare (AIHW). (2014). pp. 423–469). St Louis: Elsevier.
Australia’s health report: Body weight, exercise and nutrition.
Canberra: Author. Hunter, J. (2013). Muscle function and neuromuscular block-
ade. In A. Aitkenhead, I. Moppett, & J. Thompson (Eds.), Smith
Bogod, D. (2012). Editorial. The sting in the tail: Antiseptics & Aitkenhead textbook of anaesthesia (6th ed., pp. 87–104).
and the neuraxis revisited. Anaesthesia, 67, 1305–1320. Edinburgh: Churchill Livingstone.
Brammer, A., & Forrest, M. (2014). Anaesthesia in the obese
Jones, N., Long, L., & Zeitz, K. (2011). The role of the nurse
patient. Anaesthesia and Intensive Care Medicine, 15(10),
sedationist. Collegian (Royal College of Nursing, Australia),
446–448.
18(3), 115–123.
Bryant, B., & Knights, K. (2015). Pharmacology for health
professions (4th ed.). Sydney: Elsevier. Knoop, K. J., Storrow, A. B., Stack, L. B., & Thurman, R. J. (Eds.).
(2010). The atlas of emergency medicine (3rd ed.). New York:
Campbell, B. (2015). Anesthesia. In J. Rothrock & D. McEwen McGraw-Hill.
(Eds.), Alexander’s care of the patient in surgery (15th ed.,
pp. 124–154). St Louis: Elsevier. Kossick, M. (2014a). Inhalational anesthesia. In J. Nagelhout
& K. Plaus (Eds.), Nurse anesthesia (5th ed., pp. 55–103).
Cook, T. (2012). Airway management equipment. In A. Davey
St Louis: Elsevier Saunders.
& A. Diba (Eds.), Ward’s anaesthetic equipment (6th ed.,
pp. 139–205). Edinburgh: Elsevier. Kossick, M. (2014b). Clinical monitoring 1: Cardiovascular
Cook, T., & Simpson, T. (2013). Management of the difficult system. In J. Nagelhout & K. Plaus (Eds.), Nurse anesthesia
airway. In A. Aitkenhead, I. Moppett, & J. Thompson (Eds.), (5th ed., pp. 292–311). St Louis: Elsevier Saunders.
Smith & Aitkenhead textbook of anaesthesia (6th ed., Langton, J. (2013). Day surgery anaesthesia. In A. Aitkenhead,
pp. 560–567). Edinburgh: Churchill Livingstone. I. Moppett, & J. Thompson (Eds.), Smith & Aitkenhead text-
Coventry, D. (2013). Local anaesthetic techniques. In book of anaesthesia (6th ed., pp. 560–567). Edinburgh:
A. Aitkenhead, I. Moppett, & J. Thompson (Eds.), Smith & Churchill Livingstone.
Aitkenhead textbook of anaesthesia (6th ed., pp. 514–549). Lynn, R., & Winner, L. (2014). Fluids, electrolytes and blood
Edinburgh: Churchill Livingstone. component therapy. In J. Nagelhout & K. Plaus (Eds.), Nurse
De Melo, E. (2013). Paediatric anaesthesia. In A. Aitkenhead, anesthesia (5th ed., pp. 382–402). St Louis: Elsevier
I. Moppett, & J. Thompson (Eds.), Smith & Aitkenhead Saunders.
230
Marley, R., & Calabrese, T. (2014). Outpatient anesthesia. In Pfenninger, J. L., & Fowler, G. C. (2011). Pfenninger and Fowl-
J. Nagelhout & K. Plaus (Eds.), Nurse anesthesia (5th ed., pp. er’s procedures for primary care (3rd ed.). St Louis: Mosby.
930–951). St Louis: Elsevier Saunders. Rieker, M. (2014). Respiratory anatomy, physiology, patho-
Marley, R., Calabrese, T., & Thompson, K. (2014). Preoperative physiology and anesthetic management. In J. Nagelhout
evaluation and patient preparation. In J. Nagelhout & & K. Plaus (Eds.), Nurse anesthesia (5th ed., pp. 590–661).
K. Plaus (Eds.), Nurse anesthesia (5th ed., pp. 335–382). St Louis: Elsevier Saunders.
St Louis: Elsevier Saunders. Royal College of Anaesthetists and the Association of Anaes-
Matsumoto, T., & de Carvalho, W. B. (2007). Tracheal intuba- thetists of Great Britain and Ireland. (2014). 5th national
tion. Jornal de Pediatria, 83(2 Suppl.), S83–S90. audit project. Retrieved from <www.nationalauditprojects
.org.uk/NAP5report>.
Murphy, E. (2015). Patient safety and risk management. In
J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient Sabharwal, A., & Christelis, N. (2010). Anesthesia for bariatric
in surgery (15th ed., pp. 16–45). St Louis: Elsevier Saunders. surgery. Continuing Education in Anaesthesia, Critical Care &
Pain, 10(4), 99–103. doi:10.1093/bjaceaccp/mkq020.
Nagelhout, J. (2014a). Local anesthetics. In J. Nagelhout
& K. Plaus (Eds.), Nurse anesthesia (5th ed., pp. 125–140). Scott, S. (2013). Clinical measurement and monitoring. In A.
St Louis: Elsevier Saunders. Aitkenhead, I. Moppett, & J. Thompson (Eds.), Smith & Aitken-
head textbook of anaesthesia (6th ed., pp. 312–356). Edin-
Nagelhout, J. (2014b). Obesity and anesthesia practice. In burgh: Churchill Livingstone.
J. Nagelhout & K. Plaus (Eds.), Nurse anesthesia (5th ed.,
pp. 1050–1069). St Louis: Elsevier Saunders. Tasch, M., & Langeron, O. (2013). Aspiration prevention and
prophylaxis: Preoperative considerations. In C. Hagberg
Nagelhout, J. (2014c). Neuromuscular blocking agents, (Ed.), Benumof and Hagberg’s airway management (3rd ed.,
reversal agents, and their monitoring. In J. Nagelhout & pp. 265–279). St Louis: Elsevier Saunders.
K. Plaus (Eds.), Nurse anesthesia (5th ed., pp. 158–183).
St Louis: Elsevier Saunders. Thompson, C. (2012). Anaesthetic gas supplies. Lecture notes,
University of Sydney Nuffield Department of Anaesthetics.
Naguib, M., Lien, C., & Meistelman, C. (2015). Pharmacology
Tiziani, A. (2013). Harvard’s nursing guide to drugs (9th ed.).
of neuromuscular blocking drugs. In R. Miller (Ed.), Miller’s
Sydney: Elsevier.
Anesthesia (8th ed., pp. 958–994). Philadelphia: Elsevier.
Williams, A. (2014). Anesthesia for therapeutic and diagnostic
National Blood Authority. (2011). Patient blood management
procedures. In J. Nagelhout & K. Plaus (Eds.), Nurse anesthesia
guidelines. Retrieved from <www.blood.gov.au/national
(5th ed., pp. 1260–1286). St Louis: Elsevier Saunders.
-standard>.
World Health Organization (WHO). (2015). Factsheet No
New Zealand Blood Service (NZBS). (2008). Transfusion medi- 3111: Obesity and overweight. Retrieved from <www.who.int/
cine handbook. Auckland: NZBS. mediacentre/factsheets/fs311/en>.
New Zealand Nurses Organisation (NZNO). (2014). Regis-
tered nurse assistant to the anaesthetist. Knowledge and Skills FURTHER READING
Framework. Retrieved from <www.nzno.org.nz/groups/ Acott, C. (2011). Cricoid pressure: Is there any evidence?
colleges/perioperative_nurses_college/resources/ ANZCA Australian Anaesthesia invited papers and selected
registerednurse_assistant_to_the_anaesthetist>. continuing education lectures. Melbourne: ANZCA.
NSW Agency for Clinical Innovation (ACI), Anaesthesia Peri- Aitken, L., Marshall, A., & Chaboyer, W. (2012). ACCCN’s critical
operative Care Network. (2013). Safe procedural sedation care nursing. Melbourne: Australian College of Critical Care
project phase 1: Diagnostic and solution design report. Sydney: Nurses.
Author.
Lawyers and Legal Services Australia. (2010). Shocking case
NSW Health. (2010). Safety notice: SN 010/10. Correct identi- of medical negligence. Lawyers and Legal Services Australia.
fication of medication and solutions for epidural anaesthesia Retrieved from <www.legallawyers.com.au/insurance-law/
and analgesia. Sydney: Author. shocking-case-of-medical-negligence>.
NSW Health. (2011). PD2011_060: Central venous access MacGregor, K. (2013). A waking nightmare: How can we
device insertion and post insertion care. Sydney: Author. avoid accidental awareness during general anaesthesia?
NSW Health. (2014). GL2014_009: Standards for paediatric Journal of Perioperative Practice, 23(9), 185–190.
intravenous fluids. Sydney: Author. Munk, L., Anderson, L., & Gogenur, I. (2013). Emergence
Odom- Forren, J. (2012). Drain’s perianaesthesia nursing: A delirium. Journal of Perioperative Practice, 23(11), 251–254.
critical approach (6th ed.). St Louis: Saunders. Olsen, R., Pellegrini, J., & Movinsky, B. (2014). Regional
Pandit, J., & Cook, T. (Eds). (2014). Accidental awareness during anaesthesia: Spinal and epidural anesthesia. In J. Nagelhout
general anaesthesia in the United Kingdom and Ireland. & K. Plaus (Eds.), Nurse anesthesia (5th ed., pp. 1070–1101).
NAPP5 Report and Findings. Royal College of Anesthetists Missouri: Elsevier.
and the Association of Anesthetists of Britain and Ireland. O’Shaughnessy, K. (2012). Cholinergic and antimuscarinic
Retrieved from <www.nationalauditprojects.org.uk>. (anticholinergic) mechanisms and drugs. In P. Bennett, M.
Patty, A. (2015). Cardiac arrest during cosmetic surgery: Brown, & P. Sharma (Eds.), Clinical pharmacology (11th ed.,
Overdose of local anaesthetic likely. Sydney Morning Herald, pp. 372–381). Edinburgh: Elsevier.
28 July. Retrieved from <www.smh.com.au/nsw/cardiac Singh, A. (2014). Strategies for the management and avoid-
-arrest-during-cosmetic-surgery-overdose-of-local ance of hypothermia in the perioperative environment.
-anaesthetic-likely-20150723-gijcn8.html#ixzz3hcudyFNU>. Journal of Perioperative Practice, 24(4), 75–78.
231
Chapter 9
INTRAOPERATIVE PATIENT CARE
LOIS HAMLIN AND SHARON MINTON

EDITOR: LOIS HAMLIN
LEARNING OUTCOMES
• Understand the anatomical and physiological concepts related to patient positioning
• Explore the neurovascular and integumentary consequences associated with anaesthesia and surgery,
and ways to manage them
• Identify the nature and incidence of perioperative pressure injuries and ways to prevent them
• Examine several core nursing interventions aimed at ensuring patient safety, including the use of
tourniquets, the WHO Surgical Safety Checklist and the surgical count
• Discuss best practice when handling tissue specimens for pathology
KEY TERMS
accountable items
inadvertent perioperative hypothermia
patient positioning
patient safety
patient transfer
pressure injuries
skin integrity
surgical count
Surgical Safety Checklist
tissue specimens
tourniquets
venous thromboembolism
232
CHAPTER 9 | Intraoperative patient care
• the patient’s age, height and weight

INTRODUCTION
• the patient’s nutritional status
This chapter explores several key concepts and
issues that are directly relevant to patient safety • patient history, including previous surgeries
during anaesthesia and surgery. Where feasible, and comorbidities
these are discussed in the context of the patient • the patient’s mobility and range of motion
journey; however, the need for brevity militates • skin integrity and pressure injury risk
against strict adherence to this concept. The chapter assessment
discusses the prevention of venous thromboembo-
lism (VTE), maintenance of normothermia, and • patient exposure
ensuring the correct patient and site of surgery. It • areas of patient discomfort, both physical and
also examines management of accountable items psychological
used during surgery, a primary nursing responsibil-
• the surgical procedure to be undertaken
ity. Pertinent anatomical and physiological aspects
associated with correct patient positioning for the • the length of time the patient is to remain in
intended surgery are discussed, along with nursing the position
interventions aimed at keeping patients unharmed. • the requirements of the surgeon, the
The perioperative environment and related tech- anaesthetist and others for access to the
nologies, such as the use of tourniquets, pose their surgical site/airway
own unique risks; these are explored, along with
• the presence of drains, catheters, intravenous
methods to eliminate, reduce or control them.
lines or other items/equipment
Finally, the chapter looks at correct identification
and handling of specimens. • the type and availability of transferring
equipment
The risk that surgery poses should not be under-
estimated, with adverse events occurring more • the available team members (Australian
commonly among surgical patients than among College of Operating Room Nurses [ACORN],
other patient cohorts (World Health Organization 2016a; Heizenroth, 2015).
[WHO], nd). Several of these adverse events origi- These factors will influence the team’s preparation
nate in the perioperative environment. and the equipment required to carry out the trans-
fer. The patient’s age and mobility have a bearing
on the resources required; for example, a mobile
patient may be able to move to the operating table
PATIENT POSITIONING unaided. In contrast, an elderly, frail or less mobile
To ensure patient safety and the safety of surgi- patient will require greater assistance from the sur-
cal team members during patient transfer and gical team and equipment. Particular care, plan-
positioning, a planned approach is needed. This ning and/or equipment are required to manage
includes identification and verification of the paediatric patients, frail elderly patients (those
correct patient, correct site and correct procedure; over 80 years of age) and obese patients, especially
patient assessment; consideration of the surgical the morbidly obese (Phillips, 2013); see Feature box
position required; the availability and preparation 9-1 and Research box 9-2 later in the chapter.
of positioning equipment; and the transfer method Care must be taken when transferring patients
to be used. Patient assessment should comprise with intravenous (IV) cannulae, IV infusions,
patient and carer discussion, physical examination drains, catheters or other items already in place.
and review of the patient’s medical records (Asso- Their dislodgement can create discomfort (or
ciation of periOperative Registered Nurses [AORN], worse) and re-siting them delays progress. The
2015a; Heizenroth, 2015; Phillips, 2013). planned procedure, the patient’s condition, and
staff and equipment availability will determine
PATIENT TRANSFER whether the initial transfer occurs while the patient
Before patient transfer (lateral transfer) from a is conscious or following induction of anaesthesia.
trolley or bed to the operating table (and vice versa) Additionally, consideration must be given to
the following must be considered: patients who need repositioning intraoperatively
233
FEATURE BOX 9-1 » TRANSFERRING AND POSITIONING THE BARIATRIC PATIENT
The most commonly used measure to classify a patient’s weight is body mass index (BMI) (not-
withstanding its limitations—Reynolds [2013]). BMI is calculated by dividing weight in kilograms
by height in metres squared (kg/m2). Currently, about 62.8% of Australian adults are overweight
or obese (Australian Bureau of Statistics [ABS], 2013), while in New Zealand, 34% of adults are
overweight and 31% are obese. Among the Māori and Pacific Islander populations, the figures for
obesity are 48% and 68%, respectively (New Zealand Ministry of Health, 2013). These data reflect
an upward trend that is worrisome.
As an individual’s BMI increases, so do the risks associated with anaesthesia and surgery. These
include:
• difficulty accessing and controlling the airway, and reduced tolerance for positioning due to
decreased pulmonary function
• greater risk of peripheral nerve and pressure injuries
• increased risk of VTE
• increased risk of compartment syndrome from overly tight BP cuffs, calf compression
devices and so forth
• greater risk of a fall (Heizenroth, 2015).
Bariatric patients require specialised lifting equipment such as air-assisted lateral transfer devices
(e.g. HoverMatt) with adequate numbers of staff to perform the transfer safely (ACORN, 2016b).
Weight tolerance of beds and positional equipment needs to be ascertained and deemed appro-
priate for use prior to patient arrival. Patients may require modified positioning to minimise risk,
such as ‘ramping’ the torso to achieve airway alignment (Heizenroth, 2015). Special care must be
taken to ensure that skin folds are not trapped under the patient (Spruce & Van Wicklin, 2014).
In addition, excess soft tissue can hamper exposure of the operative field and it may need to be
retracted with adhesive tape (Bozzio, Gala, Villasenor, Hao & Mauffrey, 2014; National Pressure
Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance
[NPU/EPU/PPPIA], 2014). While many operating suites currently do not provide bariatric surgical
services, increasingly operating suites will be required to provide for greater numbers of over-
weight and obese patients.
(e.g. during bilateral hip replacement), as disorgan- At all times, the anaesthetist must be able to ensure
ised or unplanned movements during repositioning ventilatory adequacy, have IV access and address
increase the risk of: requirements for haemodynamic monitoring. The
• physical damage to the patient surgeon needs access to the surgical site and the
instrument nurse needs to be able to maintain an
• damage to the initial operative site aseptic field throughout the procedure (Phillips,
• airway compromise 2013). Consequently, the patient’s position is often
• additional and unnecessary exposure to a compromise between competing demands for
anaesthesia surgical access balanced against the patient’s need
for safety and protection. The perioperative nurse’s
• disconnection, displacement or dislodgement role within the surgical team is a crucial one. Con-
of anaesthetic tubing or monitoring tinuous monitoring of the patient and patient
(Aitkenhead, 2013). advocacy are required to help prevent positioning-
Surgeon, anaesthetist and other staff require- related injuries (ACORN, 2016b; Spruce & Van
ments for patient access also need to be considered. Wicklin, 2014).
234
TRANSFER METHODS AND RATIONALES

Clear communication and coordinated care are
essential, with all surgical team members taking
equal responsibility for maintaining patient safety
during transfer. The duty of the perioperative nurse
is to assess the surgical environment and the
patient and ensure that the most appropriate trans-
fer equipment, positional aids and staff are availa-
ble. The anaesthetist, who has responsibility for the
patient’s airway, generally coordinates the transfer
(Phillips, 2013) and directs the team, as well as the
patient if the latter is conscious. When the patient
is anaesthetised and/or unconscious, coordination
FIGURE 9-1: Air-assisted lateral transfer device
of the transfer is managed by the anaesthetist in Source: Heizenroth (2015).
most instances, as maintenance of a patent airway,
ventilation and cerebral circulation are the main
priorities (AORN, 2015a; Phillips, 2013). airway and supports the head. As the patient has
When a conscious patient is able to participate no muscle control, limbs need safeguarding so they
in the move, interventions needed to secure a safe do not overhang the operating table, predisposing
transfer include: them to injury. The patient’s arms are secured
• giving clear directions and explanations across their chest or by their side and their legs are
supported and moved in alignment with the body.
• ensuring there is a minimal gap between the These patients will have IV access and monitoring
trolley and the operating table devices established and care must be taken not to
• using the brakes on both the trolley and the obstruct or dislodge them.
operating table
• making sure the patient’s gown is loosened
COMPLICATIONS
and not caught in the trolley/bed side rails Injuries associated with patient transfer include
skin tears, joint dislocations, muscle and/or nerve
• placing team members on either side of the
damage, obstruction or dislodgement of IV infusion
moving patient to assist with lateral transfer
tubing or catheters, and patient falls (ACORN,
and to prevent the patient from sustaining
2016a). These complications can also occur when
a fall.
the patient is being positioned or during the course
Patients should be instructed by a staff member of the surgery. Staff members are also at risk of
who directs them to feel for the sides of the operat- injury and many hospitals and other facilities have
ing table as they move across, so that they can be a ‘no lift’ policy in place, so nursing staff must
confident they are centrally located. The trolley or familiarise themselves with the particular policy for
bed should not be moved away until the patient is their organisation.
securely positioned and confirms this.
Complications are likely to arise if:
If the patient has reduced mobility and cannot
• surgical team members are too few in number
move independently, then a lateral transfer device
or are inexperienced
such as a patient slide board, patient slide sheet or
mechanical device, such as an air-assisted lateral • the appropriate patient-lifting/transfer device,
transfer device (e.g. HoverMatt) is needed (see positional aids and/or pressure-redistribution
Fig. 9-1). These devices enable patient transfer support devices are absent, incorrectly used or
while reducing the risk of injury to staff members. are not used at all (ACORN, 2016a; Waters,
A minimum of four staff members is generally Baptiste, Short, Plante-Mallon & Nelson, 2011).
required for the safe transfer of these patients, Surgical team members require training in
using the safety precautions described above. manual handling, as well as in-service education
When transferring an unconscious or anaesthe- when new mechanical devices are commissioned
tised patient, the anaesthetist manages the patient’s (ACORN, 2016b, 2016c). They must also be aware of
235
the potential adverse events associated with trans- surgery takes, the greater the risk (AWMA,
ferring and positioning patients so that they can 2012)
enact prevention strategies and lessen the risk of • type of operating table used, mattress or
such events (ACORN, 2016a). overlay, and positioning aids required/
available (McInnes, Jammali-Blasi, Bell-Sayer,
PATIENT POSITIONING Dumville & Cullum, 2012)
Correct patient positioning is essential to per-
• type of anaesthetic given
forming a safe and unconstrained surgical pro
cedure. Patients are positioned so that: • planned surgical procedure (ACORN, 2016a).
• there is correct musculoskeletal alignment Integumentary system
• undue pressure on nerves, skin over bony The integumentary system can be injured as a
prominences, earlobes, eyes, breasts and result of the physical forces used to maintain the
external genitalia is avoided surgical position, as well as the way the patient is
moved. These physical forces include pressure,
• there is provision for adequate thoracic shear, friction and moisture (AWMA, 2012). Addi-
excursion tional risk factors for pressure injuries specific to
• arteries and veins are not occluded individuals undergoing surgery include:
• other medical conditions, deformities and/or • increased hypotensive episodes during
previous surgery are considered surgery
• patient modesty is preserved (ACORN, 2016a). • low core temperature during surgery
Patients are immobile during surgery and unable to • reduced mobility on day one postoperatively
change and control their body position or complain (NPU/EPU/PPPIA, 2014).
of pain. Consequently, their risk of developing an Pressure
injury and other complications, such as VTE or pul-
monary dysfunction is increased (ACORN, 2016a; Pressure is the force placed on the patient’s under-
Phillips, 2013). lying tissues. In order to avoid injury, normal capil-
lary interface pressure (23–32 mmHg) must be
maintained (Phillips, 2013). Above these levels,
ANATOMICAL AND PHYSIOLOGICAL
CONSIDERATIONS FOR PATIENT POSITIONING blood flow and tissue perfusion become restricted
(see Fig. 9-2).
A patient’s tolerance of the stresses imposed by
the surgical intervention depends significantly on Pressure can be created by the patient’s own
the normal functioning of the vital systems, and body weight as gravity presses it downwards.
each body system must be considered when plan- This can be ameliorated by the use of pressure-
ning the patient’s position for surgery. The goals of redistribution support surfaces (Mulligan, Prentice
positioning include the prevention of injury from & Scott, 2011; NPU/EPU/PPPIA, 2014). A high-
pressure, crushing, stretching, pinching or obstruc- specification reactive (constant low pressure) foam
tion (Australian Wound Management Association mattress or an active (alternating pressure) mat-
[AWMA], 2012). The development of such injuries tress is recommended on the operating table for
is influenced by the: high-risk patients (AWMA, 2012; Huang, Chen &
Xu, 2013; McInnes et al., 2012). Particular atten-
• position required for the procedure—all tion must be given to ensure that pressure on the
positions pose a risk, some more so than others heels is offloaded with the knees in slight flexion
• patient’s health status and physical (NPU/EPU/PPPIA, 2014) and all bony prominences
condition—the very young, the elderly and are padded (AWMA, 2012).
debilitated patients present greater positional Additional pressure can also come from the
challenges (AWMA, 2012), as do obese patients weight of devices that are placed on or against the
(Bozzio et al., 2014) irrespective of any other patient, such as instruments, drills or Mayo stands,
underlying pathophysiology or surgical team members leaning on the patient.
• estimated length of time for the procedure and Likewise, bed attachments or positioning aids can
the associated immobility—the longer the press against or pinch parts of the patient’s body.
236
Pressure
Epidermis
Skin
Dermis
Subcutaneous fat
Deep fascia
Muscle
Periosteum
Bone
FIGURE 9-2: Tissues affected by pressure, which causes deep tissue damage and necrosis
Source: Phillips (2013).
Consequently, it is necessary for the surgical team Pressure injury prevention

to be vigilant when using any of these devices, as The National Pressure Ulcer Advisory Panel
well as being mindful when assisting during surgery. (NPUAP), the European Pressure Ulcer Advisory
Panel (EPUAP) and the Pan Pacific Pressure Injury
Shear Alliance (PPPIA) have collaborated to develop evi-
Shear is the movement of underlying tissue when dence-based recommendations for the prevention
the skeletal structure moves while the skin remains and treatment of pressure injuries. Their clinical
stationary. A parallel force creates shear. This occurs practice guideline was developed using a rigorous
when, for example, the head of the operating table scientific methodology to appraise available
is lowered and the patient is placed in a head-down, research and make 575 evidence-based recommen-
supine position (Trendelenburg). As gravity pulls dations. Their recommendations for perioperative
the skeleton down, the underlying tissues are patients are listed in Research box 9-1.
stretched, folded or torn as they move with it. This The magnitude of the burden associated with
can result in vascular occlusion as well as damaging pressure injuries should not be underestimated. In
the (static) skin. Australia, the incidence of hospital-acquired pres-
sure injuries ranges from 6.3% to 18% (Mulligan
Friction et al., 2011) and many of these originate in the
Friction is the force produced when two surfaces operating room (Australian Commission on Safety
rub against each other. Friction to the patient’s skin and Quality in Health Care [ACSQHC/the Commis-
occurs when the body is dragged across the operat- sion], 2012a). The significance of pressure injuries
ing table rather than lifted; this can abrade, burn or is reflected in the National Standard developed by
tear the patient’s skin and encourage the develop- the Commission (2012a). Furthermore, some state-
ment of pressure ulcers (NPU/EPU/PPPIA, 2014). based health departments are initiating financial
penalties for hospital-acquired pressure injuries
Moisture (Mulligan et al., 2011).
The presence of moisture, such as prepping solu- Perioperative nurses have a key role and respon-
tion pooling underneath the patient, can result in sibility related to pressure injury prevention. This
maceration of the skin and increase the likelihood involves the use of a validated pressure injury risk
of damage to it (AWMA, 2012) and requires meas- assessment tool that will assist in determining the
ures to prevent its occurrence. degree of individual patient risk. The outcomes of
237
RESEARCH BOX 9-1: NPU/EPU/PPPIA Recommendations for Perioperative Patients
1. Consider additional risk factors specific to individuals undergoing surgery.

2. Use a high specification reactive or alternating pressure support surface on the operating table for
all individuals identified as being at risk of pressure ulcer development.
3. Position the individual in such a way as to reduce the risk of pressure ulcer development during
surgery.
4. Ensure that the heels are free of the surface of the operating table. Ideally, heels should be free of
all pressure—a state sometimes called ‘floating heels’.
5. Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute
the weight of the leg along the calf without placing pressure on the Achilles tendon. Positioning the
knees in slight flexion prevents popliteal vein compression and decreases the risk of perioperative
DVT.
6. Consider pressure redistribution prior to and after surgery.
SOURCE: NPU/EPU/PPPIA (2014).
pressure injury risk assessment subsequently Nervous system

inform the measures needed to prevent patient The action of anaesthetic agents, which cause a loss
injury intraoperatively. However, there is limited of sensation and protective reflexes, increases the
evidence that perioperative nurses know about or likelihood of nerve injury occurring. In most cases
use such tools (or other perioperative assessment these injuries occur due to the formation of lesions,
activities) (Sutherland-Fraser, McInnes, Maher & secondary to damage incurred by undue pressure,
Middleton, 2012). There are, however, notable stretching, twisting and pinching of nerves, which
exceptions. Figure 9-3 is an example of a periopera- may be temporary or permanent, depending on the
tive nursing care record that addresses the need to severity of damage sustained. The ulnar nerve is the
assess skin integrity intraoperatively, as well as nerve most frequently injured during the periop-
providing options to record information about erative period, followed by injury to the brachial
patient positioning and the use of pressure injury plexus (Nilsson, 2013). Table 9-1 outlines nerves
prevention devices. that are commonly injured and the causes (Heizen-
roth, 2015).
Musculoskeletal system
During surgery and anaesthesia, normal protective Cardiovascular system
reflexes (e.g. pain and pressure receptors) are Anaesthetic agents can affect the cardiovascular
depressed in the patient and muscle tone is lost system by causing peripheral vasodilation and sub-
as a result of the action of the pharmacological sequent pooling of blood in the extremities, result-
agents used. Consequently, patients are no longer ing in hypotension (Heizenroth, 2015). Patient
able to respond normally if, during positioning and positioning can further affect this; for example, a
surgery, their muscles, tendons and/or ligaments head-up, supine (reverse Trendelenburg) position
are overstretched, twisted or strained; or body will cause blood to pool in the lower extremities.
alignment (particularly for the patient’s range of Consequently, the movement of patients into and
motion) is not maintained. Injury can also occur if out of these positions must be coordinated and
dependent limbs fall over the edge of the operating unhurried. Positioning should be postponed if the
table. It is advisable to use a body strap/safety belt patient’s blood pressure is unstable. Pregnant
to secure the patient to the operating table (Nilsson, women, obese patients and patients with large
2013). Bariatric patients may need two straps. Text continued on p. 242
238
MRN SURNAME
GIVEN NAME(S)
DOB SEX AMO WARD/CLINIC

Perioperative Nursing Care Record
ALERTS / ALLERGIES:
(Please enter information or affix Patient Information Label)
DATE THEATRE OPERATION TYPE Infection Control Precautions
Emergency Elective
Contact Airborne/Droplet N/A
Clinical Handover N/A Ward to Anaes to OR to
Anaes OR Recovery Intra Operative Skin Integrity
Verbal handover Frail / fragile Intact Skin tear
Notes Pressure Injury: Stage 1 2 3 4
Dentures Not observed
Xrays Comments/Location:
Glasses / lenses
Hearing aids
Jewellery / watches Waterlow Risk Category Day only
Bagged belongings <10 15+ High risk
(Indicate Number of bags) 10+ At risk 20+ Very high
Transfer to Op Table Transfer from Op Table Patient Position Eyes/Ears
Left Right
PERIOPERATIVE NURSING CARE RECORD

Self with assistance Self with assistance Supine Eyes lubricated: Yes No
Pat slide Pat slide Lithotomy Eyes taped: Yes No Left Right
BINDING MARGIN - NO WRITING
St. Vincent's Hospital Sydney Limited
Slide sheet Slide sheet Right lateral Eyes padded: Yes No Left Right
Hovermatt Hovermatt Left lateral Eyes covered by drape: Yes No Left Right
ABN 77054 038 872
Other Other Prone Ear pack: Yes No Left Right

Beach chair
Positioning Equipment / Pressure Injury Prevention Devices
J board (with foam): Left Right Own bed Lithotomy stirrups Gel head ring
Arm board: Left Right Standard mattress Yellowfins Gel horseshoe
Arm rest : Left Right Gel mat: Full Half Leg supports Mayfield horseshoe
Arm wrap: Left Right Andrews/Jackson table Bed/thigh straps Mayfield frame with
Hand table: Left Right Traction table Pillow under legs skull pins
GuardaHeel: Left Right Bean bag Wedge pillow Eye pillow
Lateral supports: Back Front Beach chair Prone pillows Prone face pillow
Gel pads: Site Harbour Bridge
Pillows: Site Comments/Other:
Foam: Site
Sandbags: Site
Anti DVT Appliance Warming Devices Diathermy / Plate
Anti DVT Appliance
Anti embolic stockings Yes No Left Righ t Yes No Plate Site 1:
Calf compressors Yes No Left Righ t Fluid warmer Warm air blanket Left Right
Mattress warmer
Tourniquet Skin Prep Catheterisation Plate Site 2:
Site 1: Left Right Povidone lodine Yes No Insitu Left Right
Povidone lodine + In/Out Volume: mls
Solutions / Medications
alcohol
Pressure: mm/Hg Normal saline Chlorhexidine Diathermy not used
Povidone lodine 1/2 Lignocaine 2% gel Lubricant
ON: OFF: No plate required
SVH 01/15 8807
strength Water for balloon mls

Site 2: Left Right
Chlorhexidine Catheter size / type: Lead Protection
P380
Nil
Pressure: mm/Hg Inserted by: Yes No N/A
ON: OFF: Removed in OR
SV013*****
G:SVHFORMS:2013:Perioperative.Nursing.Care.Record NO WRITING Page 1
FIGURE 9-3: Perioperative nursing care record
Source: St Vincent’s Hospital.
Continued
239
*SPECIMEN DETAILS (totals which applies to each specimen) Fresh Histo

Fresh Frozen Micro Frozen Garvan
Micro Hist Garvan
Cyto Other
*'Additional Specimens' Form (P380.1) completed Yes No
Sterilisation / Disinfection Tracking

Point of Use Processing
Item Serial No.
tion
Bronchoscope
Gastroscope
rilisa e
Colonoscope ste er
lace el/s h
CMAC P lab
Savary Gilliard Dilators
Other:
Medivator - Cycle No.
St. Vincent's Hospital Sydney Limited

DRAINS: Size Location Sutured Suction Shortened
(Please tick applicable)
ABN 77054 038 872

Thoracic 28FG Right Pleural Yes No
Thoracic 28FG Left Pleural Yes No
Thoracic 28FG Mediastinal Yes No
Thoracic 28FG Pericardial Yes No
Blake Yes No
Survac (Redivac) Yes No
Yes No
Yes No
Yes No
Medications/ irrigations provided to surgical team / sterile field
Water for irrigation Ringers Chloramphenicol ointment Glycine 1.5% ________ mls Duovisc BSS
Co-phenylcaine forte spray Xylocaine 2% topical spray SurgiGel Balanced Salt Solution with adrenaline
Normal saline 0.9% for irrigation ________ mls Normal saline 0.9% IV
Dressing / additional care details
Pacing Wires Post Operative Patient Checks
Atrial Diathermy plate site checked: Skin integrity intact Skin integrity not observed
Ventricular N/A Yes No abnormality *Skin tear *Pressure Injury: Stage 1 2 3 4
N/A Comments:
*Location:
Instrument Nurse Name: Signature: Time:

Page 2
240
TABLE 9-1: Peripheral Nerves at Risk of Injury
NERVE INVOLVED CAUSE OF DAMAGE

Femoral nerve • Inappropriate positioning of abdominal or vaginal retractors
• Inappropriate positioning of the patient in the lithotomy position, resulting in over-
stretching of the nerve (see Fig. 9-4)
• Team members leaning against patient thighs
• Slippage of pneumatic tourniquet cuff.
Sciatic nerve • Hyperflexion of the hip joint, particularly when the patient’s legs are lifted incorrectly
during surgery (see Fig. 9-5).
Common peroneal • Pressure of the stirrups or leg-holding devices on the patient’s calf when in the lithotomy
nerve position (all variants)
• Failure to place a pillow between the patient’s legs when lateral position used
• Incorrectly sized or inappropriate application of sequential compressive devices
• Pressure from devices placed under the patient’s knees (see Fig. 9-6)
Median, radial and • Pressure on the medial aspect of the patient’s arm when devices used to secure the arm
ulnar nerves are unpadded, or restraints are too tight (see Fig. 9-7)
• Poorly placed blood pressure cuff
• Patient’s body weight on the lower (dependent) arm when in lateral position
• Patient positioned with flexed elbows and hands placed on the chest.
Brachial plexus • Extending the arm beyond 90° angle when an arm board is used
• Pressure from shoulder braces (used in the Trendelenburg position)—these should be
avoided
• Patient’s body weight on the lower (dependent) arm when in lateral position
• Arm unsecured and allowed to fall off the table
• Splitting of the sternum during cardiac surgery
• Over-rotation and lateral flexion of the patient’s head (see Fig. 9-8).
SOURCE: BOWEN (2015) AND HEIZENROTH (2015).
Common peroneal nerve

Femoral nerve
Obturator nerve
FIGURE 9-4: Nerves of the inner thigh

Source: Adapted from Heizenroth (2015).
241
placed in the lithotomy position are at risk of

compartment syndrome in their lower limb(s),
which occurs when perfusion pressure falls below
tissue pressure in a closed anatomical space or
Sciatic nerve compartment (Bauer, Koch, Janni, Bender & Fleisch,
2014). This can occur when patients are in this
position for extended periods of time. Compart-
ment syndrome develops via a combination of pro-
longed tissue ischaemia and subsequent reperfusion
Tibial or posterior Common peroneal
tibial nerve nerve of muscle within a tight osseofascial compartment
and, untreated, leads to necrosis and functional
impairment (Heizenroth, 2015).
FIGURE 9-5: Right sciatic nerve and right thigh and upper leg, posterior view Additionally, there is increased potential for
Source: Adapted from Heizenroth (2015). thromboembolic episodes. Different positions, such
as lithotomy, the time spent in these positions and
the devices used to maintain them (e.g. safety belts,
stirrups or other leg-holding devices) contribute to
venostasis and the formation of thrombi (Bauer
et al., 2014).
Common peroneal nerve
Deep peroneal nerve Respiratory system
Respiratory function can be compromised, particu-
larly when a patient is positioned head-down,
supine (Trendelenburg), which causes the abdomi-
nal viscera and organs to shift up towards the dia-
Superficial peroneal nerve phragm, subsequently affecting lung tidal volumes.
This is especially so for patients who are obese,
pregnant or have pre-existing respiratory disease
(Heizenroth, 2015). The prone position also impedes
respiratory function, as does the lateral position,
where asymmetrical ventilation of the lungs and
impaired gas exchange pose a risk (Fell & Kirkbride,
Sural nerve 2013). Ideally, patients should spend as little time
as possible in these positions. Excessive pressure
caused by positional aids or the placement of the
patient’s arms on the chest area should also be
avoided (Heizenroth, 2015).
FIGURE 9-6: Right leg, lateral view SURGICAL POSITIONS

Source: Adapted from Heizenroth (2015). There are several standard surgical positions, with
a range of variations, and standard operating tables
abdominal masses are particularly at risk of supine are designed to accommodate this range. Positions
hypotensive syndrome, due to increased pressure commonly used include:
on the aorta and inferior vena cava (IVC) (Fell & • supine
Kirkbride, 2013). These patients should be posi-
• Trendelenburg and reverse Trendelenburg
tioned with a wedge under the right side to shift
pressure off the underlying structures. • prone
Adequate arterial circulation is necessary to • lateral
perfuse tissue, and occlusion or pressure on periph- • lithotomy
eral vessels (such as might be caused by positioning
devices or safety belts/straps) must be avoided • sitting: Fowler’s and semi-Fowler’s
(Phillips, 2013). For example, patients who are • fracture table position.
242
Musculocutaneous nerve
• All muscles in anterior
compartment of arm
Median nerve
• Most flexors in forearm
• Thenar muscles in hand
Radial nerve
• All muscles in posterior
compartment of arm Ulnar nerve
and forearm • Most intrinsic muscles in hand
• Flexor carpi ulnaris and medial
half of flexor digitorum profundus
in forearm
Anterior Posterior
Axillary nerve Axillary nerve

• Superior lateral • Superior lateral
cutaneous cutaneous
nerve of arm nerve of arm
Radial nerve Radial nerve

• Inferior lateral T2 • Inferior lateral cutaneous T2
cutaneous nerve of arm
nerve of arm • Posterior cutaneous
nerve of arm
• Posterior cutaneous
nerve of forearm
• Lateral cutaneous
nerve of forearm Musculocutaneous nerve
• Lateral cutaneous T1
T1 nerve of forearm
Radial nerve
• Superficial branch Radial nerve
• Superficial branch
A
Ulnar nerve
Ulnar nerve
Median nerve
B Median nerve
FIGURE 9-7: Nerves of the upper limb. A. Major nerves in the arm and forearm. B. Anterior and posterior areas of skin innervated by major peripheral nerves in the arm and
forearm.
Source: Drake, Vogl & Mitchell (2015).
243
Anterior rami C5
C6
Brachial plexus
C7
C8
T1
Nerves
(C5 to C7)
Median nerve
(C6 to C8,T1)
Radial nerve
(C5 to C8,T1)
Ulnar nerve
(C[7], C8, T1)
FIGURE 9-8: Innervation of the upper limb

Source: Drake, Vogl & Mitchell (2015).
SUPINE POSITION
In the supine position, patients lie on their back
with their arms either secured at their sides or
placed out on an arm board. This commonly used
position provides access to the abdominal, perito-
neal and cardiothoracic cavities, the extremities
and the head and neck. Table 9-2 shows nursing
interventions and rationales for this position.
TRENDELENBURG AND REVERSE FIGURE 9-9: Trendelenburg position

TRENDELENBURG POSITIONS Source: Adapted from Miller et al. (2010).
These positions are variations of the supine posi-
tion, with patients lying in a dorsal recumbent posi-
tion (i.e. on their back). For the Trendelenburg Fig. 9-10). An important factor to consider for these
position, which is used for lower abdominal or pelvic positions is the potential for shearing forces to
surgery, the operating table is tilted head down occur. These can be avoided by flexing the table at
(see Fig. 9-9). In the reverse Trendelenburg posi- the position of the patient’s knees, decreasing the
tion, the patient is head up, feet down, supine; this gravitational pull towards the head in the Trende-
position is used for head and neck surgery and mini- lenburg position. Shoulder braces previously used
mally invasive, upper abdominal procedures (see to prevent patient slippage should be avoided, as
244
TABLE 9-2: Supine Position—Nursing Interventions and Rationales
NURSING INTERVENTION RATIONALE

1. Pressure-relieving OR mattress, gel overlay or air 1. Pressure-relieving OR mattress or mattress overlays
support surface overlay protect occiput, scapulae, olecranon, vertebrae, sacrum,
coccyx and calcaneus from undue pressure
2. Padding or gel pads placed on extensions or other 2. Protects the ulnar nerve from undue pressure
positional aids as required (arm boards, J boards)
3. Heels should be offloaded and knees slightly flexed 3. Protects the heels from undue pressure and reduces
the risk of VTE, respectively
4. Keep arm board(s) level with the operating table and 4. Protects peripheral vasculature and nerves from
at an angle of 90° (or less); arm(s) must be loosely damage, including the brachial plexus and ulnar
secured to the board and positioned with the palms nerve
facing up
5. Legs remain uncrossed at the ankle 5. Relieves undue pressure, decreasing risk of venous
thrombosis
SOURCE: HEIZENROTH (2015), NILSSON (2013) AND NPU/EPU/PPPIA (2014).
The patient is anaesthetised in the supine posi-

tion prior to transfer, and the airway is secured
using a reinforced, flexible endotracheal tube (ETT),
which will not kink. The ETT is secured with tape
by the anaesthetist. The patient is then lifted and
placed with the abdomen down on the operating
table, and the face placed on a face pillow made of
foam or gel. Head placement in the neutral position
is recommended to minimise stress on the carotid
and vertebral arteries and reduce the risk of cere-
bral vascular accident (Heizenroth, 2015). Unless a
FIGURE 9-10: Reverse Trendelenburg position mechanical lifter is available or a Jackson table is
Source: Adapted from Miller et al. (2010). used, this transfer requires a minimum of four
people to be executed safely, with one member of
the team, usually the anaesthetist, supporting the
they are known to damage the brachial plexus patient’s head and neck and safeguarding the
(Sutton, Link & Makic, 2013). In the reverse Trende- airway at all times. The position requires additional
lenburg position, a padded table attachment can be padding (often in the form of a specialised face
fitted to the foot of the operating table on which the pillow plus multiple pillows or rolls on the operat-
patient’s feet rest. Tables 9-3 and 9-4 show nursing ing table) to protect vulnerable areas, such as the
interventions and rationales for these positions. patient’s eyes, ears, cheeks, lips and chin, breasts
(females), genitalia (males), patellae and toes (see
PRONE POSITION Fig. 9-11). Table 9-5 shows nursing interventions
In the prone position, patients lie face down. This and rationales for the prone position.
position is used when surgical access to the spine,
rectum or dorsal areas of the extremities is required. LATERAL POSITION
It can be achieved on a standard operating table or In the lateral position, which is used for procedures
it may require a specially designed table or table involving the chest, kidney or hip joint, the patient
fittings (e.g. a laminectomy frame); the choice is lies on the non-operative (dependent) side, with the
determined by the particular surgical intervention. operative side uppermost. It requires a selection of
245
TABLE 9-3: Trendelenburg Position—Nursing Interventions and Rationales

1. Observe the same precautions as for the supine 1. This is a supine position variation; placement of the
position patient directly on the gel overlay prevents slippage
2. Break the table slightly at the position of the 2. Helps prevent the effects of shearing forces as it
patient’s knees counteracts gravitational pull
3. Observe respiratory function closely 3. Severely angled tilts diminish the patient’s lung
capacity due to the pressure of the abdominal organs
on the diaphragm, resulting in compression of the
lung bases
4. Observe lower extremity circulation 4. May be diminished due to blood pooling in the head
and upper torso
5. Tilt the patient in and out of the position slowly 5. Avoids sudden blood pressure shifts
SOURCE: HEIZENROTH (2015).
TABLE 9-4: Reverse Trendelenburg Position—Nursing Interventions and Rationales

1. Observe the same precautions as for the 1. This is a supine position variation
supine position
2. Use of intermittent pneumatic compression 2. Aids with lower limb venous return
devices and graduated compression
stockings is recommended
3. Tilt the patient in and out of the position slowly 3. Avoids sudden blood pressure shifts
4. Ensure a padded footrest is secured to the 4. Prevents the patient slipping off the table
foot of operating table
SOURCE: HEIZENROTH (2015).
positional aids to secure the patient because there

is a risk of the patient rolling forwards or backwards
intraoperatively or even falling off the table. The
patient is anaesthetised in the supine position and
then transferred or turned onto the dependent
(non-operative) side. Positional aids include spe-
cially designed, padded arm rests (e.g. Carter Brain
arm rest) to support the upper arm and keep it away
from the operative area, plus table/safety straps and
pliable bean bags, used to hold the patient securely
to the operating table and to maintain the position
FIGURE 9-11: Prone position using Wilson laminectomy frame for spinal
throughout surgery (see Fig. 9-12). Alternatively,
procedures and face pillow head support padded table attachments (lateral supports or
Source: Heizenroth (2015). kidney braces), one at the patient’s back and a larger
246
TABLE 9-5: Prone Position—Nursing Interventions and Rationales

1. Use a latex-free foam or gel face pillow, or specialised 1. Specialised positioning devices allow for the head
head positioning frames (e.g. horseshoe headrest) and neck to be maintained in normal anatomical
alignment and allow access to the patient’s airway
2. Use a padded operating table mattress—gel mattress 2. Extra padding protects vulnerable areas, such as the
or pillows/rolls (or gel pad over laminectomy frame, cheeks, ears, chin, lips, breasts (female), genitalia
if used) (males), patellae and toes
3. Place padding on extensions as required (arm boards, 3. Arms are moved down and forwards and placed on
J boards); arms should be secured loosely, palms the arm board slowly and carefully to minimise the
down on padded arm boards and kept in natural risk of damage to the brachial plexus; arms hanging
alignment—they should not be allowed to hang over over the table edge can sustain damage to the radial
the edge of the operating table nerve
4. Place eye ointment in both eyes and ensure eyelids 4. The eyes are vulnerable to corneal abrasion,
are securely taped closed; avoid direct pressure on neuropathy and increases in intraocular pressure
the globe of the eye
SOURCE: HEIZENROTH (2015) AND NPU/EPU/PPPIA (2014).
adjustment of abduction and lithotomy while main-

taining an aseptic field. The boots are padded and
some are extended on the lateral side to protect the
head of the fibula and the peroneal nerve (e.g. Yel-
lofins) (see Fig. 9-15).
One of the most important precautions to
consider when placing a patient in this position is
FIGURE 9-12: Left lateral position with arm board
Source: Macke & Nason (2014). the high risk of nerve damage and hip dislocation
if the legs are not raised simultaneously, slowly
and at the same angle and height at all times.
one supporting the abdomen, can be used. Table 9-6 The lithotomy and steep Trendelenburg (LST)
shows nursing interventions and rationales for the position is used for some laparoscopic, gynaeco-
lateral position. logical and urological procedures, particularly when
robotic-assisted surgery is undertaken. The LST
LITHOTOMY POSITION incurs the same risks associated with both lithot-
For patients undergoing gynaecological and uro- omy and Trendelenburg positions but with the
logical surgery, the lithotomy position is required. additional risk of skin breakdown as a result of
This position involves the patient lying supine with shear and friction. This is due to the steep head-
their legs raised, abducted and secured in leg-posi- down position (see Figs 9-16 and 9-17) (Sutton
tioning devices (stirrups) to expose the perineal et al., 2013). Table 9-7 shows nursing interventions
area. Depending on the surgical access required, the and rationales for the lithotomy position.
patient’s legs can be held at various angles to the
trunk—in a low, standard or high lithotomy posi- SITTING POSITIONS: FOWLER’S/
tion. These positions are maintained with the use SEMI-FOWLER’S POSITION
of a range of stirrups, which are chosen after con- The patient placed in the Fowler’s/semi-Fowler’s
sidering the type of surgery and the proposed position is secured in an upright sitting position.
length of time for the procedure (see Figs 9-13 and This position is used for surgery involving the
9-14). Some stirrups feature hydraulic lift-assisted ears, nose, shoulders, abdomen and breasts and for
technology that provides easier movement of the some cranial procedures.
leg into the desired position. They also permit Text continued on p. 250
247
TABLE 9-6: Lateral Position—Nursing Interventions and Rationales

1. Use padded operating table mattress and place 1. Protects pressure points on the dependent side—ear,
padding on extensions as required (arm boards and shoulder, hip, ankle
arm supports)
2. Place a pillow between the patient’s knees 2. Knees will rub against each other, damaging the skin;
additionally, undue pressure can damage the peroneal
nerve
3. Keep the spine in alignment by placing a pillow 3. The spine is vulnerable to misalignment and twisting;
under the patient’s head this can place pressure on the dependent brachial
plexus
4. Secure the patient using either lateral supports 4. Prevents the patient from falling off the operating
(kidney braces) (padded) at the abdomen and back, or table and ensures the patient does not move
devices such as beanbags or a vacuum beanbag intraoperatively
positioner; additionally, a safety belt/table strap over
the patient’s upper thigh is required
5. Ensure the patient’s shoulder on the non-operative 5. Prevents damage to the brachial plexus and ulnar
(dependent) side is not over-extended and the lower nerve
arm is protected, usually by securing it to an arm
board; place the upper arm on a lateral arm support
6. Kidney surgery requires access to the retroperitoneal 6. Prevents the dependent flank area from compression
area of the flank—in this case, the patient is and subsequent pooling of blood in the lower
positioned so that the lower iliac crest is below the extremities
lumbar break where the kidney bridge is located on
operating table; the latter is subsequently elevated
(slowly) and the operating table flexed to lower the
patient’s upper torso and legs
A B
C D
FIGURE 9-13: Four basic types of lithotomy position with progressively increasing leg elevation
Source: Heizenroth (2015).
248
B C
FIGURE 9-14: A, Lithotomy using boot-type stirrups. B, Knee crutch stirrup. C, Candy
cane stirrup.
Source: Heizenroth (2015).
FIGURE 9-15: Hydraulic lift-assisted stirrups

Source: Courtesy Allen Medical Systems, Inc.
FIGURE 9-16: Recommended positioning of a patient in the steep Trendelenburg position by using an air-inflated position device
Source: Courtesy of the University of Colorado Hospital, Aurora, CO.
249
FIGURE 9-17: Recommended positioning of a patient in the steep Trendelenburg position when using high-density foam
Source: Courtesy of the University of Colorado Hospital, Aurora, CO.
TABLE 9-7: Lithotomy Position—Nursing Interventions and Rationales

1. Secure stirrups/leg-holding devices at an equal level 1. Ensures stirrups do not dislodge during surgery, and
and height that the patient’s hips and legs are kept in alignment
2. Bring the patient’s legs up into the stirrups 2. Maintains hip alignment and prevents dislocation of
simultaneously and slowly, keeping them at an equal the hip joint and overstretching of the femoral nerve;
height and angle at all times moving them slowly prevents blood pressure
fluctuations
3. Ensure that the patient’s buttocks remain on the 3. Reduces the risk of lumbosacral strain and sciatic
table at all times and do not overhang it nerve damage
4. Ensure that the patient’s fingers are not in the way of 4. Fingers can be crushed in the stirrup joints and lower
the stirrups or table break when adjusting equipment table break
or the OR table
5. Ensure that the stirrup poles and footrests are 5. Decreases the risk of thrombus formation or
padded compartment syndrome and protects the posterior
tibial and common peroneal nerves
6. Observe precautions for VTE during longer 6. Pressure on veins from the stirrups can increase the
procedures risk of thrombosis formation
In the latter case, the patient’s head is held in must be secured so that they do not fall by the side
a brace or supported with a head support attach- of the body. They can rest on a pillow on the
ment. Initially, the patient is placed in the supine patient’s lap. A padded footboard prevents foot
position and, once anaesthetised, the table is drop. This position can cause pelvic pooling or
manipulated so that the patient assumes a sitting venous stasis, resulting in cardiovascular instabil-
position. The angle of this position (Fowler’s or ity, orthopaedic injury and/or tissue injury/necrosis
semi-Fowler’s) will vary according to the type of (Heizenroth, 2015). It can also cause an air embolus
surgery and the access required. The patient’s arms to enter the right atrium, necessitating immediate
250
Perineal post Boot lock

Fine traction
Hemoral hook handle
Hand control
Spar handle
FIGURE 9-18: Model on fracture bed

Source: Hozack & Parvizi (2009).
repositioning of the patient to a left lateral posi- effective airway and attention to ensure there is no
tion, placement of the table into the steep Trende- undue pressure on the patient’s body remain para-
lenburg position and insertion of a central venous mount (ACORN, 2016a).
catheter to withdraw the air bubble (Phillips, 2013).
FRACTURE TABLE POSITION

PREVENTION AND MANAGEMENT
Some orthopaedic procedures require the use of a
OF VENOUS THROMBOEMBOLISM
specialised fracture table. Indications for use The development of venous thrombosis and sub
include correcting a fractured neck of femur, as well sequent pulmonary embolus (PE) make up two
as performing some femoral procedures, because components of the condition of venous throm-
the table permits the necessary rotation and manip- boembolism. VTE is a mostly preventable surgical
ulation of the operative limb. Where possible, complication, yet remains a significant cause of
patients are anaesthetised prior to transfer onto postoperative (PO) morbidity and mortality in the
this table. They are placed supine on the fracture form of chronic venous insufficiency, recurrent
table with the pelvis stabilised against a well- thromboembolism and postthrombotic syndrome
padded perineal post to protect against genital (Australia and New Zealand Working Party on
injury (see Fig. 9-18). If needed, traction is achieved Management and Prevention of VTE [ANZWP/VTE],
by restraining the injured limb in a well-padded, nd). Despite extensive evidence to guide proper
boot-like device that is part of the table’s movable prophylaxis and treatment of VTE, therapies con-
traction arm. The non-operative leg is placed on tinue to be underutilised (ANZWP/VTE, nd; Kahn
a support attachment and kept out of the way of et al., 2013; National Health and Medical Research
the operative limb. The patient’s arms are also Council [NHMRC], 2011).
secured away from the operative field. Nursing Venous thrombus formation is associated with
interventions associated with the supine position systemic alterations in the coagulability of blood,
apply. Additionally, the distal lower extremity venous stasis and damage to walls of blood vessels
pulses should be assessed before, during and on (Bryant & Knights, 2015). All surgical interventions
case completion (Heizenroth, 2015). pose some risk, but those patients with an increased
On completion of surgery, patient transfer to susceptibility of developing VTE are shown in
the bed or trolley requires the same care and con- Box 9-1. It is important to note that there are addi-
siderations as highlighted earlier. Additionally, skin tional intraoperative risks for the development of
integrity needs reassessing to ensure it has not VTE. These include:
changed during the intraoperative period and the • length of surgery
outcome documenting, to highlight continuity of
patient care. Irrespective of the position that the • venous compression
patient is placed in for transfer, maintenance of an • hypovolaemia
251
BOX 9-1 » PATIENTS AT INCREASED RISK OF DEVELOPING VTE

• Those undergoing major surgery, especially intraabdominal and pelvic procedures
• Those undergoing surgery longer than 45 minutes and aged >40 years
• Orthopaedic patients, especially those undergoing reconstructive surgery
• The elderly
• Patients with an acute inflammatory condition
• Smokers
• The obese
• Those with a family history of thromboembolism
• Major trauma victims
• Those with metabolic disorders or blood dyscrasias (e.g. inherited thrombophilia disorders)
• Those with certain kinds of cancer
• Those on oral contraception and hormone replacement medications
SOURCES: ANZWP/VTE (ND ) AND BRYANT & KNIGHTS (2015).
• hypotension
• hypothermia
TABLE 9-8: Signs and Symptoms of VTE
• use of a tourniquet (Hicks & Denholm, 2013). DEEP VEIN PULMONARY

THROMBOSIS EMBOLISM*
SIGNS AND SYMPTOMS OF VTE
Calf tenderness and pain, Tachycardia
Many patients with VTE are asymptomatic (ANZWP/ especially on dorsiflexion
VTE, nd), but the symptoms that may develop are (positive Homan’s sign)
summarised in Table 9-8. A greater risk to the
patient occurs if a thrombus breaks off and travels Swelling and warmth of Dyspnoea
the affected limb
via the venous system to the right ventricle and
from there to the pulmonary artery or one of its Low-grade fever Chest pain
branches, resulting in a PE, which can be life-
Skin colour changes Hypotension
threatening. Most PEs originate in a lower limb or (erythema)
pelvic veins (NHMRC, 2011).
Hypoxaemia
PREVENTION Acute decrease in
All surgical patients should be assessed preopera- end-tidal carbon dioxide
tively to determine their risk for VTE and this concentration
should guide decision making regarding the use Cardiovascular collapse/
of anticoagulant and/or mechanical prophylaxis sudden death
(NHMRC, 2011). Appropriate, local VTE risk assess-
*INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS.
ment guidelines are essential so that prophylactic SOURCE: KAHN ET AL. (2013).
measures are used in the correct at-risk group but
are avoided in low-risk groups (ANZWP/VTE, nd).
Both pharmacological and non-pharmacological VTE prophylaxis requires further research, although
therapies and actions should be used to prevent some guidance is provided in Figure 9-19. The
VTE, with multimodal interventions being more timing of commencement and duration of therapy
efficacious than single therapies (Bryant & Knights, should be determined for each individual patient
2015; Kakkos et al., 2011). The optimum length of (ANZWP/VTE, nd).
252
Surgical VTE Prophylaxis Guide
For ALL patients undergoing surgery or when surgery is imminent
STEP 1 STEP 2 STEP 3
Assess Patient Risk Assess for Anticoagulant Prophylaxis Assess Mechanical Prophylaxis
NO Prescribe: enoxaparin 40mg daily

Are there any
or dalteparin 5000U daily
contraindications to or for orthopaedic surgery Are there any NO Apply IPC and/or GCS
• Hip or knee arthrophasty anticoagulant fondaparinux 2.5mg daily contraindications to
H prophylaxis? (commence 6-8 hrs post-op) mechanical
• Major trauma Duration 5-10 days EXCEPT
I (see below) prophylaxis?
28-35 days for hip arthrophasty (see below) YES Observe closely for VTE
G
YES No anticoagulant
H
• Hip fracture surgery
• Other surgery with prior Are there any NO Prescribe: enoxaparin 40mg daily
R or dalteparin 5000U daily
VTE and/or active cancer contraindications to Are there any NO Apply GCS and/or IPC
I or LDUH 5000 TDS
anticoagulant contraindications to
or for hip fracture surgery
S prophylaxis? fondaparinux 2.5mg daily mechanical
K (see below) (commence 6-8 hrs post-op) prophylaxis?
• Major surgery* age > 40 years Duration 5-10 days EXCEPT (see below) YES Observe closely for VTE
28-35 days for hip fracture surgery
YES No anticoagulant
Are there any Are there any NO Apply GCS and/or IPC
NO Prescribe: enoxaparin 20mg daily
contraindications to or dalteparin 2500U daily contraindications to
L anticoagulant or LDUH 5000 BD or TDS mechanical
O prophylaxis? Duration 5-10 days prophylaxis?
(see below) (see below) YES Observe closely for VTE
W YES No anticoagulant
E
R
• All other surgery
Are there any Are there any
R NO Consider LMWH or LDUH if NO Consider GCS
contraindications to contraindications to
additional risk factors †
I anticoagulant mechanical
Duration until hospital discharge prophylaxis?
S prophylaxis?
(see below) No anticoagulant (see below) YES Observe closely for VTE
K YES
*Major surgery: intra-abdominal surgery or Contraindications to anticoagulant prophylaxis Contraindications to mechanical prophylaxis
any surgery > 45 minutes duration Active bleeding / high risk of bleeding eg. haemophilia, thrombocytopenia Severe peripheral arterial disease: Recent skin graft
(platelet count <50 × 109/L), history of GI bleeding Severe peripheral neuropathy: Severe leg deformity
† Additional VTE Risk Factors Severe hepatic disease (INR > 1.3) / adverse reaction to heparin
immobility, thrombophilia, oestrogen therapy, On current anticoagulation LMWH - Low Molecular Weight Heparin
pregnancy or puerperium, active inflammation, Other eg. very high falls risk and palliative management LDUH - Low Dose Unfractionated Heparin
strong family history of VTE and/or obesity. GCS - Graduated Compression Stockings
Renal impairment with LMWH - see manufacturer’s product information
IPC - Intermittent Pneumatic Compression
VTE - Venous Thromboembolism
The Australia & New Zealand Working Party
ABN 14 411 043 068
on the Management and Prevention
Supported by a non directed grant from Health Education & Management Innovations
of Venous Thromboembolism.
Email: [email protected]
© For copyright information contact [email protected]
FIGURE 9-19: Surgical VTE prophylaxis guide

Source: © HEMI Australia.
253
BOX 9-2 » RECOMMENDATIONS FOR THE USE OF GRADUATED COMPRESSION STOCKINGS FOR
DVT PROPHYLAXIS
• Graduated compression stockings should be worn continuously during the period of immobility and
until the return of full ambulation.
• The stockings must be measured and fitted for the individual patient.
• Patient compliance is essential, as the stockings must not be rolled down. It is not known if full-
length stockings provide any more protection than below-knee stockings, as there are few
comparative studies.
• Ideally, there should be pressure of 16–20 mmHg at the ankle when the patient is supine, with
graduated compression to the knee and above.
• The stockings should be manufactured to a high standard, be independently tested, have a
compression profile and be washable.
NOTE: GRADUATED COMPRESSION STOCKINGS ARE CONTRAINDICATED IN THE PRESENCE OF CRITICAL LIMB ISCHAEMIA.
SOURCE: ANZWP/VTE (nd).
ANTICOAGULANT PROPHYLAXIS against DVT should be used as a prophylactic

The main groups of anticoagulants include: measure. The other type is used to treat chronic
venous insufficiency (ANZWP/VTE, nd). The correct
• heparin (unfractionated) use of graduated compression stockings is outlined
• low-molecular-weight heparins (LMWHs) in Box 9-2.
(e.g. enoxaparin, dalteparin) Intermittent pneumatic compression devices
• warfarin also reduce the incidence of DVT and are more
• various other novel drugs that act on specific effective in high-risk patients when used in combi-
factors that are part of the blood coagulation nation with anticoagulants; they can also be used
cascade (e.g. fondaparinux, dabigatran when anticoagulants are contraindicated (ANZWP/
etexilate, rivaroxaban) (Bryant & Knights, VTE, nd). In orthopaedic surgery, foot impulse tech-
2015). nology can be utilised with graduated compression
stockings if the use of intermittent pneumatic com-
Some of these novel anticoagulants are believed pression devices is not possible. Recommendations
to have safer outcomes compared to traditional for intermittent pneumatic compression device use
anticoagulants (Skeik, Murphy & Porten, 2014). for the purpose of prophylaxis are similar to those
However, heparin and the LMWHs are the mainstay for the use of graduated compression stockings;
of treatment when a rapid anticoagulant effect is namely, they should be used throughout the period
required. Their use is contraindicated in patients of immobility until the patient returns to full ambu-
who have active bleeding or who are at high risk of lation and their use should be avoided in the pres-
this (e.g. haemophiliacs) (ANZWP/VTE, nd; Bryant ence of limb ischaemia (ANZWP/VTE, nd).
& Knights, 2015).
Complications with the use of either type of
MECHANICAL PROPHYLAXIS mechanical device are rare but include:
There are two main types of mechanical devices • compartment syndrome
used in the prevention of DVT: graduated com • skin ulceration
pression stockings and intermittent pneumatic
compression devices. There are two distinct, non- • pressure injury
interchangeable types of graduated compression • common peroneal nerve palsy (ANZWP/VTE,
stockings and only those designed for protection nd; NPU/EPU/PPPIA, 2014).
254
PREVENTION AND MANAGEMENT PATIENTS AT RISK OF DEVELOPING IPH

All patients have some risk of developing IPH;
OF INADVERTENT PERIOPERATIVE however, some patients have an increased risk. This
HYPOTHERMIA includes:
Inadvertent perioperative hypothermia (IPH) is • burns patients, in particular, those with
a commonly reported complication in surgical full-thickness burns to more than 10% of body
patients, particularly in the intraoperative and surface area (BSA) or partial-thickness burns
immediate postoperative periods (Australia and (>25% BSA)
New Zealand College of Anaesthetists [ANZCA], • trauma patients
2014a; Hirvonen & Niskanen, 2011), with a reported
prevalence ranging from 45% to 90% (Duff, Walker, • immunocompromised patients who have
Edward, Williams & Sutherland-Fraser, 2014; depleted cellular-level energy stores
Knaepel, 2012; Moola & Lockwood, 2011). IPH is • patients with small body mass
defined as the unintentional drop of a patient’s • patients with conditions such as
core body temperature to below 36°C during the hyperthyroidism or hypothyroidism, impaired
perioperative period (Warttig, Alderson, Campbell metabolic rate, diabetes mellitus or circulatory
& Smith, 2014). (Note: It is to be distinguished from failure (Duff et al., 2014; Nimmo & Nimmo,
planned hypothermia, which is used in some cardio 2013).
thoracic and neurosurgical procedures.)
Additionally, patients have a higher risk if any two
Two factors contribute to the development of of the following apply:
a hypothermic state: anaesthesia and environmen-
• ASA Grade II–V (the higher the grade, the
tal factors (ANZCA 2014a; Knaepel, 2012). As dis-
greater the risk)—see Chapter 8
cussed in Chapter 8, general anaesthesia inhibits
the thermoregulatory system, consequently pro- • preoperative temperature <36°C
hibiting cellular metabolism and resulting in a • combined regional and general anaesthesia
loss of normal physiological responses (e.g. shiver-
• at risk of cardiac complications
ing and vasoconstriction). Environmental factors,
such as inadequately clothed surgical patients • extremes of age (ANZCA, 2014a).
and a low ambient operating room temperature
(which is normally 20–22°C), compound the risk, MANAGEMENT STRATEGIES
as do lengthy surgery, prolonged exposure of major Maintenance of normothermia is the goal for every
abdominal/thoracic organs and the use of cool IV perioperative patient. This requires that all patients
and irrigating fluids and cold prepping solution are assessed for risk of developing IPH and have
(AORN, 2015b; Knaepel, 2012; Warttig et al., 2014). their temperature monitored regularly pre-, intra-
and postoperatively. Other than in an emergency,
ADVERSE EFFECTS OF IPH patients should have their temperature recorded in
The consequences of IPH can include: the hour prior to transfer to the OR; it should be
36°C or above. If it is not, active warming should be
• morbid cardiac events
initiated prior to induction of anaesthesia (ANZCA,
• increased blood loss 2014a; Knaepel, 2012). Active warming should be
• increased blood transfusion initiated in the anaesthetic room for all procedures
where total operative time (i.e. from initiation of
• reduced hepatic blood flow and slower drug
anaesthesia until arrival in the postanaesthesia
metabolism
care unit [PACU]) is greater than 30 minutes. In
• postoperative shivering and increased oxygen procedures of shorter duration, only higher risk
consumption patients should be actively warmed. Box 9-3 iden
• prolonged recovery and hospital stay tifies ways to maintain or restore normothermia.
See also Chapter 5 for further information on OR
• surgical wound infection temperature control and Chapter 8 for information
• thermal discomfort (ANZCA, 2014a; Knaepel, about maintaining normothermia during the induc-
2012). tion of anaesthesia.
255
BOX 9-3 » WAYS TO MAINTAIN OR RESTORE NORMOTHERMIA

• Ensure all surgical patients have a minimum of one sheet and two blankets.
• Use active warming devices, such as forced-air warming devices, warming mattresses, heated gel
pads and circulating water garments. Note that while forced-air warming devices have
demonstrated efficacy, there is only provisional evidence that other active warming devices may be
as effective (John, Ford & Harper, 2014; Moola & Lockwood, 2011; Rowley et al., 2014).
• Use fluid warmers for IV fluids (including blood) when >500 mL is to be given.
• Warm the irrigation fluids used intraoperatively.
• Increase the ambient operating room temperature to 21°C or above while active warming is being
established. This is essential for paediatric patients.
SOURCE: ANZCA (2014a).
Intraoperatively, patients should have their Out) and to improve communication and team-
temperature recorded every 30 minutes. Once in work, activities known to improve patient safety
the PACU, the temperature should be recorded (Braaf, Manias, Finch, Riley & Munro, 2013; Lee
every 15 minutes until the patient is discharged et al., 2012; Russ et al., 2013; Treadwell, Lucas &
to the ward. If a patient is hypothermic postop Tsou, 2014). The SSC spells out critical activities
eratively, active warming should be initiated and that must occur at particular times during a surgi-
discharge from the PACU delayed until the patient’s cal procedure. These times are:
temperature is >36°C (ANZCA, 2014a). • the period prior to induction of anaesthesia
Despite the availability of cost-effective and (Sign In)
easily implemented evidence-based guidelines • the period after induction and before the
aimed at preventing or treating IPH, they are surgical incision (Time Out)
frequently underutilised, both intra- and postop-
eratively (Duff et al., 2014; Knaepel, 2012). The • the period during or immediately after wound
reasons for poor compliance with guidelines are closure (Sign Out) (see Fig. 9-20).
unclear and identifying the barriers to implementa- During Sign In, and in the presence of the
tion may be a fruitful area for further research. patient, the anaesthetic nurse verbally confirms:
• the presence of the correct patient
SURGICAL COMPLICATIONS AND
• the planned procedure
THE ELDERLY
• the marking of the surgical site (when
The complications previously discussed are par- applicable)
ticularly significant if they occur in elderly patients.
Research box 9-2 explores perioperative implica- • that consent has been obtained
tions of surgery in elderly patients with fractured • the patient’s allergy status
hips.
• that the anaesthesia safety check (i.e. the
anaesthetic machine and patient medications)
ENSURING CORRECT PATIENT/SITE is complete
OF SURGERY • the availability and functionality of pulse
Surgery is not without risks and a safe environment oximetry
for surgical patients requires a planned and sys- • if the patient has a difficult airway or
tematic approach to perioperative care delivery. aspiration risk
WHO’s Surgical Safety Checklist (SSC), discussed
in earlier chapters, was developed to reduce the • risk of blood loss >500 mL (or 7 mL/kg in
occurrence of unnecessary surgical deaths and children)
avoidable complications (WHO, 2009). Its aim is to • availability of prosthesis/other special
reinforce accepted safety practices (such as Time equipment, if required.
256
RESEARCH BOX 9-2: Perioperative Implications of Surgery in Elderly Patients with Fractured Hips
Literature published in the English language concerning hip fracture prevalence trends suggests that hip
fractures are and will remain a serious global health issue (White, Khan & Smitham, 2011). Despite a
decline in the incidence of osteoporotic hip fractures over past one to two decades in Australasia, the
number of cases continues to increase due to population growth and ageing (Australian Institute of Health
and Welfare [AIHW], 2010; New Zealand Guidelines Group [NZGG], 2003a, 2003b). Māori and Pacific Island-
ers have a lower incidence of hip fractures compared to New Zealanders of European origin; in contrast,
the incidence among Indigenous Australians is greater than for other Australians.
Fractured hips are a major cause of mortality and morbidity, significantly affecting the independence and
quality of life of the elderly. Surgical fixation of fractured hips remains the standard of care because it
allows early mobilisation and return to independence. The incidence of perioperative complications is
increased in the elderly due to loss of functional reserve and general organ decline (Nimmo & Nimmo,
2013). Furthermore, the incidence of PO complications is proportional to the number of comorbidities
present among this cohort (White et al., 2011). The most common complications are cardiac (AIHW, 2010,
White et al., 2011) and pulmonary (ANZCA, 2014b; White et al., 2011).
Additionally, management of this cohort of patients requires careful consideration of the following:
~ PO pain control
~ prevention of pressure injuries
~ prevention of VTE
~ prevention or management of PO delirium.
A multidisciplinary approach including geriatricians is crucial for the successful care of these patients
(White et al., 2011).
Ideally, the surgeon should be present for Sign In; In Sign Out, the final stage of the SSC process,
however, his/her presence is not essential to com- team members review and confirm:
plete this part of the SSC process (WHO, 2008). • the nature of the surgical procedure completed
Time Out involves all members of the surgical • the count is correct and that all accountable
team and occurs prior to skin incision. Staff must
items used during the procedure are accounted
verbally confirm:
for
• that all team members have introduced
• any surgical specimens obtained are correctly
themselves by name and role
labelled
• the patient’s identification, the planned
• equipment malfunctions or issues that need
procedure and the operative site
addressing are identified
• the anticipated critical events, which include:
• there is a review of PO care and any concerns
– surgeon review (e.g. anticipated blood loss, are identified before the patient is transferred
unexpected steps in procedure) from the operating room.
– anaesthetist review (e.g. patient-specific The SSC is a useful, validated tool for patient
issues) identification and for prevention of wrong site
– nursing review (e.g. sterility of items surgery (Lee et al., 2012). It is simple, brief and
confirmed, any equipment issues noted) quick to complete (Treadwell et al., 2014) and is also
• prophylactic antibiotics administered within adaptable. Thus, in Australia and New Zealand, the
last 60 minutes use of VTE prophylaxis and the availability of surgi-
cal prostheses/implants (items not included in the
• VTE prophylaxis ordered original SSC) form an integral part of the SSC ANZ
• essential imaging displayed (as appropriate). edition (Royal Australasian College of Surgeons
257
258
SURGICAL SAFETY CHECKLIST (AUSTRALIA AND NEW ZEALAND)
Before inducon of anaesthesia Before skin incision Before paent leaves operang room
SIGN IN TIME OUT SIGN OUT
PATIENT HAS CONFIRMED CONFIRM ALL TEAM MEMBERS HAVE NURSE VERBALLY CONFIRMS WITH THE
• IDENTITY INTRODUCED THEMSELVES BY NAME AND TEAM:
• SITE ROLE
• PROCEDURE THE NAME OF THE PROCEDURE RECORDED
• CONSENT SURGEON, ANAESTHESIA PROFESSIONAL AND
NURSE VERBALLY CONFIRM THAT INSTRUMENT, SPONGE, NEEDLE AND

SITE MARKED/NOT APPLICABLE • PATIENT OTHER COUNTS ARE CORRECT
• SITE
ANAESTHESIA SAFETY CHECK COMPLETED • PROCEDURE HOW THE SPECIMEN IS LABELLED
(INCLUDING PATIENT NAME)
PULSE OXIMETER ON PATIENT AND ANTICIPATED CRITICAL EVENTS
FUNCTIONING WHETHER THERE ARE ANY EQUIPMENT
SURGEON REVIEWS: WHAT ARE THE CRITICAL PROBLEMS TO BE ADDRESSED
DOES PATIENT HAVE A : OR UNEXPECTED STEPS, OPERATIVE
DURATION, ANTICIPATED SURGEON, ANAESTHESIA PROFESSIONAL
KNOWN ALLERGY? BLOOD LOSS? AND NURSE REVIEW THE KEY CONCERNS
NO FOR RECOVERY AND MANAGEMENT
YES ANAESTHESIA TEAM REVIEWS: ARE THERE ANY OF THIS PATIENT
PATIENT-SPECIFIC CONCERNS?
DIFFICULT AIRWAY/ASPIRATION RISK?
NO NURSING TEAM REVIEWS: HAS STERILITY
YES, AND EQUIPMENT/ASSISTANCE AVAILABLE (INCLUDING INDICATOR RESULTS) BEEN
CONFIRMED? ARE THERE EQUIPMENT
RISK OF >500ML BLOOD LOSS ISSUES OR ANY CONCERNS?
(7ML/KG IN CHILDREN)?
NO HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
YES, AND ADEQUATE INTRAVENOUS ACCESS WITHIN THE LAST 60 MINUTES?
AND FLUIDS PLANNED YES
NOT APPLICABLE
PROSTHESIS/SPECIAL EQUIPMENT: HAS THROMBOPROPHYLAXIS BEEN ORDERED?

YES
IF PROSTHESIS (OR SPECIAL EQUIPMENT) IS NOT REQUIRED
TO BE USED IN THEATRE, HAS IT BEEN
CHECKED AND CONFIRMED? IS ESSENTIAL IMAGING DISPLAYED?
YES YES
NOT APPLICABLE NOT APPLICABLE
This checklist has been adapted from the World Health Organization Surgical Safety Checklist by the Royal Australasian College of Surgeons in consultation with the Australian and New Zealand College of
Anaesthetists, the Royal Australian and New Zealand College of Ophthalmologists, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Australian College of Operating
Room Nurses and the Perioperative Nurses College of the New Zealand Nurses Organisation; it is not intended to be comprehensive, additions and modifications to fit local practice are encouraged (Oct 09)
FIGURE 9-20: WHO Surgical Safety Checklist

Source: © Royal Australasian College of Surgeons.
[RACS], 2009). Note, however, that any adaptations of tourniquets is associated with significant risk
must be done without sacrificing the primary focus (Hicks & Denholm, 2013) as tourniquets compress
on team function and communication (ACORN, underlying soft tissue, as well as depriving the area
2016d). The use of the trans-Tasman–endorsed SSC of blood supply. Consequently, they have been
requires the participation of all members of the linked to soft-tissue injuries involving skin, muscle,
surgical team, who must be present and must cease nerves and vasculature; additionally, their use can
all other activities to participate. It is important have systemic sequelae (Hardman & Bedforth,
that the same team member leads and coordinates 2013). Complications include:
all stages of the checklist process and in most • nerve injury
instances this is the anaesthetic nurse.
• post-tourniquet syndrome (sustained PO
Notwithstanding its utility and formal endorse- swelling, stiffness and painful limb)
ment by key stakeholders, non-compliance with the
• compartment syndrome
SSC (Tang, Ranmuthugala & Cunningham, 2014)
and resistance to its use from senior clinicians • impaired wound healing
remain (Lee et al., 2012; Russ et al., 2013). • pressure injuries and chemical burns
• subcutaneous fat necrosis
TOURNIQUETS • digital necrosis
Tourniquets are often used during surgery on limbs • toxic reactions
and digits to constrict their blood flow, resulting in
• fatal or near-fatal PE and DVT after deflation
a bloodless field at the distal surgical site. These
(Bowen, 2015; Kvederas et al., 2013; Hicks &
devices may be mechanical (e.g. a blood pressure
Denholm, 2013).
cuff) or electronic or pneumatic (utilising a heavier,
more secure type of blood pressure cuff for use on TOURNIQUET USE
the arms or legs) (AORN, 2015c; Phillips, 2013).
Pneumatic tourniquets consist of an inflatable cuff When selecting a cuff, the length and width should
connected via double or single tubing to a pressure be individualised for each patient (ACORN, 2016e;
regulator, compressed gas supply and display unit. AORN, 2015c; Phillips, 2013). This will depend on
Simpler devices, such as rubber tubing or bands, are the shape and diameter of the extremity and the
used on digits. particular procedure the patient is undergoing
(Hicks & Denholm, 2013). The widest cuff possible
Recommendations for the safe use of tourni- within any given length should be selected because
quets include: wider cuffs occlude blood flow at lower pressures.
• staff training and education Contoured cuffs are recommended for bariatric
patients where limbs tend to be conical in shape.
• checking and maintenance of all equipment
These prevent the risk of neurovascular damage,
• patient identification, verification and cuff slippage and subsequent underlying soft-tissue
operative limb marking damage. The length of the cuff also needs to be
• patient assessment for contraindications considered; it should overlap itself by at least 7.5 cm
but no more than 15 cm, as excessively long cuffs
• correct application of the cuff
increase pressure on the underlying tissue and
• use of the correct amount of pressure wrinkle the underlying skin. Additionally, the need
• observance of maximum inflation time for a latex-free cuff and selection of a single-use
versus reusable cuff needs to be determined
• accurate patient observation and (ACORN, 2016e). Cuffs should be located at the
documentation of use point of maximum circumference of the extremity;
• directions for cleaning and decontamination of that is, the upper arm or the proximal third of the
cuffs (ACORN, 2016e; Bowen, 2015). thigh (Phillips, 2013).
As there are several different (and complex) Prior to tourniquet inflation, the operative limb
types of tourniquets, the specific manufacturer’s requires exsanguination to prevent intravascular
recommendations should guide use, in conjunction thrombosis and formation of embolus (Phillips,
with departmental policy and procedures. The use 2013). Exsanguination of the limb may be achieved
259
Non-automated tourniquets still require the opera-

TABLE 9-9: Tourniquet Inflation Pressures (Adults) tor of the unit to pre-set the inflation pressure. The
use of rubber bands or tubing (e.g. a Penrose drain)
LIMB OCCLUSION on digits precludes the use of pressure monitoring
PRESSURE ( LOP) PNEUMATIC CUFF PRESSURE devices. However, as with pneumatic tourniquets,
Upper limb Add 50–75 mmHg above
the operative digit should be assessed before and
systolic arterial blood pressure after application, and tourniquet use documented.
Lower limb Add 100–150 mmHg above

The circulating nurse should assess the use of
systolic arterial blood pressure the pneumatic tourniquet regularly to:
For paediatric patients, adding 100 mmHg above • monitor the inflation pressure to detect
systolic blood pressure is recommended (ACORN, 2016e). fluctuations
• monitor and record the duration of inflation
and inform the surgical team when the cuff
by either elevating the limb for 3–5 minutes or has been inflated for 1 hour, and every 15
wrapping an Esmarch’s (rubber) bandage from the minutes thereafter (Phillips, 2013)
distal part of the limb to the proximally located cuff. • document the use of a tourniquet, including
To avoid skin damage, soft wrinkle-free padding is cuff location, name of the staff member who
wrapped around the limb before applying the tour- applied and removed it, devices used for skin
niquet cuff. To prevent skin preparation solution protection, cuff pressure, and times of
from collecting under the cuff and causing skin inflation and deflation
maceration or burns, an impervious U-shaped drape
• assess skin integrity under the cuff before and
is placed around the cuff. The requisite cuff (or
after use (ACORN, 2016e).
inflation) pressure varies, depending on the patient’s
limb occlusion pressure (LOP) (see Table 9-9). Cuff
inflation should be rapid to allow arteries and veins THE MANAGEMENT OF
to occlude simultaneously (Phillips, 2013). ACCOUNTABLE ITEMS USED
The use of pneumatic tourniquets is contrain- DURING SURGERY
dicated in patients with vascular disease, impaired
limb circulation or malignancy or in the presence To ensure that all items used during a surgical pro-
of an arteriovenous access fistula because of the cedure are removed from the patient (unless inten-
increased risk of injury and paralysis (Phillips, tionally retained) a systematic and standardised
2013). Complications from tourniquet use arise approach is required. This is necessary to reduce
due to excessive cuff pressures and/or length of the risk of injury associated with inadvertent reten-
inflation time. However, there is a paucity of evi- tion of a surgical item (RSI) (ACORN, 2016f). As
dence to determine safe duration, inflation pres- discussed in Chapter 4, the management of account-
sure or reperfusion periods (Fitzgibbons, DiGiovanni, able items is the primary responsibility of the
Hares & Akelman, 2012). ACORN guidelines (2016e) instrument and circulating nurses, one of whom
recommend 60 minutes of inflation time for upper must be an RN, and it is achieved by undertaking
limbs and 60–90 minutes for lower limbs. Once the a surgical count (the count). Accountable items
tourniquet inflation time is reached, the surgeon are instruments, sharps, absorbent items such as
and anaesthetist must be notified and the tourni- sponges and gauze swabs, and small miscellaneous
quet should be deflated with a 10–15 minute release items and device fragments that by their nature and
of pressure before reinflation (ACORN, 2016e). In usage may be retained. Due to continuous techno-
general, upper limbs tolerate shorter periods of logical advances there is no definitive list of account-
ischaemia compared to lower limbs (Hicks & able items, and perioperative nurses must remain
Denholm, 2013). alert, as practice and surgical items continue to
evolve. Broadly speaking, however, those items that
Newer, automated tourniquets now incorporate must be counted include but are not limited to:
pressure-control devices that measure limb occlu-
sion pressure. These devices stop inflating the cuff • instruments recorded on the tray list
once the minimum pressure necessary to occlude • absorbent items, including sponges, swabs,
the arterial blood flow, distal to the cuff, is reached. patties, cherries, peanuts, eye swabs (strolls),
260
gauze strips, cottonwool balls and skin to take in emergency surgery or in the event of
preparation swabs an incorrect surgical count being recorded. In
• sharps, including needles, detachable blades, Australia, the ACORN standard, Management of
disposable scalpels and diathermy tips accountable items used during surgery/procedures
in the perioperative environment (ACORN, 2016f),
• vascular items, comprising vessel loops has been established in common law as the stand-
(‘ligaloops’), ‘snuggers’, cardiac snares, tapes, ard for the practice of counting (Staunton &
ligature reels, ‘ligaboots’, clip cartridges and Chiarella, 2013).
disposable bulldog clips
The standards should be used in conjunction
• disposable retraction instruments such as fish with respective state/territory or national health
hooks and visceral retractors department policies or guidelines (if evident)
• items that are identified in the local count (ACORN, 2016f). It is acknowledged that the risk of
policy items being retained unintentionally can vary
• additional items opened during the depending on the nature of the surgical procedure
procedure. (among other things). Consequently, those proce-
dures that require the management of accountable
Other items can be counted at the discretion of the items should be defined and items that must be
RN in charge and/or the instrument nurse (ACORN, counted should be determined by each hospital or
2016f).
facility’s multidisciplinary perioperative manage-
However, counting is not always sufficient to ment committee, who must also ensure that their
prevent RSIs (Feldman, 2011; Gibbs, 2011; Stawicki surgical teams comply with any locally developed
et al., 2013) and other ways to prevent these adverse policy (ACORN, 2016f; Agrawal, 2012).
events are evolving as attempts to identify their
General principles and roles and responsibili-
causes are explored. Research in the early 2000s
ties of staff are as follows:
highlighted that patient-specific characteristics
(obesity) and case-specific characteristics (emer- • The circulating and instrument nurses are
gencies, unanticipated change in procedure) responsible for ensuring that the count is
increased the risk; however, more recent research accurate and documented in the patient’s
indicates that OR culture, team attentiveness and intraoperative nursing record and the count
communication may be more significant (Gibbs, sheet. They also work collaboratively with
2011, 2014). Other ways to prevent RSIs, taking a other members of the surgical team to ensure
systems approach to error reduction, are continu- that all surgical items are retrieved on
ing to be developed and trialled. These include the completion of surgery.
use of information technologies such as bar coding • The surgeon must allow sufficient time for the
and radiofrequency identification systems in surgi- instrument and circulating nurses to conduct
cal sponges and other items (Ellner & Joyner, 2012; the count before, during and on completion of
Feldman, 2011; Goldberg & Feldman, 2012), and the surgical procedure.
the implementation of surgical team behavioural
changes (D’Lima, Sacks, Blackman & Benn, 2014; • The surgeon must carry out a manual and
Gibbs, 2014; Stawicki et al., 2013). Notwithstanding visual search of the operative field to ensure
the use of evolving technologies, they remain that all instruments and equipment are
adjuncts to completing the surgical count, which removed prior to completion of the surgical
remains paramount (ACORN, 2016f; Agrawal, 2012; procedure.
AORN, 2015d; Donnelly, 2014; Goldberg & Feldman, • If an accountable item is opened by the
2012). anaesthetic team during the surgical
procedure, it is the responsibility of that team
THE COUNT member to inform the instrument nurse and/
or the circulating nurse, who must sight the
Perioperative nursing standards guide the conduct
of the count (ACORN, 2016f; AORN, 2015d). These item and ensure that it is documented on the
standards identify roles and responsibilities, spell count sheet.
out a detailed process for conducting the count The procedure for completing the count is high-
and provide rationales. They also describe actions lighted in Box 9-4.
261
BOX 9-4 » UNDERTAKING THE SURGICAL COUNT

• The count is performed whenever accountable items are used during a surgical procedure.
• The surgeon is informed of the outcome of each count.
• A minimum of two counts of all accountable items should be completed. Where a body cavity is
entered, an additional count is undertaken when the body cavity is closed.
• The initial count is performed immediately prior to the commencement of the surgical procedure.
After the completion of the first count, all accountable items remain in the operating room until the
completion of the surgery and the final count.
• Additional counts can be undertaken at any time during the surgical procedure, at the discretion of
the instrument nurse and/or if local policy dictates this.
• The third or final count is performed and documented on commencement of the closure of the skin
or an equivalent closure.
• The count is carried out by two nurses, one of whom must be an RN, with both nurses counting
aloud together.
• A progressive ‘counting away’ technique is used.
• If it is necessary to relieve one or both nurses (e.g. as part of a fatigue management plan for
lengthy surgical procedures), the name(s) of the relieving nurse(s) and relieving times must be
documented on patient’s intraoperative nursing record.
• The tray list is used to check that all instruments in the tray are accounted for prior to the
commencement of the surgical procedure. This list is signed by the instrument nurse prior to the
return of the tray for cleaning and sterilisation.
• The surgeon is notified immediately of any discrepancy in the count and appropriate interventions
are undertaken to rectify this situation (see the section on ‘Incorrect count’ on p. 262).
• All accountable items remain in their packing until counted. All items are then separated and
counted. When counting swabs and sponges, each is opened so that both nurses can see the X-ray
detectable marker.
• Additional items added during the surgical procedure are counted and recorded.
• Those nurses responsible for the count must sign the count sheet.
• If the count is interrupted, counting of that item is recommenced.
• On completion of the surgical procedure, the surgeon also documents the outcome of the count in
accordance with local policy.
• The completed count sheet is included in the patient’s medical record.
• All accountable items are removed from the operating room only at the end of the surgical procedure
and completion of the final count, and prior to the commencement of the next surgical procedure.
SOURCE: ACORN (2016f ).
INCORRECT COUNT a thorough search of the surgical site (Stawicki

An incorrect count occurs when the items recorded et al., 2013). If this is unsuccessful, an immediate
on the count sheet do not match the actual number search of the surgical environment, including the
of items evidenced in the closing count(s). If there surgical drapes and linen, the floor and rubbish
is a discrepancy, the instrument nurse must notify containers should be completed, and the anaes-
the surgeon/proceduralist immediately and ask for thetist and the nurse in charge of the operating
262
suite should be notified. If the missing item is

one that is X-ray detectable, an X-ray should be
COLLECTION OF SPECIMENS
taken prior to the patient leaving the operating Many surgical procedures involve the collection
room (unless contraindicated by the patient’s con- of a specimen for pathology testing. The removal
dition) and the outcome documented (ACORN, of a tissue specimen frequently necessitates an
2016f). If a microneedle is missing and it is not invasive process and it can be potentially devastat-
X-ray detectable, a microscope and/or magnet may ing if mishandling/loss of the specimen occurs
be utilised (Goldberg & Feldman, 2012). If the (Brown, 2015). Cases of specimen mishandling have
missing item remains unaccounted for, the intraop- resulted in misdiagnoses and, in some instances,
erative nursing record must reflect this. Addition- patients have been required to undergo additional
ally, a record of the incident, including actions surgery to remove more tissue for pathology
taken to address it, is necessary, in line with local (ACORN, 2016g). In other cases, patients have had
policy (ACORN, 2016f). There are many more cases necessary treatment withheld or received inappro-
where an ‘incorrect’ count is in fact a miscount and/ priate or aggressive forms of treatment as
or an error of documentation and these are associ- a consequence (ACORN, 2016g; Brown, 2015).
ated with complacency and/or failure to adhere to Mismanagement of specimens has cost implica-
recommended guidelines (Donnelly, 2014; D’Lima tions for healthcare facilities, legal ramifications
et al., 2014). for hospitals and surgical team members, and
results in distress for all involved (ACORN, 2016g).
EMERGENCY SITUATIONS It is imperative to establish clear and unambiguous
In an emergency and when the patient’s condition processes for the identification, collection and
is critical, normal counting procedures may be transportation of specimens. To this end, specimen
waived and an X-ray performed at the end of the handling is now a component of the WHO SSC,
surgical intervention (or when the patient’s condi- whereby all team members are required to identify
tion is sufficiently stable) (ACORN, 2016f; AORN, and verify patient and specimen information prior
2015d). This is a long-standing practice, which con- to the patient leaving the OR (ACORN, 2016g;
tinues in many operating rooms and remains a rec- AORN, 2015e; WHO, 2009).
ommended standard. This is notwithstanding the Recommended practices provide guidance for
limitation of X-rays and/or their interpretation the handling, containment, identification, labelling
(Gibbs, 2011) and the resultant failure to detect and transporting of specimens within the periop-
many surgical items used in practice currently. erative environment and beyond, and these are
The surgeon must be informed when a count is not outlined in Table 9-10. While such guidelines are
completed and participate in actions to redress useful, they must be used in conjunction with other
the consequences (ACORN, 2016f; Gibbs, 2014; practices, such as those associated with infection
Goldberg & Feldman, 2012). Additionally, the peri- control and the use of personal protective equip-
operative nurse must document when a count is not ment, and the management of specimens must be
completed. subjected to regular audit.
TABLE 9-10: Correct Handling and Transportation of Specimens
RECOMMENDED
PRACTICE PROCESS
Undertake • Identify the type and number of specimens to be procured via patient assessment and
assessment for discussion with the surgeon.
specimen handling • Confirm the use of preservative or the need for fresh or frozen tissue sections with the
requirements surgeon.
• Collect and prepare specimen receptacles and preservative.
• Communicate with the pathology department regarding the management and transfer of
specimens.
Continued
263
TABLE 9-10: Correct Handling and Transportation of Specimens—cont’d
RECOMMENDED
PRACTICE PROCESS
Ensure an accurate • Confirm that the labels to be used for specimen identification contain the correct patient
patient and name, date of birth and unique hospital identifier and have been cross-checked against
specimen the patient’s ID bracelet, operative list and consent form. Commence specimen
identification identification at the time of removal of tissue from the body.
procedure is • The instrument nurse receives specimen from surgeon, who identifies specimen type,
undertaken identification markers (if relevant, e.g. marking stitch at 6 o’clock) and whether
preservative is required.
• The instrument nurse verifies information using ‘repeat back’ technique with the surgeon.
• The instrument nurse confirms specimen information with the circulating nurse.
• The circulating nurse verifies information using ‘repeat back’ technique with the
instrument nurse.
• The circulating nurse documents specimen information on verified labels with details of
specimen type, identifying markers, fixative used, and date and time of collection.
• The instrument nurse and the circulating nurse reconfirm patient name and specimen
information using a ‘write down, read back’ process and visual confirmation.
• The specimen is transferred to the labelled specimen container.
• Only one specimen should be handled on the aseptic field at one time utilising the
above-mentioned identification procedure.
• The circulating nurse ensures that all specimens removed from the patient are
documented on the specimen container, perioperative nursing record, pathology request
form and pathology register, including verified patient and specimen details, as above.
• A final team check is conducted of all specimens and associated documentation prior to
the patient leaving the OR.
Provide secure • Specimens are contained and then labelled as soon as possible after collection to prevent
collection and mishandling and identification errors.
handling of • The size of specimen and amount of required preservative solution are considered when
specimen without selecting the most appropriate container.
contamination • All containers are rigid, impervious, leak-proof and have tight-fitting lids.
• Staff use personal protective equipment and observe workplace health and safety
practices when handling fixative solutions.
Provide accurate • Verified patient identification labels with specimen details are securely attached to the
labelling of the specimen container.
specimen container • All labels are placed on the container and not the lid, to ensure that the information is
not lost when the lid is removed in the pathology department.
Establish accurate • Hospitals should establish methods to document the collection of pathology specimens.
communication and • Pathology registers or logbooks are commonly used to document specimens taken from
documentation of the operating suite to the pathology department and all specimens should be recorded
the collection, and therein. Information in these logbooks includes name, number and type of specimen(s,)
chain of custody patient details, diagnosis, studies required, date and time of collection, the surgeon’s name
and contact details, and the name of the nurse who prepared the specimen for transport.
• Whenever possible, printed documentation, such as patient identification labels, should be
used.
• When details are handwritten, they should be clear and legible.
• All documentation logged should establish a clear chain of custody from time of
specimen removal to arrival in the pathology department.
Ensure safe and • The pathology logbook may contain a place for the signature of the pathology technician,
appropriate who takes custody of the specimen.
transportation of • Staff need to check that all documentation and labels on the specimen containers are
specimen to fully completed prior to sending them to the pathology department.
pathology laboratory
SOURCE: ACORN (2016g) AND WHO (2009).
264
positioned patients and the interventions necessary

CONCLUSION to avoid them. Common complications related to
This chapter provided information pertinent to surgery, such as inadvertent perioperative hypo-
patient safety within the perioperative setting. It thermia and VTE, and the measures used to prevent
outlined a range of nursing activities along with or ameliorate them, were also explored and their
their rationales aimed at ensuring that the patient limitations in practice noted. This chapter also
is provided with the safest possible care. The chapter examined the policies, procedures and standards
explored the basic anatomical and physiological that underpin correct site surgery and the surgical
considerations related to patient transfer and count. Finally, best practice related to the care and
positioning, the potential sequelae for incorrectly handling of tissue specimens was addressed.

1. Patient identification
Accompanied by an undergraduate student nurse who you are precepting, you initiate Sign In of a
patient in the OR where you are the anaesthetic nurse. The student subsequently asks you to explain
the SSC with particular reference to patient identification.
• How would you address this request? Include rationales for your answers.
2. Patient positioning
Outline the risks associated with the following positions, and the actions you would take to ameliorate
them. Provide rationales for your responses.
A. An obese patient in the prone position
B. A middle-aged woman in the lithotomy position
C. An elderly patient placed on a fracture table
3. Management of accountable items
You are the circulating nurse caring for a patient undergoing a major abdominal procedure; an expe-
rienced perioperative EN is in the scrub role. The final count reveals that a sponge is missing.
• Outline the steps you would take, and provide rationales for your actions.
4. Tourniquet use
You are the circulating nurse caring for an obese patient undergoing bilateral total knee replacement.
Tourniquet cuffs are to be placed on both operative limbs. Outline the risks associated with each of the
following and the steps you would take to minimise patient injury. Provide rationales for your actions.
A. Tourniquet cuff selection and placement
B. Cuff inflation
C. Cuff deflation
Australian College of Operating Room Nurses

RESOURCES www.acorn.org.au
Agency for Clinical Innovation International Federation of Perioperative Nurses
www.aci.health.nsw.gov.au www.ifpn.org.uk
Association for Perioperative Practice Operating Room Nurses Association of Canada
www.afpp.org.uk www.ornac.ca
Association of periOperative Registered Nurses ORNursesDownUnder
www.aorn.org www.angelfire.com/nd/ornursesdownunder
Australian and New Zealand College of Anaesthetists Patient Safety Institute
www.anzca.edu.au www.ptsafety.org
265
Royal Australasian College of Surgeons Australian College of Operating Room Nurses (ACORN).
www.surgeons.org (2016b). ACORN standards for perioperative nursing 2016–
2017: Safe patient and manual handling. Adelaide: Author.
VIDEO RESOURCES Australian College of Operating Room Nurses (ACORN).

(2016c). ACORN standards for perioperative nursing 2016–
Action Products. (2012, 23 April). Basic principles of patient 2017: Purchasing and safety considerations for new equipment
positioning [Video.] Retrieved from www.youtube.com/ and instrumentation. Adelaide: Author.
watch?v=5_97uVDeO7Q. Australian College of Operating Room Nurses (ACORN).
Cameron, I. (2012, 3 February). The surgical count [Video.] (2016d). ACORN standards for perioperative nursing 2016–
Retrieved from www.youtube.com/watch?v=s4RCzhdQlVA. 2017: Position statement: Surgical safety. Adelaide: Author.
REFERENCES (2016e). ACORN standards for perioperative nursing 2016–
Agrawal, A. (2012). Counting matters: Lessons from the root 2017: Use of the pneumatic tourniquet. Adelaide: Author.
cause analysis of a retained surgical item. Joint Commission Australian College of Operating Room Nurses (ACORN).
Journal on Quality and Patient Safety/Joint Commission (2016f). ACORN standards for perioperative nursing 2016–
Resources, 38(12), 566–574. 2017: Management of accountable items used during surgery/
Aitkenhead, A. R. (2013). The operating theatre environment. procedures in the perioperative environment. Adelaide: Author.
In A. R. Aitkenhead, I. K. Moppett, & J. P. Thompson (Eds.), Australian College of Operating Room Nurses (ACORN).
Smith and Aitkenhead’s textbook of anaesthesia (6th ed., (2016g). ACORN standards for perioperative nursing 2016–
pp. 428–443). Edinburgh: Churchill Livingstone. 2017: Specimen identification, collection and handling.
Association of periOperative Registered Nurses (AORN). Adelaide: Author.
(2015a). Guideline for positioning the patient. In Guidelines Australian Commission on Safety and Quality in Health Care
for perioperative practice. Denver, CO: Author. (ACSQHC/the Commission). (2012a). National safety and
quality health service standards: Standard 8: Preventing and
managing pressure injuries. Retrieved from <www.safetyand
(2015b). Guideline for prevention of unplanned periopera-
quality.gov.au>.
tive hypothermia. In Guidelines for perioperative practice.
Denver, CO: Author. Australian Institute of Health and Welfare (AIHW). (2010).
The problem of osteoporotic hip fracture in Australia. Bulletin
no. 76. Cat. no. AUS 121. Retrieved from <www.aihw.gov.au/
(2015c). Guideline for care of patients undergoing pneu-
publication-detail/?id=6442468333>.
matically-assisted tourniquet procedures. In Guidelines for
perioperative practice. Denver, CO: Author. Australian Wound Management Association (AWMA). (2012).
Pan-Pacific clinical practice guideline for the prevention and
Association of periOperative Registered Nurses (AORN). management of pressure injury. Osborne Park, WA: Cambridge
(2015d). Guideline for prevention of retained surgical items. Media.
In Guidelines for perioperative practice. Denver, CO: Author.
Bauer, E. C., Koch, N., Janni, W., Bender, H. G., & Fleisch, M. C.
Association of periOperative Registered Nurses (AORN). (2014). Compartment syndrome after gynecologic opera-
(2015e). Guideline for specimen management. In Guidelines tions: Evidence from case reports and reviews. European
for perioperative practice. Denver, CO: Author. Journal of Obstetrics, Gynecology & Reproductive Biology, 173,
Australian and New Zealand College of Anaesthetists 7–12.
(ANZCA). (2014a). Clinical audit guide for perioperative nor- Bowen, B. (2015). Orthopedic surgery. In J. Rothrock & D.
mothermia. Retrieved from <www.anzca.edu.au>. McEwen (Eds.), Alexander’s care of the patient in surgery (15th
Australian and New Zealand College of Anaesthetists ed., pp. 679–767). St Louis: Elsevier Mosby.
(ANZCA). (2014b). Safety of anaesthesia: Review of anaesthe- Bozzio, A. E., Gala, R. J., Villasenor, M. A., Hao, H., & Mauffrey,
sia-related mortality reporting in Australia and New Zealand, C. (2014). Orthopedic trauma surgery in the morbidly obese
2009–2011. Retrieved from <www.anzca.edu.au>. patient. European Journal of Orthopedic Surgical Traumatolo-
Australia and New Zealand Working Party on the Manage- gie, 24, 421–425.
ment and Prevention of Venous Thromboembolism (ANZWP/ Braaf, S., Manias, E., Finch, S., Riley, R., & Munro, F. (2013).
VTE). (nd). Prevention of venous thromboembolism: Best prac- Healthcare service provider perceptions of organisational
tice guidelines for Australia and New Zealand (4th ed). communication across the perioperative pathway: A ques-
Retrieved from <https://www.surgeons.org/media/19372/ tionnaire survey. Journal of Clinical Nursing, 22(1–2), 180–
VTE_Guidelines.pdf>. 189. doi:10.1111/j.1365-2702.2012.04228.
Australian Bureau of Statistics (ABS). (2013). Profiles of Brown, R. W. (2015). Error reduction in the preanalytic
health, Australia, 2011–2013. Cat. no. 4338.0. Retrieved from process. In R. E. Nakhleh (Ed.), Error reduction and prevention
<www.abs.gov.au>. in surgical pathology (pp. 43–58). New York: Springer. doi:
Australian College of Operating Room Nurses (ACORN). 10.1007/978-1-4939-2339-7.
(2016a). ACORN standards for perioperative nursing 2016– Bryant, B., & Knights, K. (2015). Pharmacology for health
2017: Positioning the patient for surgery. Adelaide: Author. professionals (4th ed.). Sydney: Mosby Elsevier.
266
D’Lima, D., Sacks, M., Blackman, W., & Benn, J. (2014). Surgical Huang, H. Y., Chen, H. L., & Xu, X. J. (2013). Pressure-redistri-
swab counting: A qualitative analysis from the perspective bution surfaces for prevention of surgery-related pressure
of the scrub nurse. Journal of Perioperative Practice, 24(5), ulcers: A meta-analysis. Ostomy/Wound Management, 59(4),
103–111. 36–38, 42, 44, 46, 48.
Donnelly, T. (2014). Two, four, six, eight … stop and count John, M., Ford, J., & Harper, M. (2014). Perioperative warming
before it is too late! An audit on swab, needle and instru- devices: Performance and clinical application. Anaesthesia,
ment counts in theatre. Journal of Perioperative Practice, 69(6), 623–638.
26(6), 178–181. Kahn, S. R., Morrison, D. R., Cohen, J. M., Emed, J., Tagalakis,
Drake, R., Vogl, W., & Mitchell, A. (2015). Gray’s anatomy for V., Roussib, A., et al. (2013). Interventions for implementa-
students (3rd ed.). Philadelphia: Elsevier. tion of thromboprophylaxis in hospitalized medical and
Duff, J., Walker, K., Edward, K., Williams, R., & Sutherland- surgical patients at risk for venous thromboembolism.
Fraser, S. (2014). Incidence of perioperative inadvertent Cochrane Database of Systematic Reviews, (7), CD008201, doi:
hypothermia and compliance with evidence-based recom- 10.1002/14651858.CD008201.pub2.
mendations at four Australian hospitals: A retrospective Kakkos, S. K., Caprini, J. A., Geroulakos, G., Nicolaides, A. N.,
chart audit. ACORN Journal, 27(3), 16–23. Stansby, G. P., & Reddy, D. J. (2011). Combined intermittent
Ellner, S. J., & Joyner, P. W. (2012). Information technologies pneumatic leg compression and pharmacological prophy-
and patient safety. The Surgical Clinics of North America, laxis for prevention of venous thromboembolism in high-
92(1), 79–87. risk patients. Cochrane Database of Systematic Reviews, (3),
CD005258, doi:10.1002/14651858.CD005258.pub2.
Feldman, D. (2011). Prevention of retained surgical items.
Knaepel, A. (2012). Inadvertent perioperative hypothermia:
Mount Sinai Journal of Medicine, 78(6), 865–871. doi: 10.1002/
A literature review. Journal of Perioperative Practice, 22(3),
msj.20299.
86–90.
Fell, D., & Kirkbride, D. (2013). The practical conduct of anaes-
Kvederas, G., Porvaneckas, N., Andrijauskas, A., Svensen, C. H.,
thesia. In A. R. Aitkenhead, I. K. Moppett, & J. P. Thompson
Ivaskevicius, J., Mazunaitis, J., et al. (2013). A randomized
(Eds.), Smith and Aitkenhead’s textbook of anaesthesia (6th ed.,
double-blind clinical trial of tourniquet application strate-
pp. 444–461). Edinburgh: Churchill Livingstone.
gies for total knee arthroplasty. Knee Surgery, Sports Trauma-
Fitzgibbons, P. G., DiGiovanni, C., Hares, S., & Akelman, E. tology, Arthroscopy, 21(12), 2790–2799.
(2012). Safe tourniquet use: A review of the evidence. Journal
Lee, A. J., Raniga, S., Hooper, G., Perry, A., Bisset, R., Darley, D.,
of the American Academy of Orthopedic Surgery, 20(5), 310–
et al. (2012). The Time Out procedure: Have we changed our
319. doi:10.5435/JAAOS-20-05-310.
practice? New Zealand Medical Journal, 125, 26–35.
Gibbs, V. (2011). Retained surgical items and minimally inva-
Macke, R. A., & Nason, K. S. (2014). Minimally invasive resec-
sive surgery. World Journal of Surgery, 35, 1532–1539.
tion of benign esophageal lesions. Operative Techniques in
doi:10.1007/s00268-011-1060-4.
Thoracic and Cardiovascular Surgery: A Comparative Atlas,
Gibbs, V. (2014). Retained surgical items. In A. Agrawal (Ed.), 19(4), 396–413.
Patient safety a case-based comprehensive guide (pp. 129– McInnes, E., Jammali-Blasi, A., Bell-Sayer, S., Dumville, J., &
143). New York: Springer. Cullum, N. (2012). Preventing pressure ulcers: Are pressure-
Goldberg, J., & Feldman, D. (2012). Implementing AORN rec- redistributing support surfaces effective? A Cochrane sys-
ommended practices for prevention of retained surgical tematic review and meta-analysis. International Journal of
items. AORN Journal, 95(2), 205–219. Nursing Studies, 49(3), 345–359.
Hardman, J. G., & Bedforth, N. M. (2013). Anaesthesia for Miller, R. D., Eriksson, L., et al. (2010). Miller’s anesthesia
orthopaedic surgery. In A. R. Aitkenhead, I. K. Moppett, & (7th ed.). Philadelphia: Churchill Livingstone.
J. P. Thompson (Eds.), Smith and Aitkenhead’s textbook of Moola, S., & Lockwood, C. (2011). Effectiveness of strategies
anaesthesia (6th ed., pp. 578–589). Edinburgh: Churchill for the management and/or prevention of hypothermia
Livingstone. within the adult perioperative environment. International
Heizenroth, J. (2015). Positioning the patient for surgery. In Journal of Evidence Based Healthcare, 9(4), 337–345. doi:
J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient 10.1111/j.1744-1609.2011.00227.x.
in surgery (15th ed., pp. 155–185). St Louis: Elsevier Mosby. Mulligan, S., Prentice, J., & Scott, L. (2011). WoundsWest
Hicks, R. W., & Denholm, B. (2013). Implementing AORN wound prevalence survey 2011: State-wide overview report.
recommended practices for care of patients undergoing Perth: Ambulatory Care Services, Department of Health.
pneumatic tourniquet-assisted procedures. AORN Journal, National Health and Medical Research Council (NHMRC).
98(4), 382–396. (2011). Stop the clot: Integrating VTE prevention guideline
Hirvonen, E. A., & Niskanen, M. (2011). Thermal suits as an recommendations into routine hospital care (3rd ed.). Retrieved
alternative way to keep patients warm peri-operatively: A from <www.nhmrc.gov.au>.
randomised trial. European Journal of Anaesthesiology, 28(5), National Pressure Ulcer Advisory Panel, European Pressure
376–381. doi:10.1097/EJA.0b013e328340507d. Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance
Hozack, W. J., Parvizi, J., & Bender, B. (2009). Surgical treat- (NPU/EPU/PPPIA). (2014). Prevention and treatment of pres-
ment of hip arthritis: Reconstruction, replacement, and revision. sure ulcers: Quick reference guide. Retrieved from <www
Philadelphia: Elsevier. .internationalguideline.com/guideline>.
267
New Zealand Guidelines Group (NZGG). (2003a). Acute man- 25. Retrieved from <www.biomedcentral.com/1472-6955/
agement and immediate rehabilitation after hip fracture 11/25>.
amongst people aged 65 years and over. Retrieved from Sutton, S., Link, T., & Makic, M. B. (2013). A quality improve-
<www.health.govt.nz/publication/acute-management-and ment project for safe and effective patient positioning
-immediate-rehabilitation-after-hip-fracture-amongst during robot-assisted surgery. AORN Journal, 97(4), 448–456.
-people-aged-65-years-and-over>.
Tang, R., Ranmuthugala, G., & Cunningham, F. (2014). Surgi-
New Zealand Guidelines Group (NZGG). (2003b). Preven- cal safety checklists: A review. ANZ Journal of Surgery, 84(3),
tion of hip fracture amongst people aged 65 years and 148–154.
over. Retrieved from <www.health.govt.nz/publication/
Treadwell, J., Lucas, S., & Tsou, A. (2014). Surgical checklists:
prevention-hip-fracture-amongst-people-aged-65-years
A systematic review of impacts and implementation. BMJ
-and-over.
Quality & Safety, 23(4), 299–318. doi:10.1136/bmjqs-2012
New Zealand Ministry of Health. (2013). New Zealand health -001797.
survey: Annual update of key findings (2012/2013). Retrieved Warttig, S., Alderson, P., Campbell, G., & Smith, A. F. (2014).
from <www.health.govt.nz/nz-health-statistics/health Interventions for treating inadvertent postoperative hypo-
-statistics-and-data-sets/obesity-data-and-stats>. thermia. Cochrane Database of Systematic Reviews, (11),
Nilsson, U. G. (2013). Intraoperative positioning of patients CD009892. doi:10.1002/14651858.CD009892.pub2.
under general anesthesia and the risk of postoperative pain Waters, T., Baptiste, A., Short, M., Plante-Mallon, L., & Nelson,
and pressure ulcers. Journal of Perianesthesia Nursing, 28(3), A. (2011). AORN ergonomic tool 1: Lateral transfer of a
137–143. patient from a stretcher to an OR bed. AORN Journal, 93(3),
Nimmo, S., & Nimmo, G. R. (2013). Intercurrent disease 334–339.
and anaesthesia. In A. R. Aitkenhead, I. K. Moppett, & White, J. J., Khan, W. S., & Smitham, P. J. (2011). Perioperative
J. P. Thompson (Eds.), Smith and Aitkenhead’s textbook of implications of surgery in elderly patients with hip frac-
anaesthesia (6th ed., pp. 377–421). Edinburgh: Churchill tures: An evidence-based review. Journal of Perioperative
Livingstone. Practice, 21(6), 192–197.
Phillips, N. (2013). Berry and Kohn’s operating room technique World Health Organization (WHO). (2009). Surgical Safety
(12th ed.). St Louis: Elsevier Mosby. Checklist. Retrieved from <www.who.int/patientsafety/
Reynolds, N. (2013). Anaesthesia for the bariatric patient. In safesurgery/checklist/en>.
A. R. Aitkenhead, I. K. Moppett, & J. P. Thompson (Eds.), Smith World Health Organization (WHO). (nd). Safe surgery. Retrieved
and Aitkenhead’s textbook of anaesthesia (6th ed., pp. 550– from <www.who.int/patientsafety/safesurgery/en>.
559). Edinburgh: Churchill Livingstone. World Health Organization (WHO) World Alliance for Patient
Rowley, B., Kerr, M., Van Poperin, J., Everett, C., Stommel, M., Safety. (2008). The second global patient safety challenge:
& Lehto, R. (2014). Perioperative warming in surgical Safe surgery saves lives. WHO/IER/PSP/2008.07. Retrieved
patients: A comparison of interventions. Clinical Nursing from <www.who.int/patientsafety/safesurgery/en>.
Research, 24(4), 432–441. doi:10.1177/1054773814535428.
FURTHER READING
Royal Australasian College of Surgeons (RACS). (2009). Sur-
gical Safety Checklist. Retrieved from <www.surgeons.org/ Aurini, L., & White, P. F. (2014). Anesthesia for the elderly
member-services/college-resources/#surgicalsafety>. outpatient. Current Opinion in Anaesthesiology, 27(6),
563–575.
Russ, S., Rout, S., Sevdalis, N., Moorthy, K., Darzi, A., & Vincent,
C. (2013). Do safety checklists improve teamwork and Chiu, F., Hung, S., Chuang, T., & Chiang, S. (2012). The impact
communication in the operating room? A systematic of exsanguination by Esmarch bandage on venous hemo-
review. Annals of Surgery, 258(6), 856–871. doi:10.1097/ dynamic changes in total knee arthroplasty: A prospective
SLA.0000000000000206. randomized study of 38 knees. The Knee, 19, 213–217.
Graybill-D’Ercole, P. (2014). Recommended practices imple-
Skeik, N., Murphy, C. J., & Porten, B. R. (2014). The role of mentation: Specimen management. AORN Journal, 100(6),
novel anticoagulants in the management of venous throm- 625–636.
boembolism. Vascular Medicine, 19(3), 205–214.
Odom-Forren, J. (2013). Drain’s perianesthesia nursing: A criti-
Spruce, L., & Van Wicklin, S. A. (2014). Back-to-basics: Posi- cal care approach (6th ed.). St Louis: Elsevier Saunders.
tioning the patient. AORN Journal, 100(3), 298–305.
Steelman, V. M., & Alasagheirin, M. H. (2012). Assessment
Staunton, P., & Chiarella, M. (2013). Law for nurses and mid- of radiofrequency device sensitivity for the detection
wives (7th ed.). Sydney: Churchill Livingstone. of retained surgical sponges in patients with morbid
Stawicki, S. P. A., Moffatt-Bruce, S., Ahmed, H. M., Anderson, obesity. Archives of Surgery, 147(10), 955–960. doi:10.1001/
H. L., Balija, T. M., Bernescu, I., et al. (2013). Retained surgical archsurg.2012.1556.
items: A problem yet to be solved. Journal of American Yoon, R. S., Alaia, M. J., Hutzler, L. H., & Bosco, J. A. (2013).
College of Surgeons, 216(1), 15–22. Retrieved from <http:// Using ‘near miss’ analysis to prevent wrong site surgery.
dx.doi.org/10.1016/j.jamcollsurg.2012.08.026>. Journal of Healthcare Quality, August, doi:10.1111/jhq.12037.
Sutherland-Fraser, S., McInnes, E., Maher, E., & Middleton, S. Younger, A. S. E., Manzary, M., Wing, K. J., & Stothers, K. (2011).
(2012). Perioperative nurses’ knowledge and reported prac- Automated cuff occlusion pressure effect on quality of oper-
tice of pressure injury risk assessment and prevention: A ative fields in foot and ankle surgery: A randomized prospec-
before-after intervention study. BioMed Central Nursing, 11, tive study. Foot & Ankle International, 32(3), 239–243.
268
Chapter 10
SURGICAL INTERVENTION
SERENA COLE AND ANNE MAREE ALLANSON

LEARNING OUTCOMES
• Discuss the five instrument categories, including the names of at least two instruments from each
category
• Identify the two main classifications of suture material
• State the two main groups of needles available and explain their differences
• Describe the layout of the operating room for surgery, identifying placement of trolleys and the surgical
team
• Identify the stages of surgery
• Discuss the rationale for having a surgical sequence
• Discuss the two insertion techniques used in minimally invasive abdominal surgery
• Identify advances in techniques and technology
KEY TERMS
atraumatic needle
instrumentation
minimal access surgery
needle
operating room layout
surgical instruments
surgical sequence
suture
tie
269
INTRODUCTION TABLE 10-1: Common Indications for Surgical Procedures

The perioperative nurse plays an important role in
the surgical intervention of patients. Underpinning INDICATION FOR
this role is a sound knowledge of anatomy, the SURGICAL
physiological response to surgery, aseptic tech- PROCEDURE EXAMPLE
nique, safety, and legal and ethical aspects. Impor- Aesthetics Facelift
tantly, in order to provide appropriate assistance to
the surgical team nurses also require knowledge of Bypass/shunt Vascular rerouting
the sequence of surgery and the instrumentation Diagnostics Biopsy tissue sample
and wound closure materials used. This chapter dis-
cusses the instrumentation, suture materials and Diversion Creation of a stoma for urine
surgical needles required for a surgery. It also pro- Drainage/evacuation Incision of abscess
vides an historical overview of surgery along with
an outline of the principles of surgical intervention Excision Removal of tissue or structure
by sharp dissection
and the sequence of surgery. The chapter concludes
with an examination of some of the innovations Exploration Invasive examination
associated with minimally invasive surgery.
Extraction Removal of a tooth
Harvest Autologous skin graft

HISTORICAL SURGICAL PERSPECTIVE
Incision Opening tissue or structure by
Surgery is as old as human beings, with archaeolo- sharp dissection
gists finding skulls with evidence of having had
a surgical procedure performed dating back to Palliation Relief of obstruction
350,000 BC (Sullivan, 1996). Prior to anaesthesia Parturition Caesarean section
and anaesthetic technique, surgery was performed
only if absolutely necessary. Surgery developed Procurement Donor organ
along with knowledge in microbiology, disinfection Reconstruction Creation of a new breast
and anaesthetics.
Removal Foreign body
Modern surgery is the branch of medicine that
comprises perioperative patient care encompassing Repair Closing of a hernia
such activities as preoperative preparation, intra-
Termination Abortion of a pregnancy
operative judgement and management, and post-
operative care of patients (Phillips, 2013). Surgery Transplant Placement of donor organ
as a discipline combines physiological manage-
Stabilisation Repair of a fracture
ment with an interventional aspect of treatment,
which may be restorative, corrective, diagnostic or Staging Checking cancer progression
palliative (see Table 10-1). SOURCE: PHILLIPS (2013).
Surgical procedures are carried out in hospitals,
day surgery units or surgeons’ rooms. A surgical
procedure may be invasive, minimally invasive, constantly predictable and the surgical team must,
minimal access or non-invasive in nature. Any inva- at all times, be prepared for the unexpected.
sive or minimal access procedures involve entry Surgery and surgical techniques are continuing
into the body through an opening in the tissues or to evolve along with technology: the result is
a body orifice (Phillips, 2013). Non-invasive proce- increasingly less-invasive procedures and more
dures are frequently diagnostic and do not enter the rapid patient recovery. Improvements in technol-
body. Advances in diagnostic methodologies and ogy in perioperative patient care are attributed to:
drug therapies enable more individuals to be con-
sidered for surgery; however, each patient and each • surgical specialisation of surgeons and teams
procedure is unique. Surgery cannot be considered • sophisticated diagnostic and intraoperative
always completely safe, patient outcomes are not imaging techniques
270
CHAPTER 10 | Surgical intervention
• Making the skin incision with one stroke of evenly

Plan the incision
applied pressure minimises trauma
Handle tissue carefully • Ensures optimal and uncomplicated healing

and as little as possible • Helps minimise postsurgical pain
• Allows visualisation of the surgical field and preserves

Provide haemostasis
total blood volume
Preserve blood supply • Promotes wound healing
Debride necrotic and

• Promotes wound healing
devitalised tissue
Keep tissue moist • Promotes wound healing
Carefully and accurately • Eliminates dead space

approximate tissues • Promotes wound healing
Immobilise the wound • Protects and supports operative site
FIGURE 10-1: Principles of operative technique

• minimally invasive equipment and technology Approach used
• ongoing research and technological • Understand the

anatomy involved
advancements (Phillips, 2013). Procedure to be undertaken
• Know the surgeon’s approach
All surgery has clearly defined principles of (position and incision)
operative technique (Phillips, 2013). These princi- • Know the general condition of
ples are illustrated in Figure 10-1. the patient
Possible complications to be
SEQUENCE OF SURGERY encountered
• Understand the possible
Every surgical procedure, no matter how simple or complications related to the
complex, follows a defined surgical sequence. This proposed surgery
generalised sequence is adapted for the specific (intraoperative, postoperative)
surgical procedure being performed. Knowledge of
the stages of surgical intervention, instrumenta-
tion and suture material assists the perioperative Closure technique
nurse in ensuring safe patient outcomes. A working FIGURE 10-2: The four concepts that should be considered for any surgical event
knowledge is required of the sequential steps for a Source: Adapted from Phillips (2013).
specific surgical procedure based on four concepts
that should be considered for any surgical event.
These concepts are illustrated in Figure 10-2. have an in-depth knowledge of each stage of the
surgical sequence in order to anticipate the sur-
STAGES OF THE SURGICAL PROCEDURE geon’s requirements. The focus for the circulating
There are five sequential stages of a surgical proce- nurse is the provision of support to the surgical
dure (see Fig. 10-3). The instrument nurse must team, and management and coordination of the
271
III Exploration
I Open and isolation V Close
II IV
Dissection Repair, revise,
and excise or
exposure replace
FIGURE 10-3: Sequential stages of a surgical procedure
Source: Adapted from Phillips (2013) and Richardson-Tench & Martens (2005).
operating room. Refer to Chapter 1 for more Shank

Ring handle
information. Box lock
Ratchets
INSTRUMENTS Serrated
jaws
Surgical instruments are critical to the surgical
procedure. There are many elements to learn
regarding instrumentation, such as names, han-
dling, function, intended use, cleaning, sterilisation
FIGURE 10-4: Anatomy of a ring-handled instrument
and reassembly. All are very important; however, Source: Adapted from Phillips (2013).
for many new nurses the most important element
is to follow the progression of an operation and,
through observation, learn which instruments are
required for the various steps in the procedure,
their names and function. This knowledge enhances ANATOMY OF A RING-HANDLED INSTRUMENT
the nurse’s performance and leads to an ability to The features of a ring-handled instrument are out-
anticipate the surgeon’s requirements throughout lined below as an example of a surgical instrument
the operative procedure. In preparing instrumenta- (see also Fig. 10-4).
tion for an operation, the instrument nurse should
• Tips should mesh together evenly when the
check the sterility, working condition and com-
instrument is closed.
pleteness of the instruments being used.
• Jaws hold tissue or perioperative
INSTRUMENT CATEGORIES materials securely and the pattern of
Some basic manoeuvres are common to all surgical the jaws dictates its purpose. Artery
procedures. The surgeon dissects, resects or alters clamps/forceps have a serrated pattern,
tissue and/or organs to restore or repair body func- whereas needle holders have a cross-hatched
tions or body parts (Phillips, 2013). Surgical instru- pattern.
ments are designed to act as the tools that the • The box lock has a pin that holds
surgeon needs for each manoeuvre and are com- the two sides of the instrument
monly categorised into five major groups: together.
• cutting and dissecting instruments • The shank is the area between the box lock
• grasping and holding instruments and ring handles; the length is appropriate to
the wound depth.
• clamps
• Ratchets interlock to keep the jaws
• retractors locked when the instrument is
• miscellaneous/ancillary/accessory. closed.
Some of these instruments are ring-handled. • Ring handles are for ease of holding.
272
CUTTING AND DISSECTING INSTRUMENTS surgical specialty; for example, Potts scissors
Sharp dissection for vascular surgery have sharp-angled jaws.
Sharp dissection is the process of using a cutting • Suture scissors have round tips to prevent
instrument such as a scalpel, scissors or an alterna- trauma to the delicate surrounding structures;
tive energy source (electrosurgical device) to dissect, the blades are most commonly straight. When
incise, separate or excise tissue (Davies, 2014). holding suture scissors, the ring finger and
thumb are placed into the ring handles, and
Scalpels the index finger is placed along the outside of
the blade to stabilise the scissors. If more
Various scalpel blades are available with configura-
stability is needed while cutting sutures, the
tions for different uses. The Bard Parker and Beaver
fingers of the opposite hand may be placed
scalpel handles hold disposable scalpel or knife
under the box joint.
blades. The Fischer tonsil, Smillie cartilage and
Myringotome scalpel handles incorporate the blade • Dressing scissors are heavier to prevent
into the handle. damage to the scissors themselves.
Scalpel blades are a potential sharps hazard and • Wire cutters are used to cut stainless steel
therefore scalpels are passed by the instrument wires; the blades are short and heavy.
nurse and returned by the surgeon in a designated Some other instruments that belong under this
sharps receptacle. Where possible the creation of a heading include bone-cutting instruments, such as
neutral/safe zone will further decrease the poten- chisels, gouges, rasps, osteomes, files, drills, saws,
tial for a percutaneous injury (Ford, 2014; De Giro- rongeurs and bone nibblers. Curettes, biopsy
lamo, Courtemanche, Hill, Kennedy & Scarskard, forceps, punches, snares and dermatomes are also
2013). This neutral zone is a designated area created included in this category.
to hold any sharp instrumentation in a receptacle
and it is accessed by only one scrubbed person at a Blunt dissection
time (Patten, 2015). In certain surgical specialities—
such as cardiac, vascular and neurosurgery—it is Another form of separating tissues is blunt dissec-
not possible to pass scalpel blades and atraumatic tion. This involves separating tissues along a tissue
needles in this manner; hence, the instrument plane without actively cutting. This can be achieved
nurse should grasp the top of the scalpel handle by the surgeon using the fingers, a swab on a stick
and pass the scalpel with the handle towards the or a blunt instrument (Royal Australasian College
surgeon and the blade pointing downwards and of Surgeons, 2015).
back towards the instrument nurse.
GRASPING AND HOLDING INSTRUMENTS
Scissors Grasping and holding instruments are used to grasp
Scissors may open and close or have a spring action. or hold onto tissue, sutures, swabs or drapes. They
The spring action provides better control and more include:
precision, which is important when dissecting deli- • dissecting/tissue forceps
cate tissues, such as those within the eye. Handles • towel clips
can be short or long, with blades straight or angled.
Four basic types of scissors are available (see also • needle holders
Fig. 10-5): • sponge-holding forceps.
• Dissecting scissors must have sharp edges and When preparing instrumentation, the points of
are available in several types. The curvature, forceps should be checked to ensure that they are
weight and size vary according to the intended of equal length and that the teeth or serrations
use. The two most commonly utilised are the mesh smoothly and evenly when gently closed. The
Mayo (for dissection of heavy tissue, such as surgeon will grip the dissecting forceps like a pencil,
the fascia) and the much finer Metzenbaum with the tips pointing down. The instrument nurse
scissors (for dissection of delicate tissue, such should pass these forceps by holding the tips or the
as intestine or blood vessels). There are base of the forceps, allowing the surgeon to place
various styles of scissors designed for each his or her hand in the middle, ready for use.
273
B C
D E
F G
FIGURE 10-5: Types of surgical scissors. A, Tissue scissors. Blades may be straight or curved and either tip can be sharp or blunt. B, Joseph nasal scissors. C, Tenotomy
scissors. D, Wire suture scissors. E, Lister bandage scissors. F, Suture scissors. G, Potts angled scissors
Source: Adapted from Phillips (2013).
Dissecting/tissue forceps example, the Gillies forceps have finer teeth and are
Dissecting/tissue forceps hold tissue to stabilise it more likely to be used on the skin, whereas the
so that the surgeon can perform a manoeuvre, such thick heavy teeth of Bonney’s forceps means that
as dissecting or suturing, without injuring the sur- they are likely to be used for the fascia, cartilage or
rounding tissues (see Fig. 10-6). One group of dis- muscle. A common version of the non-toothed
secting forceps have a tweezer-like action; they variety is the DeBakey forceps, which are routinely
vary in length and are available as toothed or non- used on delicate tissues, such as blood vessels,
toothed. Toothed dissecting forceps have opposing bowel, nerves and ureters.
‘spurs’ or ‘teeth’ on either side of the jaws, which The other group of tissue forceps are ring-
interlock to provide extra grip. Toothed dissecting handled and have a scissor action. They can be
forceps are most commonly used on thick, strong either traumatic or atraumatic. The Allis forceps
tissues, such as skin, muscle, cartilage and fascia. have a row of teeth (traumatic) at the end to hold
The size of the ‘spurs’ or ‘teeth’ on the forceps indi- tissue gently but securely. The Babcock forceps
cates the type of tissue each would be used for. For have a smooth rounded end (atraumatic) that is
274
A B
C 1:2 2:3 3:4 4:5 D E

FIGURE 10-6: Types of tissue forceps. A, Bishop eye or forceps. B, Bayonet forceps. C, Forceps with teeth. D, Smooth forceps. E, Adson forceps
designed to fit around a structure or to grasp tissue Needle holders

without injury, and are commonly used on the Needle holders grasp the needle securely so that
bowel or appendix. Other ring-handled forceps may it can be passed through tissues without moving
be straight or curved (e.g. stone forceps), have sharp (see Fig. 10-7). The pattern is cross-hatched rather
points (e.g. Lahey forceps) or have curved or angled than grooved, and provides a smoother surface to
points on the ends of the jaws (e.g. tenaculum, enable a good grip on the needle. This pattern also
bone-holding forceps). prevents rotation and flattening of the needle,
which inhibits damage to the needle. Needle holders
Towel clips can be straight or curved. Most have a ratchet;
To secure drapes, diathermy quivers or other items however, in some surgical specialties (e.g. cardiac,
in order to prevent them falling off or below the ophthalmology and vascular surgery) they have
level of the aseptic field, towel clips are used. Care spring-action handles. The spring-action handle
must be taken not to loop an electrosurgical lead on a needle holder provides a much smoother,
through the handles of the towel clips to prevent gentler motion for the surgeon. Another style of
current leakage through the lead, thus heating the non-ratcheted needle holder incorporates scissors
towel clip (Covidien, 2011). Some disposable drapes within the shaft of the needle holder for ease of
have loops for attaching the diathermy leads or the cutting sutures. This style is often favoured by
sucker tubing to the drapes without the need for plastic surgeons, who use these needle holders
towel clips. when there are many individual sutures needed
275
A
B
C D
E
F
FIGURE 10-7: Needle holders. A, Crile needle holder. B, Mayo Hegar needle holder. C, Heaney needle holder. D, Derf snub-jaw needle holder. E, Ryder narrow tip needle holder.
F, Webster smooth jaw needle holder. G, Tungsten carbide insert in jaws of needle holder, with diamond-cut teeth, is designed to eliminate needle twisting and turning
to approximate a wound, thus minimising surgical around the tips to make what is referred to as a
time. ‘swab on a stick’, which can be used to soak up fluid
The general rule of thumb is that the size of in a small space, for blunt dissection or gentle
the needle indicates the tip of the needle holder retraction of tissues. The gauze squares used for a
required. A fine needle requires a smaller tip and a ‘swab on a stick’ must contain a radio-opaque
large needle a larger tip. Inappropriate selection of marker that will show up on X-ray in the case of an
the needle holder will damage either the instru- incorrect count.
ment or the needle being used. The length of the
needle holder is determined by the depth of the CLAMPS
wound. Clamps occlude, manipulate, crush or hold tissue
and other material. Between the ring handles is a
Sponge-holding forceps ratchet that is designed to lock the jaws onto tissue
Sponge-holding forceps have several functions. or other material. Within this category are artery
Their most common use is to pick up swabs for clamps/forceps, and crushing and non-crushing
skin preparation. Gauze squares can be wrapped clamps.
276
Artery clamps/forceps
Artery clamps/forceps occlude or clamp blood
vessels and other tissue with minimal trauma
because of the deep transverse serrations within
the jaws. They come in different sizes and styles—
straight, curved, short and long. The serrations
should be cleanly cut and mesh together evenly as
these serrations hold the tissues within the jaws of
A
the clamp. Artery clamps/forceps must not be used
for any reason other than what they are designed
for. This rule applies to all instruments.
Crushing clamps B
There are many variations of crushing clamps, all
C
designed for a specific purpose. The jaws may be
FIGURE 10-8: Manual retractors. A, Solid blade appendiceal retractor. B, Double-
straight, curved or angled, and the serrations may
ended Army-Navy retractor. C, Volkmann rake retractors (tips can be sharp or blunt)
be horizontal, diagonal or longitudinal. The tip may Source: Adapted from Phillips (2013).
be pointed or rounded or have a tooth along the
jaw, such as on a hysterectomy clamp. Some clamps
are designed for use on specific organs, such as
bowel clamps, which are used on bowel tissue that
is diseased and requires dissection and removal.
Non-crushing clamps
Non-crushing clamps are designed to gently occlude
a structure without causing injury to that structure.
Non-crushing vascular clamps are used to occlude
peripheral or major blood vessels temporarily (e.g.
non-crushing vascular DeBakey clamps), which
minimises tissue trauma. The jaws of these clamps
have opposing rows of finely serrated teeth and Upright post
may be straight, curved, angled or S-shaped. Non- attaches to
A OR bed
crushing bowel clamps are atraumatic and hold
healthy bowel tissue without causing damage.
These non-crushing clamps enable the bowel tissue
and blood vessels to be re-anastomosed.
RETRACTORS
Retractors hold back wound layers and anatomical
structures to allow visualisation of the operative
site; they can be hand-held or self-retaining (see
Figs 10-8 and 10-9). There are two types of self-
retaining retractors: those that attach to a frame,
such as the Bookwalter® or Omni-Tract® retrac-
tors; and those that are held in place by a ratchet,
such as the Weitlander retractor or Gelpi retractor. B
At the beginning and end of the surgical count, FIGURE 10-9: Bookwalter® retractor. A, Bookwalter retractor assembled.
any retractor with screws or extra blades must be B, Bookwalter retractor disassembled
checked and accounted for to ensure that no items Source: Adapted from Phillips (2013).
or loose parts are retained within the patient
(ACORN, 2016). Self-retaining retractors should be
277
handed to the surgeon in the closed position. Hand- hand, leaving the surgeon to focus on the surgical
held retractors usually come in pairs and can be field (see Table 10-2 and Fig. 10-10). The position
single- or double-ended, traumatic or atraumatic, of the instrument nurse and instrument table
with a variety of shapes and sizes (e.g. skin hooks, set-up depend on the operating room (OR) layout
cat’s paw, rakes, Czerny, Langenbeck or Deaver and subsequent traffic patterns (see Fig. 10-11). OR
retractors). designs are discussed in Chapter 5. Other determi-
nants include:
MISCELLANEOUS/ANCILLARY/ACCESSORY • positioning the set-up in an area with minimal
The miscellaneous category contains instruments traffic flow
that do not fit into any other category by virtue of
• the position of other members of the
their function. These include suction tips, probes,
perioperative team (e.g. surgeon, anaesthetist)
trocars and so on.
• site and side of the surgical procedure to be
INSTRUMENT HANDLING AND PASSING performed.
Instrument exchange occurs with the instrument As a general rule, the instrument nurse stands oppo-
nurse focusing on the instrument to be handed and site the surgeon and beside the assistant for ease of
passing the instrument directly into the surgeon’s instrument passing and maximum visibility.
TABLE 10-2: Instrument Passing Techniques
CONSIDERATIONS FOR INSTRUMENT

SKILL NURSE RATIONALE
Passing • Pass in a deliberate and committed • Weak pressure when passing an instrument
instruments manner creates a distraction of uncertainty and the
with adequate • Use a small amount of pressure potential for the surgeon to unnecessarily look
pressure away from the aseptic field
Providing a • Provide a slight pause as the surgeon • No pause technique can lead to unstable
slight pause takes the instrument to ensure the transfer and the likelihood of dropping the
when passing surgeon has a proper grasp of the instrument
an instrument instrument • A grabbing technique can lead to injury
• Allows the instrument nurse to remove the
passing hand from the transfer zone
Minimising • Count and place instruments where they • Deliberate planned movements decrease
handling of will be needed for the duration of the handling, ensure that instruments can be
instruments operation retrieved quickly and decrease the potential for
• Place instruments in the surgeon’s hand dropping the instruments
ready for use without repositioning • Instruments are passed in a way that they are
ready for immediate use and do not have to be
repositioned
Passing sharps • Transfer sharps using an established • This establishes safe practices for all the
neutral zone or designated receptacle surgical team and decreases the potential for
• If the type of surgery prevents this needlestick injury
practice, place one hand over the scalpel • A risk assessment appropriate to the specialty
handle with the blade facing down and surgery will determine the technique most
back towards the nurse appropriate for safe transfer of sharps
Passing • Hold instruments by the box joint with • The instrument curve is passed so that it is
ring-handled the tips facing up and the curve of the positioned ready for immediate use
instruments instrument ready to face towards the • The instrument is held at the box joint so that
centre of the surgeon’s hand the surgeon can grasp it easily by the ring
handles, ready to use
278
TABLE 10-2: Instrument Passing Techniques—cont’d
CONSIDERATIONS FOR INSTRUMENT

SKILL NURSE RATIONALE
Selecting the • Select the type and length of the • Using large instruments for delicate surgery is
correct instrument that will be suitable for the more likely to cause tissue damage
instruments task involved • Using delicate instruments for dense tissue is
more likely to lead to instrument damage
• Short instruments will not reach deep wounds
• Long instruments are unstable on superficial
wounds
Recognising and • Some instruments may require a • Assists in reducing operating time
passing complementary instrument (e.g. scissors
complementary and forceps, needle holder and forceps)
instruments • If the surgeon asks for an instrument
together automatically hand the complementary
instrument as well
Two-handed • When using complementary • Passing two instruments at the same time:
passing instrumentation, place one instrument in – decreases the instrument nurse’s impact
(ambidextrous) one hand and the other in the other hand on the surgical space
• Use both hands to pass the instruments – decreases instrument handling and
simultaneously to the surgeon movement
• Do not cross over hands on passing – decreases the surgical time
Anaesthesia
machine Anaesthesia
provider
Draped patient
and operating
bed
First
Surgeon assistant
FIGURE 10-10: Passing an instrument Kick Kick

Source: Phillips (2013). bucket bucket
Scrub
Suction person
container Mayo stand
The layout of the instrument table will vary
depending on the operation, the hospital’s practice Instrument
table
and the teaching staff within the perioperative Electrosurgical
unit
environment. A key consideration is to strive for
standardisation so that the nurse always knows
FIGURE 10-11: Arrangement of the operating room showing the aseptic field, team
where the instruments are for every case. The
members and unsterile equipment
relevant instruments needed for the procedure Source: Adapted from Phillips (2013).
should be prioritised so that those used most fre-
quently are placed in closest reach (see Figs 10-12
and 10-13). Points to consider: instrument nurse who manages the flow of
instruments to and from the Mayo table.
• The Mayo table (if used) should contain those Self-selection from the Mayo table by the
instruments that are used frequently. surgical team should be discouraged due
• Although the Mayo table is placed in close to the risk of sharps injury and/or
proximity to the surgical field, it is the misplacement of items. A neutral zone on
279
FIGURE 10-12: Instrument table layout
FIGURE 10-13: Mayo table and splash bowl
the Mayo table will be of benefit to the team, easily seen; the tips should not face out to
particularly if the instrument nurse is unable prevent inadvertent injury. Box joints should
to assist. be more towards the centre of the table for
• Similar instruments should be placed together ease of grasp.
(e.g. varying sizes of artery clamps, various • Instruments that are not commonly needed
tissue forceps). should be placed on the instrument tray and
• The tips of instruments should face the centre table furthest away to allow more room for
of the Mayo table so that all the tips can be surgical items that are needed more frequently
280
(e.g. sponges, sutures, wet sponge for cleaning • Damaged or blunt instruments should be set
instruments). aside for repair or replacement (ACORN, 2016;
• More instrument tables may be required for Bourdon, 2014; Goodman & Spry, 2014).
more complex procedures or if it is necessary
to have clean and contaminated areas to SUTURES AND NEEDLES
demarcate any contaminated instruments
Documented evidence regarding the use of sutures
(e.g. in bowel surgery).
dates as far back as 2000 BC (McCarthy, 2015);
CARE OF INSTRUMENTATION however, it was not until the mid-1800s, as a result
of increased infection rates, pain and haemorrhage,
Instruments are very expensive but they can last a
that a wider variety of suture materials and their
long time if they are properly cared for and main-
uses developed. Suture materials and needles were
tained. General rules for good instrument care:
not sterilised until Joseph Lister began to experi-
• Blood and/or tissue should be wiped off ment with carbolic acid as a form of sterilisation
instruments intraoperatively using a sterile during the 19th century (Muffly, Tissano & Walters,
sponge soaked with sterile water. Blood or 2011). Traditionally, the word suture referred to a
tissue that dries, becomes hard on the strand of material used to close wounds, or ligate
serrations of jaws or blades of scissors and tissues or blood vessels. These strands were passed
impairs the function of the instrument makes through the eye of a needle that resembled an ordi-
cleaning more difficult postoperatively and nary household sewing needle. Today, needle and
causes instruments to become stiff and suture materials are joined together as a continu-
damaged. Instruments with lumens or ous unit referred to as an atraumatic needle,
channels (e.g. Frazier suckers) should be which is eyeless and pre-sterilised. The ‘eyed’
irrigated periodically, intraoperatively, to needle meant that two strands of suture material
prevent blockages. were being pulled through the tissues, causing a lot
• Soaking instruments in saline can lead to of trauma. However, atraumatic needles cause less
rusting, pitting and instrument damage. tissue trauma because only one strand of suture
material is pulled through the tissues.
• Delicate or microsurgery instruments should
be kept separate from other instrumentation. The evolution of surgery has witnessed the use
Never place heavy instruments on top of of numerous materials, ranging over the years from
delicate or microsurgery instruments. gold, silver, silkworm gut, cotton, silk, linen, tendon
and intestinal tissue to the synthetic fibres of today.
• Instruments should be handled gently at all
These include, but are not limited to, nylon, poly-
times and should not be thrown, bounced or
ester, polypropylene and polymer combinations.
dropped.
• Sharp edges and pointed tips should be Table 10-3 presents the majority of sutures
protected so that staff members responsible available on the Australasian market; the informa-
for cleaning are not injured. tion incorporates both Covidien and Ethicon’s
products. If a suture material is the same product
• Fibreoptic cables should be coiled loosely and but named differently because it is produced by
placed on top, or separated from other another company, both names are included in the
instrumentation. table. Figure 10-14 illustrates a suture packet.
• Instruments should always be used for their
intended purpose! Scissors or clamps that are PROPERTIES OF SUTURE MATERIALS
misused can be forced out of alignment and The properties that are taken into consideration
break. Curved tissue scissors that are used to when choosing and evaluating the effectiveness of
cut sutures or dressings will soon become blunt. suture materials are outlined below.
• Forceps, clamps and other hinged instruments
should be inspected at the beginning and end ABSORBABLE/NON-ABSORBABLE MATERIALS
of each procedure to ensure that the jaws or Absorbable suture materials are capable of being
teeth align and they have no defects and absorbed by living tissue, yet may be treated to
function properly. modify the rate of absorption. The source may be
281
282
TABLE 10-3: Sutures Available on the Australasian Market
SUTURE
SUTURE MONOFILAMENT/ COLOUR MATERIAL
NAME NATURAL/SYNTHETIC MULTIFILAMENT CODING COLOUR USE DIAMETER
Absorbable sutures
Biosyn Glycomer 631, synthetic Monofilament Red/rose Violet and General soft-tissue approximation and/or 1–6-0
undyed ligation and ophthalmic surgery
Caprosyn* Polyglytone 6211, synthetic Monofilament Pink/rose Clear and violet General soft-tissue approximation and/or 1–6-0
ligation but not cardiovascular,
neurosurgery, microsurgery or
ophthalmic surgery
Chromic Collagen from sheep mucosa Multifilament Tan Tan and blue (for Tissues that do not require extended 3–7-0 and ties
gut** or beef serosa treated with ophthalmology) wound support and ophthalmology
chromic salts, natural
Dexon II, Polyglyclic acid, synthetic; Multifilament Green Bicolour and General soft-tissue approximation and/or Dexon II, 2–6-0
Dexon S* Dexon II is coated and Dexon (braided) beige ligation and ophthalmic surgery and ties; Dexon S,
S is not 2–10-0
Maxon Polyglyconate, synthetic Monofilament Green Green and clear General soft-tissue approximation and/or 1–7-0 and ties
ligation, paediatric, cardiovascular tissue
Monocryl Polyglecaprone 25, synthetic Monofilament Coral/ Coral/apricot, General soft-tissue approximation and/or 2–6-0
apricot undyed ligation
PDS, PDS II Polydioxanone Monofilament Silver Violet and clear Abdominal and thoracic closure, 2–9-0
subcutaneous tissue, colon/rectal surgery,
orthopaedic and plastic surgery
Polysorb* Lactomer 9-1, synthetic Multifilament Violet Violet and General soft-tissue approximation and/or 2–8-0 and ties
(braided) undyed ligation and ophthalmic surgery
Surgical Collagen from sheep mucosa Multifilament Yellow Yellow Ligation of superficial vessels and 2–7-0 (Covidien);
gut, plain or beef serosa, natural subcutaneous tissues and ophthalmology 3–7-0 (Ethicon)
gut**
Velosorb™ Synthetic polyester Multifilament Violet Violet and Soft-tissue approximation of the skin 0–5-0, 7-0, 8-0
Fast* comprised of glycolide and braided undyed and mucosa
lactide (derived from glycolic
and lactic acids)
TABLE 10-3: Sutures Available on the Australasian Market—cont’d
SUTURE
Vicryl* Polyglactin 910, synthetic Braided Violet Violet and General soft-tissue approximation and/or 10-0–2-0, 0–3
monofilament undyed ligation and ophthalmic surgery and ties
Vicryl Polyglactin 910, synthetic Multifilament Violet Violet and Superficial soft-tissue approximation of 1–7-0
Rapide— (braided) undyed skin and mucosa
coated
V-Loc™ 1. Glycomier 631(Biosyn) 1. Monofilament 1. Purple Undyed, violet, Gastrointestinal anastomosis, abdominal
barbed 2. Polyglyconate Maxon) 2. Monofilament 2. Silver green and blue sheath, fascia, plastic surgery
suture
Non-absorbable sutures
Ethibond Polyester polyethylene Braided Orange Undyed, green Cardiovascular, general, plastic 5–7-0
terephalate, synthetic; coated and light green
with polybutylate
Ethilon Polyamide polymer and Monofilament Mint green Undyed, green, Skin closure, retention sutures, plastic 2–11-0
nylon 6, synthetic blue and black surgery, ophthalmology and microsurgery
Mersilene Polyester, synthetic Multifilament Turquoise Green and Cardiovascular, general, plastic and 5–11-0
undyed ophthalmology
Monosof/ Long-chain aliphatic Monofilament Green Monosof undyed General soft-tissue approximation and/or Monosof, 2–11-0;
Dermalon polymers nylon 6 and 6.6, or black; ligation including cardiovascular, Dermalon, 2–6-0
synthetic Dermalon blue neurological and ophthalmic surgery
Novafil Polybutester, synthetic Monofilament Green Blue and undyed General soft-tissue approximation and/or 2–10-0 and ties
ligation, including cardiovascular and
ophthalmic surgery
Nurolon, Long-chain aliphatic Multifilament Green Black and General soft-tissue approximation and/or Nurolon, 1–6-0;
Surgilon polymers nylon 6 and 6.6, (braided) undyed ligation including cardiovascular, Surgilon, 2–7-0
synthetic neurological and ophthalmic surgery
Prolene, Polypropylene, synthetic Monofilament Deep blue Blue and undyed General soft-tissue approximation and/or 2–10-0
Surgipro ligation, including cardiovascular,
neurological, plastic and ophthalmic
surgery
Continued
283
284
TABLE 10-3: Sutures Available on the Australasian Market—cont’d
SUTURE
PRONOVA™ Polymer blend of poly Monofilament Blue Blue/clear Cardiovascular and vascular 3-0 –7-0
Poly (vinylidene fluoride) and poly
(vinylidene fluoride-co-
hexafluoropolypropylene
Silk, Sofsilk Natural fibre from protein of Multifilament Light blue Black and General soft-tissue approximation and/or 5, 2–9-0 and ties
raw silk, natural (braided) undyed ligation, including cardiovascular,

neurological, microsurgery and
ophthalmic surgery; common use:
central venous line, drains and retention
sutures in cardiac surgery
Surgical 316 stainless steel, natural Multifilament or Mustard Silver/steel Abdominal wall closure, tension repair, 7–10-0, with and
stainless monofilament skin closure, orthopaedic and without needles
steel, steel neurosurgery; sternal closure in
cardiothoracic surgery; hernia repair and
intestinal anastomosis
TI-Cron Polyester polyethylene Braided Orange Undyed and blue General soft-tissue approximation and/or 5–8-0 in both
terephalate, synthetic ligation, including cardiovascular, braided coated
neurological and ophthalmic surgery; and uncoated; or
particular use in cardiac valve 9-0–11-0
replacement surgery monofilament
uncoated and ties
Vascufil™ Polybutester, copolymer of Monofilament Green Blue Cardiovascular and vascular 3-0–8-0
butylene terephthalate and
polytetramethylene ether
glycol; coated with
Polytribolate™
V-Loc™ 3. Polybutester (Novafil) 3. Monofilament 3. Green Undyed, violet, Plastic surgery, skin closure, 1-0, 2-0, 3-0, 4-0
barbed green and blue gastrointestinal anastomosis, abdominal
suture sheath, fascia
*ABSORBED BY HYDROLYSIS; **ABSORBED BY ENZYMATIC.
SOURCE: ADAPTED FROM COVIDIEN AND ETHICON SUTURE RANGES.
are artificial and made from materials such as nylon,

polypropylene, polyethylene, polyester, polyglactin
or surgical steel.
DIAMETER OR SIZE OF SUTURE MATERIAL

In Australia, the diameter of a suture is determined
in millimetres. The base numeral is 0, with the sizes
ranging from 7 (largest) down to 11-0 (smallest; see
Fig. 10-15). Sizes 0 to 7 have a progressively larger
diameter, whereas sizes 0 to 11-0 are progressively
smaller. Once the scale falls below 0, the numbers
would normally be referred to as minus 1, minus 2;
however, they are referred to as 2-0, 3-0 and so on.
Sizes 0 to 4-0 are the most commonly used sizes
FIGURE 10-14: An example of a suture packet (see Fig. 10-16). The diameter of the suture mate-
rial and the size of the atraumatic needle attached
are chosen depending on the type and thickness of
natural or synthetic. Absorbable sutures break tissue being approximated.
down by hydrolysis or are digested by the body’s
MONOFILAMENT/MULTIFILAMENT
enzymes, initially losing strength and gradually
being absorbed by the body. Accelerated absorba- Monofilament sutures are made of a single strand
bility of the suture may occur if the material is of suture material (see Fig. 10-17), which is less
moistened before the suture is used or by fluid in a prone to harbouring microorganisms. Monofila-
body cavity (McCarthy, 2015). ment sutures also provide less resistance when
passing through tissue. However, crushing the
Non-absorbable suture materials are not strand weakens monofilament sutures, which can
affected by hydrolysis or enzymatic activity and can lead to premature suture failure.
be synthetic or natural. Non-absorbable sutures
become encapsulated during the healing process Multistranded or multifilament (braided) sutures
and the term non-absorbable suggests that they are composed of multiple strands that are either
remain within the body indefinitely. However, this braided or twisted together (see Fig. 10-17). These
does not equate to the suture maintaining its materials are more pliable than monofilament
original strength. The strength of any suture mat sutures and are easier to handle and tie, but they
erial will slowly lessen over time. Non-absorbable generate more friction when passing through tissue.
sutures generally retain their strength for a longer
TIES
period of time than do absorbable suture materials
(McCarthy, 2015). For example, Monosof, Dermalon A tie is a piece of suture material without a needle
and Surgilon (non-absorbable suture materials) attached to it. Ties are used to ligate a bleeding
lose strength over time, with essentially no strength vessel, as discussed in Chapter 11 (Phillips, 2013).
left after 5 years (Covidien, 2015).
HANDLING CHARACTERISTICS
NATURAL/SYNTHETIC MATERIALS Other properties that determine which suture a
Natural suture material is derived from sources surgeon may choose are based on the handling
such as collagen, silk and cotton. Synthetic sutures characteristics.
Smaller gauge Zero Larger gauge
11-0 10-0 9-0 8-0 7-0 6-0 5-0 4-0 3-0 2-0 0 1 2 3 4 5 6 7
FIGURE 10-15: Suture material gauge

285
Percentage volumetric reduction with

decreased size of suture
USP* EP+ mm
3 6 0.60–0.699
2 5 0.50–0.599
A
1 4 0.40–0.499
0 3.5 0.35–0.399
2/0 3 0.3–0.339
3/0 2 0.20–0.24 B
FIGURE 10-17: Monofilament (A) and multifilament (B)
4/0 1.5 0.15–0.19 Source: Adapted from McCarthy (2015).
5/0 1 0.10–0.14
being stretched. Once removed from its packaging,
6/0 0.7 0.07–0.099 plain gut, nylon and catgut suture material remains
coiled. After the suture material has been stretched,
7/0 0.5 0.05–0.069 although it appears straight, it still has small curves
8/0 0.4 0.04–0.049
from where it was coiled in the original packet. To
remove the elasticity of the suture material, the
9/0 0.3 0.03–0.039 atraumatic needle is loaded within the jaws of a
needle holder while grasping the swaged end of the
10/0 0.2 0.02–0.029
suture material with the thumb and forefinger. Both
hands are gently extended and, in doing so, the
*United States pharmacopeia
+
European pharmacopoeia suture material is stretched, removing the elastic-
FIGURE 10-16: Relative suture sizes
ity. The suture material should not be ‘tugged’ or
Source: Davies (2014). ‘snapped’ as this can damage the fibres within the
strand of suture material (McCarthy, 2015). Due to
Creutzfeldt-Jakob disease, plain gut and catgut are
PLIABILITY AND COEFFICIENT FRICTION slowly being removed from production and use;
The pliability of the suture material is the ease with however, they may still be seen in certain ORs.
which it bends; the coefficient friction is the drag
caused by the pulling of the material through the CAPILLARITY
tissue and the security of the knot. Suture material The capillarity of the suture material refers to its
may be coated to reduce tissue drag, thereby making ability to transmit fluid along its length. Multifila-
it easier to remove; however, this, in turn, makes the ment sutures have more capillarity, drawing fluid
knots less secure. Sutures made from nylon are not into the space along and between filaments. This
as pliable; have some elasticity, memory and a low increased absorption of fluid along its length may
coefficient friction; create knots that are less secure; act as a tract to introduce pathogens into deep
and are prone to unravelling (McCarthy, 2015). tissue (McCarthy, 2015).
ELASTICITY OR MEMORY TENSILE STRENGTH AND KNOT STRENGTH

Elasticity or memory is the ability of the suture The amount of force exerted on the suture material
strand to return to its original ‘packet’ shape after in order to make it break is known as its tensile
286
strength. Tensile strength also takes into consid- absorbables, staples, tapes and adhesive compounds.
eration the time in which the suture retains its Natural glues, surgical staples and tapes substitute
integrity before breaking down. The force necessary for sutures where appropriate for wound closure.
to cause a knot to slip or break is known as its knot Skin adhesives and barbed sutures are two examples
strength. Sutures with a high memory and low coef- of innovations in skin closure. Refer to Chapter 11
ficiency have poor knot strength (McCarthy, 2015). for detailed information on wound closure.
The Resources section at the end of the chapter
provides an illustrated step-by-step guide on how SKIN ADHESIVES
to tie knots. Skin adhesives are used to close the skin instead
of a suture or skin clips/staples. They have been on
the market for some years now and the technology
TISSUE REACTION CHARACTERISTICS is improving. As the results of using skin adhesives
All suture materials cause some tissue reaction. are becoming better known, more surgeons are
This reaction begins when the suture material willing to use the products. Some surgeons use both
passes through the tissue. The inflammatory a skin adhesive and a suture material to close the
response causes the area to be infiltrated with skin; this provides a much better waterproof barrier,
white blood cells, macrophages and fibroblasts— which assists in preventing wound infections.
the very process that initiates healing in the wound Feature box 10-1 discusses several skin adhesive
also causes the breakdown or encapsulation of the products.
suture material. The timeframe in which the suture
maintains its strength is significant to the choice of BARBED SUTURES
suture material. Suture materials such as silk have One addition for wound closure is the barbed
a higher prevalence of tissue reaction compared to suture, a suture material with barbs along the mate-
nylon, which is much less reactive. Other factors rial (see Research box 10-1). These barbs act as
that influence suture material selection are tissue anchors to secure the suture material in the tissue.
type, the patient’s nutritional status and the pres- The advantages of this suture material are there are
ence or absence of infection (Lai & Becker, 2013). no knots to tie, which decreases the time it takes to
Wound closure techniques have evolved from suture; ease of placement; and the tension pro-
the earliest development of suturing materials to vided across the incision is uniform. If there is not
comprise resources that include synthetic sutures, uniform tension across an incision the following
FEATURE BOX 10-1 » NEW TECHNOLOGIES IN SKIN CLOSURE
The original Dermabond skin adhesive required two layers of the adhesive to be applied, but the
newest formula, Dermabond Advanced, requires only one layer of adhesive. Dermabond PRINEO
is a two-part skin closure system that incorporates the use of skin adhesive and a self-adhesive
tape, which consists of a polyester mesh.
Some of the advantages of using a skin adhesive include:
• the patient does not require a dressing because the skin adhesive not only approximates
the skin edges but also provides a barrier
• the product can be used in emergency departments or GP rooms to close skin wounds in
children and there is no need for a return visit to have sutures removed after 7–10 days
• the barrier allows the patient to shower without fear of getting the dressing wet and/or
allowing a contaminant to infect the wound.
Each Dermabond product has a small ampoule within the device that needs to be broken for the
adhesive to be released. Dermabond Advanced comes in a conveniently shaped pen-like device.
287
RESEARCH BOX 10-1: Barbed Sutures
Research by Mulholland and Paul (2011) found that the benefits of using a barbed suture include shorter
suturing time, shorter operating time, shorter hospital stay, less technical skill required and less difficulty
than using normal sutures, which require knots to be tied and uniform tension across the skin closure.
However, a study by Gililland and colleagues (2014) following patients who had undergone a total knee
replacement for 6 weeks postoperatively showed no significant decrease in overall complications using
barbed sutures. A study undertaken by Campbell and colleagues (2014) followed patients undergoing a
total knee replacement postoperatively at intervals of 4–6 weeks, 3 months and 1 year. One group had
skin staples for wound closure while the other group had a barbed suture. Campbell and colleagues found
that joint replacement wounds sutured with barbed material had a higher risk of suture breakage and
suture migration, superficial and deep wound infections, dehiscence and suture abscess. The group of
patients receiving the barbed sutures had significantly higher overall complications, with two patients
requiring revision surgery.
with minimal trauma. The best surgical needles are

made of high-quality surgical steel that is strong
enough to pass through tissue without breaking;
they also need to be rigid enough to prevent exces-
sive bending but flexible enough to prevent break-
ing after bending. Needles need to be approximately
the same diameter as the suture material and sharp
enough to pass through tissue. The needle needs to
be the correct size and shape to accommodate the
type of tissue, the location and accessibility of the
repair (Lai & Becker, 2013).
Atraumatic needles can be single- or double-
FIGURE 10-18: V-Loc Absorbable Wound Close Device™. All rights reserved. Used armed—single-armed means one needle is attached
with the Permission of Covidien, a Medtronic company
and double-armed means two needles are attached,
one to each end of the suture material. Some
complications can arise: ischaemia, wound infec- needles are designed to release quickly and easily
tions and poor cosmetic appearance. Barbed sutures from the suture material without the use of scis-
are available as: sors; these are called control-release needles.
• V-Loc™ barbed suture system Covidien
(Australia) (see Fig. 10-18) ANATOMY OF A NEEDLE
Needles vary greatly depending on the type and
• Quill Self-Retaining System Angiotech
location of tissue being sutured. They can vary in
Pharmaceuticals (USA)
shape, size, point design and wire diameter. Curved
• Stratafix Ethicon (Australia). needles represent the majority of all atraumatic
needles and are described in degrees of a circle (e.g.
NEEDLES 1 , 1 , 3 , 5 ). The size of the circle depends on how
4 2 4 8
The atraumatic needles of today are processed wide or large a ‘bite’ is required and how much
in large factories and are pre-packaged and pre- room there is to insert the needle. The components
sterilised with the suture material attached. Needles of a needle are listed below.
are manufactured in different shapes and sizes, and • The point is the extreme tip of the needle; it is
most are described in degrees of circles; however, the part that penetrates the tissues. Points can
they can also be straight. be tapered or cutting, or a combination of both.
Except for free ties, surgical needles are neces- Tapered needle points pierce and spread the
sary to carry suture material through the tissue tissues without ‘cutting’ the tissues, which
288
means less trauma and bleeding. Cutting cutting-edge and taper needles. Within each clas-
needle points typically slice or cut through the sification, numerous types of needle are available.
tissues, causing trauma and bleeding. Figure 10-19 shows the different needle points.
• The body of a needle can be rounded,
triangular, rectangular or trapezoidal. The Cutting edge
body is the part of the needle that is grasped Cutting-edge needles have two or more opposing
by the needle holder and its shape determines edges, which slice through the tissues. They can be
how well it is grasped within the jaws of the divided into two main types—conventional and
needle holder. In other words, the shape of the reverse needles—which are determined by the loca-
body will depend on the type of tissues this tion of the cutting edge. A conventional cutting-
needle is expected to penetrate, the force edge needle has its cutting edge on the concave
behind the insertion of the needle and hence (inside) side of the needle, whereas the cutting edge
how securely the needle needs to be grasped of the reverse cutting-edge needle lies on the
by the needle holder. convex (outside) side of the needle. Cutting-edge
• The attachment end, which is also known as needles are predominantly used on skin; however,
the swaged end, is where the suture material special types have been designed specifically for
and the needle are joined to become one unit individual surgical specialties, such as ophthalmol-
(Phillips, 2013). ogy and plastic surgery (Phillips, 2013).
• The eye of the needle is the segment of the Taper point

needle where the suture material attaches to
Typically, the body of a taper needle is flattened or
the needle.
rounded, and is described as either oval or rectan-
Table 10-4 shows the different types of needles gular. The point of a taper needle pierces the tissue
and their uses. while the flattened/rounded body of the needle
spreads tissue without cutting. The taper point is
TYPES OF NEEDLE POINTS used in softer tissue that offers less resistance to
Both the body and the point of a needle determine the needle as it passes through. A taper needle is
which tissues the needle will penetrate. For sim- considered less traumatic due to the way in which
plicity, needles are classified into two main groups: it separates the tissues and causes less bleeding.
TABLE 10-4: Needle Types and Their Uses
NEEDLE TYPE WIRE TYPE TISSUE SURGERY EXAMPLES

Taper Fine Soft Bowel, vascular
Medium Fibrous Fascia
Heavy Tough Gynaecological
Blunt — Fibrous Fascia, gynaecological
Cutting Fine Tough Plastic
Medium — Skin closure
Heavy — Orthopaedics
Taper cutting Fine Vessels Vascular
Medium Tough Gynaecological
Spatula Fine Delicate Ophthalmic

SOURCE: COVIDIEN (2015).
289
Straight 1/ curve
2
1/ circle 3/ circle 1/ circle

2 8 4
5/ circle Compound curve

8
FIGURE 10-19: Suture needle point types
Source: Adapted from McCarthy (2015).
Taper needles can be used on all tissues except skin • tough tissue will require a heavier gauge
(i.e. blood vessels, muscle, viscera, peritoneum and needle, whereas microsurgery will require a
fat) (Phillips, 2013). fine-gauge needle
Blunt point taper needles are tapered needles • the depth of bite required to penetrate the
with a blunt point that is rounded; they are designed tissue determines the needle length
to pass through friable tissue, such as liver or • the circumference of the needle body may be
kidney. Blunt point taper needles have also been round, oval or triangular in shape (Phillips,
recommended as a safety measure to prevent 2013).
needlestick injuries for operating room staff and
are commonly seen in hepatobiliary and gynaeco- SWAGED NEEDLES
logical surgery (Phillips, 2013). The most common needle is the swaged or atrau-
The taper cut needle is another type of taper matic needle. In this type of needle, one end of the
needle. The taper cut needle was designed for suture material is enclosed inside the needle itself.
vascular/cardiothoracic surgery, particularly for use The needle and suture material are almost the same
with calcified, fibrotic blood vessels or prosthetic diameter, causing less trauma to the tissues when
grafts. The cutting edges extend only a very short passed through. A modified form of permanently
distance from the needle tip and blend into a swaged needle is the controlled-release suture,
rounded, tapered body. Hence, the cutting edges which is commonly known as a pop off. The needle
pass through the hard, calcified portion of the blood and suture begin as one unit; however, a light pull
vessel, while the remaining rounded taper body on the suture material separates the two compo-
passes through the friable section of the blood nents, leaving the tie behind (Phillips, 2013).
vessel.
ORDINARY NEEDLES
BODY OF THE NEEDLE An ordinary or eyed needle is a needle that must be
The gauge of the wire, length, shape and finish threaded with the suture material. Two strands of
determine the body or shaft of the needle. Factors suture material are pulled through the tissue, which
to consider when choosing a needle body include: is much more traumatic to tissues (Phillips, 2013).
290
• Use puncture-resistant containers and/or a

neutral zone within the aseptic field when
transferring sharps (e.g. scalpels, sutures and
Swag other sharp equipment) from instrument nurse
Point to surgeon.
• Do not recap needles after use.
Body
• Remove scalpel blades in accordance with AS/
NZS 3825: 1998.
• Dispose of blades as soon as possible and as
close to the point of use as possible. Blades
should not be removed by hand or using the
re-sheathing method. Instead, they should be
removed from the instrument using a safety-
engineered medical device and in accordance
with the manufacturer’s advice (ACORN, 2016).
• Use magnetic needle mats to store and dispose
FIGURE 10-20: Correct position of curved needle in holder of needles and blades.
Source: Vidimos, Ammirati & Poblete-Lopez (2009). • Surgeons should use designated instruments
for retracting tissue, rather than their hands,
to prevent accidental sharps injuries; and use
LOADING NEEDLES blunt suture needles and disposable stapling
Needles are loaded onto an appropriate needle equipment to minimise the risks involved in
holder. A needle holder has specifically designed using hand-held sutures to anastomose tissue.
jaws to grasp the needle securely. The gauge of the • Encourage good communication between
needle determines the appropriate-sized jaws. Fine, surgical team members to ensure that sharps
small needles are loaded onto fine-tipped needle are not left unattended within the aseptic field
holders. The length of the needle holder will depend (ACORN, 2016).
on the depth of the wound closure. The needle
• Wear two sets of gloves (double gloving) to
holder will be longer when working in deep cavities
minimise sharps injuries. Wearing a second
than that required for skin closure (Phillips, 2013).
pair of gloves has been shown to provide
As a general rule of thumb, load the needle one-
added protection against puncturing the inner
third of the distance from the swaged/attachment
gloves (ACORN, 2016; Loveday et al., 2014;
end, with the needle gripped at the tip or one-third
Society for Healthcare Epidemiology of
of the distance into the jaw of the needle holder and
America [SHEA], 2014).
at a 90° angle. The needle should never be clamped
over the swaged area as this weakens the attach-
ment. The needle should be clamped as near to the MINIMALLY INVASIVE SURGERY
tip of the needle holder as possible, on the first or The development of minimally invasive surgery has
second ratchet. The point of the needle faces in been one of the most dramatic advancements in
towards the body of the surgeon, unless it has been surgery over the past few decades and has evolved
requested to load it backwards. In some specialty from a diagnostic modality to a widespread surgical
surgery (e.g. vascular surgery), surgeons change the technique. Minimally invasive surgery can be
angle of the needle to suit the location/area they referred to as endoscopic, telescopic, laparoscopic,
are suturing (see Fig. 10-20). keyhole or minimal access surgery. Minimally
invasive surgeries are prevalent in all fields of
SHARPS SAFETY surgery on almost all anatomical areas, including
bariatric; general; gynaecological; ear, nose and
Policies to minimise the risk of sharps injuries for throat; urological; cardiovascular/thoracic; plastic;
healthcare workers include the following: orthopaedic; and neurosurgery (Morton, 2012a and
• Use safety needles/devices wherever 2012b; Ball, 2015). Minimally invasive surgery uses
possible. small incisions or no incisions, rather than the
291
Exposure—insufflation needle and trocar and cannula are

inserted
Visualisation—is achieved by the endoscope, light

source and camera
Perform procedure—dissection, haemostasis and

removal of tissue comprise the procedure
FIGURE 10-21: Sequence of surgery for an abdominal MIS
traditional open methods, and telescopes, cameras • restricted vision

and fibreoptic light leads are used to assist. The • difficulty handling the instruments
incisions are so small that they are typically closed
with one or two sutures. • restricted mobility of tissues.
Minimally invasive surgery has progressed In the case of abdominal minimally invasive
immensely over the past decade and will continue surgery, all patients should be prepped and draped
to change as more surgical procedures are per- for conversion to an open surgical procedure when
formed in this manner. The advantages of mini- warranted because of recognised or potential com-
mally invasive surgery for patients are considered plications. Instrumentation and supplies for an
to outweigh those of open surgery and include: open surgical procedure should be pre-counted and
readily available (Phillips, 2013).
• smaller surgical scars
• less trauma to the body SEQUENCE OF SURGERY FOR ABDOMINAL MIS
• decreased postoperative pain and thus less As with open surgery, minimally invasive surgery
requirement for pain relief follows a generalised sequence of surgery. The
three broad sequences involved are shown in
• shorter recovery period
Figure 10-21.
• quicker return to normal activities (Ball, 2015).
Consequently, many complex cases such as hyster- EXPOSURE
ectomy, nephrectomy and hemi-colectomy can now Pneumoperitoneum is the introduction of carbon
be undertaken either completely laparoscopically dioxide into the peritoneal cavity: filling the cavity
or laparoscopically assisted. with gas pushes the abdominal wall away from the
However, minimally invasive surgical proce- organs/structures. By doing so the organs/structures
dures are not without their risks to the patient. The within the cavity are not damaged when the trocar/
length of operating time frequently is longer than cannula is inserted and the surgeon is able to visu-
the equivalent ‘open’ surgical procedure, thereby alise the contents of the peritoneal cavity. Pneu-
increasing anaesthesia time, which may have an moperitoneum is achieved by the insertion of an
impact on patient outcomes. Serious complications insufflation needle (commonly referred to as a
of endoscopy include perforation of a major vessel Veress needle) or via the first cannula introduced.
or organ, bleeding from a biopsy site or any area Sterile tubing is attached to either the insufflation
where tissue has been cut or when endoscopic needle or a three-way tap on the cannula; the end
sutures or clips have become dislodged, and moder- of the tubing is passed off the aseptic field and con-
ate or severe hypothermia (Phillips, 2013). There nected to the gas insufflator.
are also some important disadvantages for the There are two types of insertion technique:
surgeon, which, on occasions, can lead to the pro- open technique and closed or blind technique. The
cedure becoming an open surgical procedure. These open technique (blunt Hasson technique) involves
include: a small incision into the peritoneum under direct
292
Luer lock
for insufflation Luer lock
Balloon port
Fascial gripper Advanceable cushion
Inflatable balloon
Skin and
subcutaneous tissues
FIGURE 10-22: Two types of ports

Source: Novell, Baker & Goddard (2013).
visualisation, through which a blunt trocar can be

passed (Phillips, 2013). The cannula can also be
sutured in place to reduce gas leakage, if desired.
Most general surgeons utilise a Hasson-like trocar
and cannula that is blunt tipped. This cannula
allows the remaining ports to be inserted under
direct visualisation, which helps minimise damage.
The gas tubing is attached to the cannula and the
abdominal cavity is filled with carbon dioxide
before the remaining cannulas are inserted, if
required. The majority of general surgical cases
begin in the supine position; however, once the
initial cannula is inserted the patient will be placed
in the reverse Trendelenburg position. This posi- FIGURE 10-23: Different trocars and cannulae
tion enables the internal organs (chest and
abdomen) to retract upwards away from surgical suction at the same time. All cannulae have taps:
field, facilitating access and vision and decreasing some have one, others have two. These taps can be
the risk of perforation/damage to these organs. used to attach gas tubing to allow for insufflation
The closed or blind technique involves the of the peritoneal cavity and smoke evacuation
insertion of an insufflation needle, filling the tubing can be attached to help remove any exces-
abdominal cavity with carbon dioxide first, and sive smoke flume, which can interfere with the sur-
then insertion of the first trocar and cannula. Sharp geon’s visual field.
(self-piercing) trocars are used in this technique as Trocar tips come in a range of shapes, such as
they puncture the skin on the way through the peri- triangular, conical, pyramidal or bladeless. Depend-
toneum. In both techniques, the initial cannula is ing on the manufacturer, the trocar tips can be
inserted at the inferior aspect of the umbilicus; retractable or have a shield that covers the sharp
however, alternative sites may be chosen if the tip once entry has been achieved. The bladeless
patient has had previous abdominal surgery as trocar separates tissue without cutting or stretch-
there can be a risk that loops of bowel or adhesions ing the tissue and provides the option of visualising
have adhered to the previous incision site. the insertion of this type of trocar. Recent advance-
The number of cannulae inserted will depend ments relating to the design of cannulae have
on the surgical procedure. For example, for an resulted in a newer version of cannula with a better
appendectomy three cannulae are inserted but a grip, thus preventing accidental removal or move-
cholecystectomy or bowel resection requires four or ment of the cannula during surgery (Phillips, 2013).
five cannulae as more instrumentation is needed to Figure 10-22 shows two types of ports. Figures
help retract surrounding structures and possibly 10-23 and 10-24 illustrate the differences between
293
the multitude of trocars and cannulae on the endoscopes and Figure 10-26 shows the set-up for
market. a laparoscopic procedure.
The heat from the light source is not transmit-
VISUALISATION ted down the length of the telescope, which pre-
Many types of laparoscopes are available and their vents tissue from being inadvertently damaged.
size (diameter) and length depend on the access However, it should be noted that the end of the
required to visualise the area. Flexible telescopes
provide a panoramic view, whereas rigid telescopes
provide either a direct (0° scope) or angled (30°, 70°
or 120°) view. Figure 10-25 shows examples of rigid
FIGURE 10-25: Rigid 0° endoscope with instrument channel, endoscopic sheath

FIGURE 10-24: A bladeless trocar: the Versaport™. All rights reserved. Used with and associated trocar
the permission of Covidien, a Medtronic company Source: Ishii & Gallia (2010).
FIGURE 10-26: Camera and video set-up for a laparoscopic procedure, showing both fluorescence and WL imaging
Source: McCallum, Jenkins, Gillen & Molloy. (2008). © 2008 American Society for Gastrointestinal Endoscopy, Elsevier.
294
fibreoptic cable is very hot. Once disconnected from

the telescope, the light source should be switched
to standby or off to prevent accidental burning of
the patient and/or the drapes. Ceiling
mount
PERFORMING THE PROCEDURE
In order to perform an operative procedure using
minimally invasive technique, the surgeon’s hands
must be free to manipulate the instrumentation
and the assistant and instrument nurses must also Video
be able to see the operative field. This can be monitor
achieved by the introduction of a video camera. The
video camera enlarges the images from the tele-
scope and projects them onto a television screen, Light
which means that all members of the surgical team source
can observe the procedure. Insufflator
When tissues such as the appendix, ovary and Computer
gall bladder are removed, a specially designed
laparoscopic specimen bag can be used to prevent
spillage of their contents. In the case of laparo-
scopic bowel resection, once the segment of bowel
has been resected, a slightly larger incision is made
through which the segment of bowel will be FIGURE 10-27: Ceiling-mounted endoscopic equipment
removed. A wound edge protector can be used to Source: Phillips (2013).
protect the wound from contamination from the
diseased bowel.
EQUIPMENT
Advances continue to be made in minimally inva-
sive surgery, with different surgical specialisations
developing new techniques. Many new facilities
have the equipment required on ceiling-mounted
booms rather than trolleys (see Fig. 10-27).
Although the types of instruments available for
minimally invasive surgery are similar to those
used for open surgery and can be classified accord-
ing to the five instrument categories, adaptations
have been made to allow their use via a laparo-
scope. Figure 10-28 shows a variety of laparoscopic FIGURE 10-28: Instrumentation used in endoscopes
instruments.
All instrumentation is available in reusable and
disposable form and some instruments are availa- • Diathermy: preference depends on the surgeon
ble in bariatric sizes. The following are some of the and can be either a hook (monopolar) or
most common instruments available: Marylands style (bipolar).
• Telescope: 30° 10 mm and 0° 5 mm. • Irrigator/suction device: single nozzle through
• Graspers: bowel grasper (DeBakey-like forceps) which both suction and irrigation can be
and/or a bull nose grasper. Both types are performed, but not simultaneously.
considered atraumatic, which means that the • Endoloops: these snare-like loops of suture
surgeon can handle both the bowel and the material are pre-knotted within an introducer
appendix without causing any damage. sleeve. Once the suture loop is around the
295
FIGURE 10-31: Clip applicator™. All rights reserved. Used with the permission of
Covidien, a Medtronic company
FIGURE 10-29: Endocatch specimen retrieval bag™. All rights reserved. Used with
the permission of Covidien, a Medtronic company
FIGURE 10-32: Endo GIA Stapler™. All rights reserved. Used with the permission of
FIGURE 10-30: Blunt tip laparoscopic sealer™. All rights reserved. Used with the
permission of Covidien, a Medtronic company
Endo grasp instrument

designated tissue, the existing suture knot is
pushed down the introducer sleeve until it is
tightly secured around the tissue.
• Endocatch bag: this is quite simply a specimen
bag (it looks a bit like a butterfly net) which
allows the tissue to be removed without any
spillage of its contents into the peritoneal
cavity. Endocatch bags come in 10 mm or
15 mm sizes (see Fig. 10-29).
Figures 10-30 to 10-35 are further examples of
instrumentation used in laparoscopic surgery. Mesenteric
window
A more recent advance in the field of abdominal Mudrifire Endo GIA 30
stapler
laparoscopic surgery is single-incision laparoscopic
surgery (SILS), also known as single-port access FIGURE 10-33: Use of endo grasp instrument
296
means an increase in intraabdominal pressure,

which causes significant changes in the cardiopul-
monary systems. This, plus extreme positioning
(reverse Trendelenburg), creates significant risk
to paediatric patients. Studies have indicated that
low pneumoperitoneum and intraabdominal pres-
sures no greater than 5 mmHg should be used in
infants and children to prevent the significant car-
diopulmonary changes that occur with higher
intraabdominal pressure (Perryman, Schow &
Binda, 2010). Hunter and Jobe (2010) suggest that
for infants 8 mmHg is sufficient to obtain adequate
FIGURE 10-34: Endo Shear 5mm™. All rights reserved. Used with the permission of
exposure. In addition, paediatric instrumentation
needs to be shorter and the diameter of cannula/
trocars needs to be smaller (3 mm as opposed to
5 mm, 10 mm and 15 mm used in adults) as the
paediatric abdomen is smaller than in adults.
OPERATING ROOM SET-UP FOR MINIMALLY

INVASIVE SURGERY
Each surgeon will have individual requirements
regarding the layout of equipment in the operating
room, but there are general guidelines to set up
for minimally invasive surgical procedures (see
also Fig. 10-37). The surgeon’s preference card
details specific requirements. In general surgery,
most procedures are performed with the camera
stack/trolley on the patient’s left-hand side and
towards the patient’s head. In gynaecological/
obstetric surgery, most procedures are performed
with the camera stack/trolley towards the patient’s
feet and between the patient’s legs. In urological
surgery, most procedures are performed with the
camera stack/trolley on either the right or the left
FIGURE 10-35: Laparoscopic stapler™. All rights reserved. Used with the
side (depending on the room) and towards the
permission of Covidien, a Medtronic company patient’s head.
ADVANCES IN MINIMALLY INVASIVE SURGERY

One of the most advanced technologies in the peri-
surgery (Greaves & Nicholson, 2011). SILS uses operative environment is robotic surgery. Robotic
one entry point, typically in the umbilical site. The surgery was first developed in the 1990s to address
GelPoint® advanced access platform facilitates tri- some of the limitations of minimally invasive
angulation of standard instrumentation through a surgery, although it has been suggested that the
single incision—see Feature box 10-2. term used should be computer-enhanced surgical
devices. With the addition of a robot, the surgeon
PAEDIATRIC CONSIDERATIONS sits at an operative console with three-dimensional
While paediatric minimally invasive surgical proce- (3D) imaging and hand-held controls (see Fig.
dures have advantages similar to those of adult 10-38). Robotic surgery provides enhanced 3D visu-
procedures—such as less pain, better cosmetic alisation of the anatomy. Robotic arms do not have
outcomes and shorter hospital stays—there are tremors and can stabilise telescopes and long
some serious physiological effects that need to be instruments better than an assistant. Robotic arms
considered. The creation of a pneumoperitoneum also have smaller hand movements, enabling them
297
FEATURE BOX 10-2 » GELPOINT® ACCESS PLATFORM
The GelPoint® access platform is designed for use in laparoscopic-assisted abdominal and
transanal minimally invasive surgical procedures. In laparoscopic-assisted procedures three to four
ports are inserted initially and once the dissection and ligation have been performed a small open
incision is created to enable the specimen to be retrieved. Using this device (see Fig. 10-36), a
small open incision is performed at the beginning of the procedure, the device is inserted into
the open incision and the surgery begins—hence the patient has one small incision only. Essen-
tially, the GelPoint® access platform is an Alexis wound protector that has an airtight seal; it
enables the surgeon to insert the laparoscopic ports through the airtight seal in locations that
suit the surgeon and or/the type of bowel resection being performed. Once the laparoscopic part
of the procedure has been performed, the airtight seal and laparoscopic ports are removed; what
is left is an Alexis wound protector and the open incision through which the specimen is retrieved.
B
FIGURE 10-36: A, Single-entry access platform. B, Single access platform in situ.
Source: A, Tsai & Selzer (2010). B, Wikimedia/Halfalah.
to work better in a small workspace and tolerate (Perryman et al., 2010), as instruments must be
two-dimensional visibility; however, hand dexter- disengaged from the robotic arm before the robot
ity is missing. can be wheeled away from the operating table.
The da Vinci robot is considered the biggest Results show that operating time using the da Vinci
advancement in robotic surgery. However, it is longer than a standard laparoscopic procedure
presents special challenges and limitations to but the final outcomes of surgery remain the same
patient access, especially during emergencies (Hunter & Jobe, 2010).
298
FIGURE 10-37: Basic set-up for minimally invasive surgical procedures

Source: SAGES Webmaster © 2016 Society of American Gastrointestinal and Endoscopic Surgeons.
Another extension of robotic surgery is telesur- to and during surgery, while also seeing the exact
gery, whereby surgery is performed with the assist- location of their surgical instrumentation. Stealth-
ance of robotics at a distant site. This type of Station® navigation enables surgeons to:
concept surgery has not gained wide acceptance.
• enhance tumour boundary recognition
Hunter and Jobe (2010) argue that patient safety is
jeopardised when the surgeon is not at the patient’s • determine the optimal placement and size of
bedside. the craniotomy
In the latest trend, known as natural orifice • account for brain shift during the procedure
transluminal endoscopic surgery (NOTES), flexible • plan the least-invasive surgical path
endoscopes enter via the gastrointestinal tract, (Medtronics, 2015).
urinary or reproductive tracts and traverse the wall
of the structure to enter the peritoneal cavity, Computer-assisted knee replacement surgery
mediastinum or chest. See Chapter 13 for further allows surgeons to operate with smaller incisions
information. and greater precision:
Neurosurgery imaging and surgical navigation • Surgeons can align a patient’s bones
is another advance in the use of technology. The and knee replacement implants with a
StealthStation® navigation system enables sur- degree of accuracy not possible with the
geons to visualise the patient’s anatomy in 3D prior naked eye.
299
FIGURE 10-38: Robotic instruments and hand controls

Source: © 2016 Intuitive Surgical, Inc.
• Smaller incisions offer the potential for faster

recovery, less bleeding and less pain for
CONCLUSION
patients. This chapter has focused on assisting perioperative
• Computers used during orthopaedic surgery nurses to understand the process of surgical inter-
offer visual mapping to help doctors make vention and their role in this process. Every surgical
crucial decisions before and throughout the procedure, including minimally invasive surgery,
knee replacement operation. The key is to follows a generalised sequence of steps. By research-
combine the precision and accuracy of ing and understanding this sequence, the instru-
computer technology with the surgeon’s skill ment and circulating nurses make judgements with
to perform surgery. regards to the instrumentation, sutures and needles
required to complete the surgical procedure. This
• Advanced imaging technology provides a chapter has aimed to give a greater understanding
computer-generated representation of a of the core elements of instrumentation, sutures
patient’s knee joint, allowing the surgeon to and needles to assist the perioperative nurse to
operate with smaller openings and with more make an informed selection, based on the surgical
precision. In addition, this technology provides procedure, the needs of the patient and the attend-
surgeons with greater ‘vision’ during the ing surgical team.
surgery (DePuy, 2015).
CRITICAL THINKING QUESTIONS

1. Laparoscopic surgery
You are assigned to a general surgery theatre where the cases for the day are being performed laparo-
scopically. Mrs Young, a 44-year-old female, is booked on the emergency list for a laparoscopic chole-
cystectomy. Mrs Young weighs 110 kg.
300
• Identify at least three laparoscopic instruments required to perform the cholecystectomy not
including the telescope, camera and light lead. Provide the rationale for your choice.
• With the patient’s weight in mind, what other considerations should be taken into account
when setting up the instrumentation? Provide the rationale for your answers.
2. Wound closure
There are two broad categories of suture material: absorbable and non-absorbable.
• What factors are taken into account when deciding which category of suture to use?
• What are the components of a surgical needle?
• How are surgical needles classified?
• What is the advantage of using an atraumatic suture?
• Surgical wounds can be closed by other methods apart from sutures. What are the advantages
of the alternative methods and what factors influence the decision making?
3. Instrumentation
Surgical instruments are described as the ‘tools of the trade’.
• Why is it important for the perioperative nurse to have in-depth knowledge of the design,
structure and anatomy of surgical instruments?
• What are the five different groups and uses/tasks of surgical instruments?
4. Sequence of surgery
You have been assigned to be the instrument nurse for a patient, Mr East, who is to have a right
inguinal hernia. The set-up has been completed and your preceptor says you have an hour to prepare
for this case. You are not sure what is involved in an inguinal hernia repair.
• Where will you go to source the necessary information to assist you with this case?
• Identify the sequence of surgery for Mr East’s procedure.
Lap cholecystectomy
RESOURCES https://www.youtube.com/watch?v=NWIT2yJN608
Covidien Laparoscopic sleeve gastrectomy for morbidly obese
www.covidien.com/surgical/products patients
DePuy computer-assisted knee replacement https://www.youtube.com/watch?v=KM6UQzMwbWU&
https://www.kneereplacement.com/DePuy_technology/ feature=share
surgical_adv/cas Robotic surgery
Ethicon www.clipsyndicate.com/video/play/5122574
www.ethicon.com/gateway www.clipsyndicate.com/video/play/895502
StealthStation integrated microscopes for neurosurgery
www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/ REFERENCES
@neuro/documents/documents/microscope-sales
-sheet.pdf Australian College of Operating Room Nurses (ACORN).
(2016). ACORN Standards for perioperative nursing, 2016–
Suturing techniques. In Davies, R. (Ed.), (2014). 2017. Adelaide: Author.
Fundamental skills for surgery (3rd ed., pp. 156–186).
Sydney: McGraw-Hill Education. Ball, K. A. (2015). Surgical modalities. In J. C. Rothrock &
D. R. McEwen (Eds.), Alexander’s care of the patient in surgery
(15th ed., pp. 211–252). St Louis: Elsevier Mosby.
VIDEO RESOURCES Bourdon, L. (2014). RP first look: New recommended prac-
Appendicectomy using Alexis protector tices for cleaning and care of surgical instruments. AORN
https://www.youtube.com/watch?v=yo-0DygE7CQ Connections, 100(6), C1–C9.
Knee arthroscopy Campbell, A. L., Patrick, D. A., Liabaud, B., & Geller, J. A. (2014).
https://www.youtube.com/watch?v=F3iBm3aCIzw Superficial wound closure complications with barbed
301
sutures following knee athroplasty. Journal of Arthroplasty, Morton, P. (2012a). Implementing AORN recommended prac-
29(5), 966–969. tices for minimally invasive surgery. Part 1. AORN Journal,
Covidien. (2011). Principles of electrosurgery. Sydney: Author. 96(3), 295–314.
Covidien. (2015). Suture and needle guide. Sydney: Author. Morton, P. (2012b). Implementing AORN recommended
practices for MIS. Part 2. AORN Journal, 96(4), 378–397.
Davies, R. (Ed.), (2014). Fundamental skills for surgery (3rd
ed.). Sydney: McGraw-Hill Education. Muffly, T. M., Tissano, A. P., & Walters, M. D. (2011). The history
and evolution of sutures in pelvic surgery. Journal of the
De Girolamo, K. M., Courtemanche, D. J., Hill, W. D., Kennedy, Royal Society of Medicine, 104, 107–112. doi:10.1258/
A., & Scarskard, E. D. (2013). Use of safety scalpels and other jrsm.2010.100243.
safety practices to reduce sharps injury in the operating
room: What is the evidence? Canadian Journal of Surgery, Mulholland, R. S., & Paul, M. D. (2011). Lifting and wound
56(4), 263–269. closure with barbed sutures. Clinics in Plastic Surgery, 38(3),
521–535.
DePuy. (2015). Computer-assisted knee replacement. Retrieved
from <https://www.kneereplacement.com/DePuy_ Novell, R., Baker, D. M., & Goddard, N. (Eds.). (2013).
technology/surgical_adv/cas>. Kirk’s general surgical operations (6th ed.). Philadelphia:
Elsevier.
Ford, D. (2014). Implementing AORN recommended prac-
tices for sharps safety. AORN Journal, 99(1), 106–120. Patten, R. (2015). Workplace issues and staff safety. In J. C.
Rothrock & D. R. McEwen (Eds.), Alexander’s care of the
Fuller, J. (2013). Surgical technology: Principles and practice
patient in surgery (15th ed.). St Louis: Mosby.
(6th ed.). St Louis: Elsevier Saunders.
Gililland, J. M., Anderson, L. A., Barney, J. K., Ross, H. L., Pelt, Perryman, K. M., Schow, A. J., & Binda, R. E. (2010). Anaes-
C. E., & Peters, C. L. (2014). Barbed versus standard sutures thetic considerations. In G. W. Holcomb & J. P. Murphy (Eds.),
for closure in total knee arthroplasty: A multicentre pro- Ashcraft’s pediatric surgery (5th ed., pp. 32–48). Philadelphia:
spective randomized trial. Journal of Arthroplasty, 29(9), Saunders/Elsevier.
135–138. Phillips, N. (2013). Berry & Kohn’s operating room technique
Goodman, T., & Spry, C. (2014). Essentials of perioperative (12th ed.). St Louis: Elsevier Mosby.
nursing (5th ed.). Burlington: Jones & Bartlett Learning. Richardson-Tench, M., & Martens, E. (2005). From systems to
Greaves, N., & Nicholson, J. (2011). Single incision laparo- tissues: A revolution in learning in perioperative education.
scopic surgery in general surgery: A review. Annals of the Education for Health: Change in Learning and Practice, 18(1),
Royal College of Surgery England, 93, 437–440. 22–31.
Hunter, J. G., & Jobe, B. A. (2010). Minimally invasive surgery, Royal Australasian College of Surgeons. (2015). Essential
robotics, and natural orifice transluminal endoscopic surgical skills. Skills Education Committee, Royal Australa-
surgery. In F. C. Brunicardi, D. Anderson, T. R. Billiar, D. L. Dunn, sian College of Surgeons. Retrieved from <www.surgeons
J. G. Hunter, J. B. Matthews, et al. (Eds.), Schwartz’s principles .org/media/473135/2015-01-27_gdl_essential_surgical
of surgery (9th ed., p. 373). New York: McGraw-Hill Medical. _skills_document.pdf>.
Ishii, M., & Gallia, G. L. (2010). Application of technology for Society for Healthcare Epidemiology of America (SHEA).
minimally invasive neurosurgery. Neurosurgery Clinics of (2014). Strategies to prevent surgical site infections in acute
North America, 21(4), 585–594. care hospitals. Infection Control & Hospital Epidemiology,
35(6), 605–627. doi:10.1086/676022.
Lai, S. Y., & Becker, D. G. (2013). Sutures and needles. eMedi-
cine. Retrieved from <www.emedicine.com/article/884838 Sullivan, R. (1996). The identity and work of the Ancient
-overview>. Egyptian surgeon. Journal of the Royal Society of Medicine,
89(8), 469.
Loveday, H. P., Wilsona, J. A., Pratta, R. J., Golsorkhia, M.,
Tinglea, A., Baka, A., et al. (2014). epic3: National evidence- Tsai, A. Y., & Selzer, D. J. (2010). Single-port laparoscopic
based guidelines for preventing healthcare-associated surgery. Advances in Surgery, 44(1), 1–27.
infections in NHS hospitals in England. Journal of Hospital
Vidimos, A. T., Ammirati, C. T., & Poblete-Lopez, C. (2009).
Infection, 86(1), S1–S70.
Dermatologic surgery (Chapter 11, pp. 139–156). Elsevier
McCallum, A. L., Jenkins, J. T., Gillen, D., & Molloy, R. G. (2008). Limited.
Evaluation of autofluorescence colonoscopy for the detec-
tion and diagnosis of colonic polyps. Gastrointestinal Endos-
copy, 68(2), 283–290. FURTHER READING
Medtronics. (2015). StealthSystem integrated microscopes AS/NZS 4187 (2014). Reprocessing of reusable medical devices
for neurosurgery. Retreived from <www.medtronic.com/ in health service organizations (4th ed.). Sydney: SAI Global
wcm/groups/mdtcom_sg/@mdt/@neuro/documents/ Limited.
documents/microscope-sales-sheet.pdf>. Bazrafshan, A., Abdollahi, A., & Etezadpour, M. (2014).
McCarthy, J. (2015). Sutures, needles and instruments. In J. C. Laparoscopic colon surgery for benign disease: A compari-
Rothrock & D. R. McEwen (Eds.), Alexander’s care of the son to open surgery. International Journal of Pediatrics, 3(2),
patient in surgery (15th ed., pp. 189–210). St Louis: Mosby. 19–24.
302
Behnia-Willison, F., Foroughinia, L., Sina, M., & Chesney, P. Rosenberg, A. (2013). The use of barbed suture in hip and
(2012). Single incision laparoscopic surgery (SILS) in gynae- knee replacement wound closure. Seminars in Arthroplasty,
cology: Feasibility and operative outcomes. Australian and 24(3), 132–134.
New Zealand Journal of Obstetrics and Gynaecology, 52(4), Rothrock, J. C., & McEwen, D. R. (Eds.), (2015). Alexander’s care
366–370. of the patient in surgery (15th ed.). St Louis: Mosby.
Cuss, A., & Abbott, J. (2012). Complications of laparoscopic Sherris, D. A., & Kern, E. B. (2004). Essential surgical skills (2nd
surgery. Obstetrics, Gynaecology and Reproductive Medicine, ed.). Philadelphia: Elsevier.
22(3), 59–62.
Spah, C., Elkins, A. D., Wehrenberg, A., Jaffe, M. H., Baird, D. K.,
Facy, O., De Blasi, V., Goergen, M., Arru, L., De Magistris, L., Naughton, J. F., et al. (2013). Evaluation of two novel self
& Azagra, J. S. (2013). Laparoscopic gastrointestinal anasto- anchoring barbed sutures in prophylactic laparoscopic gas-
moses using knotless barbed sutures are safe and reproduc- tropexy compared with intracorporeal tied knots. Journal of
ible: A single center experience with 201 patient’s. Journal Veterinary Surgery, 42(8), 932–942.
of Surgical Endoscopy, 27(10), 3841–3845.
Ting, N. T., Moric, M. M., Dellavalle, C. J., & Levine, B. R. (2012).
George, V. (2013). Single port laparoscopy: Market driven or Use of knotless suture for closure of total hip and knee
true advancement? Seminars in Colon and Rectal Surgery, arthroplasties: A prospective, randomized clinical trial.
24(1), 24–27. Journal of Arthroplasty, 27(10), 1783–1788.
Heneghan, H., Martin, S., Kiran, R., Khoury, W., Stocchi, L., Tjandra, J. J., Clunie, G. J., Kaye, A. H., & Smith, J. (Eds.), (2013).
Remzi, F. H., et al. (2013). Laparoscopic colorectal surgery Textbook of surgery (3rd ed.). Malden, MA: Blackwell.
for obese patients. Decreased conversions with hand
assisted technique. Journal of Gastrointestinal Surgery, 17(3), Vogel, J. D., Lian, L., Kalady, M. F., de Campos-Lobato, L. F.,
548–554. Alves-Ferreira, P. C., & Remzi, F. H. (2011). Hand assisted
laparoscopic right hemicolectomy: How does it compare to
Joyce, C. W., Joyce, K. M., Mahon, N., Chan, J. C., Sugrue, C. M., conventional laparoscopy? Journal of American College of
Dockery, P., et al. (2014). A novel barbed suture tie over Surgery, 212(3), 367–372.
dressing for skin grafts: A comparison with traditional tech-
Wright, R. C., Gillis, C. T., Yacoubian, S. V., Raven, R. B.,
niques. Journal of Plastic, Reconstructive and Aesthetic Surgery,
Falkinstein, Y., & Yacoubian, S. V. (2012). Extensor mecha-
67(9), 1237–1241.
nism repair failure with use of bidirectional barbed suture
Nano, M. (2012). A brief history of laparoscopy. Journal of Il in total knee arthroplasty. Journal of Arthroplasty, 27(7),
Giornale di Chirurgia, 33(3), 53–57. 1413–1418.
303
Chapter 11
WOUND HEALING
ANN PARKMAN AND MARILYN RICHARDSON-TENCH

LEARNING OUTCOMES
• Briefly discuss the anatomy of the skin and associated structures
• Differentiate between surgical, traumatic and chronic wounds
• Identify and utilise in practice a system for the classification of wounds
• Explain the physiology of wound healing and how this relates to patients with surgical wounds
• Discuss the mechanisms of surgical haemostasis in depth
• Discuss methods for wound closure, dressings and drainage
• Identify technological advances in wound management
KEY TERMS
debridement
drains
dressings
haemostasis
inflammation
wound closure
wound healing
coagulation (i.e. blood clotting or haemostasis) and

INTRODUCTION the methods used in surgery to enhance it are criti-
Wound healing is a complex issue with several cal as this informs many of the activities of the
interrelated and simultaneous phases. Knowledge surgeon and instrument nurse. Wound manage-
of the anatomy of the skin and the physiology of ment requires not only knowledge of the properties
wound healing is essential in order to care compe- of dressings but also an understanding of the
tently for patients with wounds created during a healing process. Common surgical incisions are
surgical procedure or those that occur as a result of presented in this chapter. The perioperative nurse
pathology or trauma. An understanding of normal requires knowledge of the various dressings and
304
CHAPTER 11 | Wound healing
drains available and their rationale for use. Knowl- which is yellow and greasy or slippery to touch,
edge and understanding of the basic concepts of with globules of fat that frequently dislodge. Blood
wound healing and wound care provide the new vessels, lymphatics and nerves are found within the
practitioner with confidence in caring for patients subcutaneous layer. The fascia, the next layer, is a
in the perioperative setting. thin membrane that fully encapsulates muscle. It is
often glossy in appearance, transparent and sepa-
SKIN ANATOMY rates the subcutaneous layer from muscles, tendons
and bones (McLafferty et al., 2012).
Knowledge of the anatomy of the skin and its asso-
ciated structures is important in order to under-
stand the physiology of wound healing. The skin WOUNDS
consists of the dermis (a type I collagen) and the
A wound is an injury that disrupts the continuity
epidermis, which together compose the outermost
of body tissue, with or without tissue loss, and
layer (McLafferty, Hendry & Farley, 2012). The epi-
may be intentional or unintentional. Wounds may
dermis is made up of many overlapping layers of
be surgical (intentional), traumatic (unintentional)
epidermal cells and has no blood vessels, so this
or chronic (Turrentine et al., 2015; Zinn, 2012).
layer is avascular, receiving its nutrients from
blood vessels in the underlying dermis (McLafferty
SURGICAL WOUNDS
et al., 2012). The structures associated with the
skin, including the capillaries, lymph channels, Surgical site incisions and/or excisions constitute
hair follicles, sebaceous glands, sweat glands and intentional wounds; an incision is a cut or an
nerve endings, are located in the dermis. Other opening into intact tissue, whereas an excision is
individual cells, such as mast cells, melanocytes the removal of tissue. Other types of intentional
and fibroblasts, are also found in the dermis wounds include occlusions, such as occlusion
(see Fig. 11-1). banding, which is used to treat haemorrhoids,
and occlusion using clips to block the passage of
The next layer of tissue is the subcutaneous the fallopian tubes. Wounds can also be created
layer. This layer contains adipose or fatty tissue, using chemicals applied to the skin or other
tissue intentionally to cause inflammation and
re-epithelialisation (e.g. performing a facial peel
during plastic surgery) (Turrentine et al., 2015).
TRAUMATIC WOUNDS
Traumatic wounds can be classified by cause—
mechanical, thermal or chemical destruction. For
example, wounds can occur following trauma
Epidermis (mechanical), as a result of being burnt (thermal)
Meissner’s or from contact with chemicals such as acid (chemi-
corpuscle
cal) (Turrentine et al., 2015; Zinn, 2012).
Sebaceous
gland Papillary
Arrector
portion CHRONIC WOUNDS
pili muscle Dermis A chronic wound has not completed the usual
Sweat wound healing process in the expected timeframe
gland (Gethin 2012; Zinn, 2012). These wounds are caused
Reticular by an underlying pathophysiological process. For
Adipose portion
tissue example, a decubitus ulcer, which may be caused by
Pacinian compromised circulation over bony prominences,
corpuscle Subcutaneous or a venous ulcer, which develops due to venous
Vein connective
tissue stasis or arterial insufficiency. On assessment, a
Artery
Nerve wound that does not appear to be healing by
FIGURE 11-1: Anatomy of the skin approximately 14–21 days is at risk of becoming a
Source: Phillips (2013). chronic wound.
305
example, if muscles are to be split or incised there

SURGICAL INCISIONS is likely to be more bleeding, requiring haemostats
An incision is made into the tissues of the body to and diathermy.
expose the underlying tissue, bone or organs so
that a surgical procedure can be performed. The LANGER’S LINES
direction of the incisional line is determined by the Natural lines of tension are formed by the relation-
anatomical plane in the body. When planning a sur- ship of the skin to the underlying musculature.
gical incision, the surgeon needs to take a number Austrian anatomist Karl Langer (1819–1887)
of issues into consideration—for example: described how incisions healed with less scarring if
• access to the structures being operated on natural cleavage lines were followed when planning
• whether rapid entry is required the surgical incision (Phillips, 2013, p. 545). These
natural cleavage lines are known as Langer’s lines.
• adequate exposure to the structures, allowing
for extension of the incision if required ABDOMINAL INCISIONS
• minimising interference with the function of The primary reference point for abdominal inci-
the abdominal wall by preserving important sions is the umbilicus, while secondary surface
structures such as nerves and blood vessels landmarks include the xiphoid, the pubis and the
• strong wound closure, minimising the risk of iliac crests (see Fig. 11-2). Incisions may be verti-
wound dehiscence and incisional hernia cal, horizontal or oblique and may occur in various
areas of the torso (Phillips, 2013)—see Figure 11-3
• cosmetic effect, although this is a secondary for anterior surface incisions. Figure 11-4 illus-
consideration. trates the abdominal muscles and Table 11-1 out-
The perioperative nurse must be aware of the lines common abdominal incisions applicable to
type of incision to be used as this will assist in open abdominal and pelvic procedures (Phillips,
setting up the necessary instrumentation—for 2013).
Sternal notch
Midline
Lateral sternal line
Hypo- Hypo- Parasternal line

chondriac chondriac
Right Left Epigastric
upper upper Mammary line
quadrant quadrant
Lumbar Umbilicus Lumbar
Right Left Xyphoid
lower lower
quadrant quadrant Hypogastric Left paramedian
Iliac Iliac
Pubic ramus
FIGURE 11-2: Surgical landmarks

306
I
J Z
A Y
L X
B M N P
C Q R
E
D O
F T
U
G
V
H
S W
Anterior surface incisions
A. Sternotomy I. Thyroidectomy P. Mercedes

B. Kocher (subcostal) J. Tracheotomy Q. Chevron
C. Supraumbilical K. Infraareolar R. Epigastric (upper midline)
D. Infraumbilical L. Inframammary S. Lower midline
E. McBurney’s appendectomy M. Midline T. Pararectus
F. Transverse N. Paramedian U. Gibson (hand-assisted laparoscopy)
G. Maylard transverse muscle cutting O. Rockey-Davis V. Inguinal
H. Pfannenstiel W. Femoral
X. Clamshell
Y. Subclavicular
Z. Carotid
FIGURE 11-3: Anterior surface incisions
Pectoralis major
Serratus
anterior
Linea alba
Tendinous
intersection
Transversus
abdominis Rectus
abdominis
Internal oblique
External
oblique Inguinal ligament
(formed by free
inferior border of
Aponeurosis
the external oblique
of the external
aponeurosis)
oblique
FIGURE 11-4: Abdominal muscles
307
TABLE 11-1: Common Abdominal Incisions
INCISION LOCATION PROCEDURE ADVANTAGES DISADVANTAGES

Midline Vertical incision Wide variety of Suitable for Higher incidence of
extending from the abdominal emergency postoperative
sternal notch to procedures (e.g. laparotomy as it incisional hernia,
the umbilicus or hemicolectomy, gains swift access particularly above
the symphysis hepatic resection, to the abdomen the umbilicus due
pubis open repair of through the to only one layer of
aortic aneurysm) relatively avascular fascia requiring
fascia layer of the closure—this
linea alba causes contraction
Can be extended the of the abdominal
whole length of wall, which can
the abdomen pull the incision
Can be closed quickly apart
in one layer
Paramedian Vertical incision Depends on the Can be extended into Time consuming to
placed 4 cm lateral location of the lower abdomen open and close,
to the midline near incision (e.g. right Fascia and muscle due to multiple
the lateral border side—access to layers provide fascia and muscle
of the rectus gallbladder) secure closure layers
abdominus muscle Limited exposure of
Can be made above all the abdominal
or below the structure—midline
umbilicus on either is preferred
side of the Rarely used due to
abdomen above reasons
depending on the
procedure
Subcostal (also Oblique incision On right side: Heals well as follows Limited ability to
known as Kocher made 4 cm below cholecystectomy Langer’s lines extend incision
incision) and parallel to the On left side: Less painful than laterally
costal margin splenectomy midline incision Can be time
consuming to open
and close
McBurney’s Located on right side Specifically used for Provides strong Does not provide
of abdomen at open wound closure as good access to
McBurney’s point, appendicectomy layers of muscle other areas of the
two-thirds of the (internal and abdomen
distance between external obliques, Incision cannot be
the umbilicus and transversus) are extended easily
the anterior iliac split rather than
spine transected
Inguinal Extends from the Hernia repair on left Strong closure, similar Potential for injury to
pubic tubercle to or right side to McBurney’s local nerves, blood
the anterior iliac incision vessels and bowel
crest, slightly above Does not enter the during fixation of
and parallel to the peritoneal cavity, mesh used to
inguinal crease reducing the risk of repair hernia
morbidity due to
infection in the
abdominal cavity
308
TABLE 11-1: Common Abdominal Incisions—cont’d
INCISION LOCATION PROCEDURE ADVANTAGES DISADVANTAGES

Mid-abdominal Located slightly Procedure determines Follows Langer’s Limited access when
transverse above or below the the location of the lines, giving strong compared with
level of the incision (e.g. wound closure and midline incision
umbilicus transverse good cosmetic
Extends laterally to colectomy or affect
lumber region at colostomy) Preserves nerves and
an angle between blood vessels
ribs and iliac crest
Thoracoabdominal Joins the thoracic and Provides exposure to Excellent exposure Increased morbidity
abdominal cavities the oesophagus, and access to due to opening two
together: a midline cardia, liver, spleen, structures cavities: the
or subcostal kidneys, adrenal previously noted abdomen and the
incision is made to glands, lungs, aorta thorax
complete the first (left side), inferior Location of extensive
part of the vena cava (right incision increases
procedure and then side) and PO pain
the incision is oesophagus Patient requires
extended in a The patient may repositioning
posterior lateral require intraoperatively
direction to the repositioning from
seventh or eighth supine to lateral
costal interspace intraoperatively to
and along the access the thoracic
interspace into the region
thorax
Pfannenstiel Curved transverse Prostatectomy, Good exposure, Cannot easily be

(suprapubic) incision 1 cm hysterectomy, strong closure and extended
above the Caesarean section good cosmetically Danger of injury to
symphysis pubis, bladder during
usually within the incision
pubic hairline
SOURCE: ADAPTED FROM JACKSON (2015), PHILLIPS (2013) AND SCOTT- CONNER (2013).
WOUND CLASSIFICATION events. There is disagreement among researchers

about the exact number of phases of wound healing
Wounds are classified into the following four types but all agree that it is complex and that there is
(Centers for Disease Control and Prevention [CDC], some overlapping of these phases because they
1999) (see also Box 11-1): occur almost simultaneously (Camp, 2014; Gethin,
• Class I: Clean wound 2012). Following haemostasis, healing progresses
through three phases:
• Class II: Clean-contaminated wound
• Class III: Contaminated wound 1. inflammatory phase
• Class IV: Dirty (infected) wound. 2. reconstructive phase (proliferative phase)
3. maturation phase (remodelling phase) (see
THE PHASES OF WOUND HEALING Fig. 11-5).
Wound healing depends on many local and sys- The same basic biochemical and cellular processes
temic factors and is a complex process that involves are involved in the healing of all soft-tissue inju-
a series of cellular processes and biochemical ries, whether they are acute or chronic.
309
BOX 11-1 » CDC CLASSIFICATION OF SURGICAL WOUNDS

CLASS I: CLEAN WOUND
Expected infection rate: 1–5%
• Elective procedure with wound made under ideal operating room conditions
• Primary closure, wound not drained
• No break in sterile technique during surgical procedure
• No inflammation present
• Alimentary, respiratory or genitourinary tract or oropharyngeal cavity not entered
• Examples include eye surgery, hernia repair, breast surgery, neurosurgery (non-traumatic), cardiac
and peripheral vascular surgery (Phillips, 2013)
CLASS II: CLEAN-CONTAMINATED WOUND

Infection rate: 3–11 %
• Primary closure, wound drained
• Minor break in aseptic technique occurred
• No inflammation or infection present
• Alimentary, respiratory or genitourinary tract or oropharyngeal cavity entered under controlled
conditions without significant spillage or unusual contamination
• Examples include gastrectomy, cholecystectomy (without spillage), elective appendicectomy,
cystoscopy and/or cystoscopy/transurethral resection (negative urine cultures), total abdominal
hysterectomy, dilation and curettage of the uterus, caesarean section and tonsillectomy (not infected
at time of surgery) (Ortega et al., 2012)
CLASS III: CONTAMINATED WOUND

Infection rate: 10–17%
• Open, fresh traumatic wound of less than 4 hours’ duration
• Major break in aseptic technique occurred
• Acute, non-purulent inflammation present
• Gross spillage/contamination from gastrointestinal tract
• Entrance into genitourinary or biliary tracts with infected urine or bile present
• Examples include rectal surgery, laparotomy (with significant spillage), traumatic wounds (e.g.
gunshot, stab wounds—non-perforation of viscera) or acute inflammation of any organ without frank
pus present (e.g. acute appendicitis or cholecystitis) (Ortega et al., 2012)
CLASS IV: DIRTY (INFECTED) WOUND

Infection rate: above 27%
• Old traumatic wound of more than 4 hours’ duration from dirty source or with retained necrotic
tissue, foreign body or faecal contamination
• Organisms present in aseptic field before procedure
• Existing clinical infection: acute bacterial inflammation encountered, with or without purulence;
incision to drain abscess
• Perforated viscus
• Examples include debridement, incision and drainage of, for example, an abscess, total evisceration,
perforated viscera, amputation or patients with positive preoperative blood (Ortega et al., 2012)
310
Healing responses
Haemostasis 1. Stop bleeding
Inflammation 2. Chemotaxis Inflammatory (reactive)
3. Epithelial migration
Connective tissue
4. Proliferation Proliferative (regenerative)
regeneration
5. Maturation
3. Contraction
Remodelling (maturational)
Contracture 4. Scarring
5. Remodelling of scar
FIGURE 11-5: Wound healing continuum

Source: Bak (2015).
THE INFLAMMATORY PHASE • presence of dead cells (host or foreign)

The process of inflammation produces classic • parasites.
symptoms: redness, heat, swelling, pain and
decreased function. Early and late inflammatory HAEMOSTASIS
responses differ and each phase involves different Following injury, bleeding in large vessels must be
biochemical mediators and cells that respond by: artificially stopped or the patient will suffer from
• destroying injurious agents and removing hypovolaemia and, without treatment, death will
them from the inflamed site occur. Following injury, blood vessels briefly con-
strict. Platelets accumulate at the damaged site,
• walling off and confining these agents to limit
adhere to one another and form a platelet plug
their effect upon the host
(Camp, 2014). When damage occurs to endothelial
• stimulating and enhancing the immune cells, which line the blood vessel walls, collagen
response fibres are exposed. When collagen fibres contact the
• promoting healing. platelets, an important release of adenosine phos-
phate (ADP), histamine and serotonin occurs. The
The inflammatory response is immediate, non- coagulation cascade is also triggered (Neveleff,
specific, self-limiting and lasts for 3–4 days. It is 2012). This is known as haemostasis and the
also referred to as the defensive phase of healing mechanism is shown in Figure 11-6.
because it is essential to enable healing to occur
(Camp, 2014). It is induced by: BIOCHEMICAL MEDIATOR RELEASE
• nutrient and oxygen deprivation Mast cells are found in the extracellular spaces
• lethal and non-lethal cellular injury due to close to blood vessels. These are the most impor-
trauma (mechanical forces) tant activators of the inflammatory response. Acti-
vation occurs in two ways. Firstly, as a result of
• genetic and immune defects
degranulation, preformed granular contents are
• chemicals released into the extracellular matrix (e.g. hista-
• temperature extremes mine release). Secondly, certain pain-producing
mediators (e.g. prostaglandins) are synthesised
• ionising radiation in response to the injury stimulus; leukotrienes,
• microorganisms which cause increased vascular permeability and
311
Injury to blood vessel Plasma reaction Consequently, leucocytes in circulation migrate to

the cell walls and adhere there. Released biochem
Vitamin K ical mediators stimulate the endothelial cells lining
the capillaries and venules, causing them to retract,
Constriction and Activates clotting
contraction factors
and a space is created at the cell junction. Conse-
quently, leucocytes are then able to squeeze out of
circulation into the surrounding tissue (Camp,
2014; Gethin, 2012).
Liberates platelet Releases plasma
factors and tissue thromboplastin
thromboplastin PHAGOCYTOSIS
Phagocytosis is the process whereby neutrophils,
monocytes and macrophages remove debris and
Platelets bacteria by engulfing them. In the process,
neutrophils die and pus may form. Importantly,
macrophages produce growth factors by releasing
angiogenesis factor, which is needed for production
Prothrombin
of capillary and lymphatic buds, and fibroblast-
Calcium activating factor, which attracts fibroblasts. This
process initiates wound repair (Camp, 2014; Gethin,
Thrombin 2012).
Fibrinogen
PLASMA PROTEIN SYSTEMS
Fibrin (clot) The inflammatory response activates three key
plasma protein systems. The complement system
activates and assists inflammation and the immune
Digestion by liver Plasmin and process, and directly destroys cells. The clotting
antithrombin
system traps bacteria in injured tissue and interacts
Anticoagulation with platelets to prevent haemorrhage. The kinin
FIGURE 11-6: Mechanism of haemostasis system helps control vascular permeability.
Generally, most surgical wounds are sealed
within hours of closure. This seal unites the wound
exudation, are also produced. Mast cell degranula- and is a barrier, to a degree, to bacterial invasion
tion also attracts leucocytes to the site of injury; (Camp, 2014; Gethin, 2012).
these cells phagocytose damaged tissue and fight
bacteria (Gethin, 2012; Neveleff, 2012). THE RECONSTRUCTIVE PHASE
VASODILATION The reconstructive phase occurs 3–4 days after
Some mediators, such as serotonin and histamine, injury and lasts for about 2 weeks. During this
are termed vasoactive amines because they cause phase the wound is filled in, sealed and then shrinks.
vasodilation and increased vessel permeability. The wound is initially sealed by a blood clot con-
Increased blood flow to the injured tissue causes taining fibrin, which traps erythrocytes, leucocytes
redness. This arteriolar dilation increases pressure and platelets. Fibrin is created by the activation of
in the microcirculation, which causes development the coagulation cascade, and the fibrin in the clot
of an exudate made up of plasma and cells; the provides a framework for collagen molecules (Camp,
exudate pushes into the surrounding tissue, which 2014; Gethin, 2012).
causes localised oedema and swelling (Camp, 2014;
Gethin, 2012). FIBROBLASTS
Fibroblasts synthesise collagen and other connec-
INCREASED CAPILLARY PERMEABILITY tive tissue proteins. They multiply rapidly and enter
As blood becomes more viscous and sticky due to the wound, forming fibres that bridge the wound
plasma leakage, the microcirculation slows down. edges and restore tissue continuity (Gethin, 2012).
312
Collagen is the most abundant protein in the body type III is replaced by collagen type I, which is much
and is the material of tissue repair. It cannot be stronger. Capillaries regress, leaving the wound
produced without iron, vitamin C or oxygen. Col- avascular and thus pale, and localised itching sub-
lagen is produced within 6 days of fibroblasts enter- sides. Within 2–3 weeks after maturation begins,
ing a wound. the scar has gained two-thirds of its maximal
strength. However, at best, the repaired tissue will
GRANULATION regain only 80% of its original tensile strength. The
Repair continues as granulation tissue grows healing process is the same for all wounds, although
inwards from the surrounding healthy tissue. Gran- the composition of healed tissue may differ.
ulation tissue is filled with new capillaries, giving
it a red, granular appearance. It is surrounded by
fibroblasts and macrophages. Capillary buds sprout
TYPES OF WOUND HEALING
out of vascular endothelial cells and extend into The three mechanisms by which surgical wounds
the debrided areas, eventually forming capillaries. may be closed and subsequently heal are primary
Loops form when these capillaries anastomose and intention, secondary intention and tertiary inten-
leak neutrophils and erythrocytes, causing further tion or delayed primary closure (see Fig. 11-7).
debridement of the wound. Capillaries differentiate
into arterioles and venules as repair continues; PRIMARY INTENTION
lymphatics are formed in the same way (Camp, Surgical (and other) clean wounds heal by a process
2014; Gethin, 2012). of collagen synthesis, which seals the wound
(Walter, Dumville, Sharp & Page, 2012). This is
EPITHELIALISATION
As a clot is being dissolved and granulation tissue
formed, the healing wound must be protected. This
occurs during a process by which epithelial cells
grow into the wound from surrounding healthy
tissue. Macrophages secrete a factor that attracts
epithelial cells, which migrate under a clot or seal. Primary closure
Eventually these epithelial cells contact other
migrating cells and seal the wound; migration/
proliferation then ceases. However, the epithelial
cells remain active, undergoing differentiation and
giving rise to various epidermal layers (Camp, 2014;
Gethin, 2012). This process is hastened when the
wound is moist.
WOUND CONTRACTION Secondary closure

Wound contraction occurs over 6–12 days and is
the final reconstructive phase necessary to close all
wounds, especially those that heal by secondary
intention. Granulation tissue contains specialised
cells called myofibroblasts, which cause wound
contraction (Camp, 2014; Gethin, 2012). The scar
will form at this point and may appear red to pink
in colour (Note: Wounds heal side to side and not
end to end.) Tertiary closure
THE MATURATION PHASE (Delayed closure)

The maturation phase is the final phase, commenc-
ing 2–3 weeks after injury and continuing for FIGURE 11-7: Mechanisms of wound healing
several years. Scar tissue is remodelled as collagen Source: Phillips (2013).
313
facilitated by minimal tissue loss and approxima- Delayed healing in a surgical wound is most
tion of wound edges, with sutures, clips or tapes. commonly caused by a surgical site infection (SSI).
There is no dead space on closure and contamina- Wound healing can also be impaired by poor surgi-
tion is held to a minimum by adherence to aseptic cal technique. Rough handling of tissue may cause
technique. Very little epithelialisation is required trauma that can lead to bleeding and other condi-
for healing and most wounds are sealed with fibrin tions conducive to infection (Bak, 2015). The elderly,
several hours after closure (Walter et al., 2012). patients with diabetes and obese patients are also
susceptible to delayed wound healing. One method
SECONDARY INTENTION of reducing the risk of an SSI is the prophylactic use
Secondary intention healing occurs when there is of antibiotics. The goal of prophylactic antibiotics
loss of tissue and the wound cannot be closed; is to ensure effective serum and tissue levels of the
consequently, the wound edges are not approxi- drug for the duration of the surgery. Recommenda-
mated. Healing occurs by granulation, eventual tions for their use include:
re-epithelialisation and wound contraction (Gethin, • initiating the antibiotic within 1 hour before
2012; Pommerening et al., 2015). The wound will surgical incision or 2 hours if vancomycin or
heal spontaneously as long as the dermal base fluoquinolones are used
is preserved. Secondary intention healing takes
• ensuring the antibiotics are appropriate for
longer than primary intention healing and produces
the specific procedure
extensive scarring. However, it is often the best
option for large open wounds (e.g. decubitus ulcers), • discontinuing the antibiotics within 24 hours
traumatic wounds or in wounds where infection is of the completion of surgery (Salkind & Rao
present (Gethin, 2012; Pommerening et al., 2015). 2011).
A loss of skin turgor, muscle tone and elasticity
TERTIARY INTENTION is a natural characteristic of the ageing process.
When approximation and suturing are delayed Thickened connective tissue, decreased subcu
intentionally by 3 or more days, or are secondary taneous fat, diminished capillary blood flow and
for the purpose of walling off an area of gross infec- reduced vascularity are all age-related factors that
tion or where extensive tissue has been removed, may delay wound healing. The tension of sutures
then healing by tertiary intention/delayed primary on aged skin can further inhibit tissue perfusion
closure occurs. This method may also be used (Phillips, 2013). Also, older patients may have
for haemodynamically unstable trauma patients inadequate nutritional intake, altered hormonal
(Brandl et al., 2014). The wound edges are closed responses, poor hydration and compromised
4–6 days postoperatively/post-trauma after metic- immune, circulatory and respiratory systems, any
ulous debridement (Bhangu, Singh, Lundy & of which can increase the risk of skin breakdown
Bowley, 2013). and delay wound healing.
Diabetes is associated with delayed cellular
FACTORS AFFECTING WOUND response to injury, compromised cellular function
HEALING at the site of injury, defects in collagen synthesis
and reduced wound tensile strength after healing.
There are numerous factors affecting wound Moreover, this population is prone to impairment
healing, including: in healing of acute wounds and to developing
• patient’s age chronic non-healing diabetic foot ulcers (DFUs).
Tsourdi and colleagues (2013) postulate that hyper-
• physical status
glycaemia itself has a deleterious effect on wound
• pre-existing conditions such as diabetes healing through the formation of advanced glyca-
• nutritional status tion end products (AGEs), which induce the pro
• oxygenation level duction of inflammatory molecules and interfere
with collagen synthesis. The authors further posit
• overall recuperative power
that an altered immune function may also contrib-
• nutritional status ute to poor wound healing in patients with diabe-
• normothermia (Bak, 2015). tes. Decreased chemotaxis, phagocytosis, bacterial
314
RESEARCH BOX 11-1: Obesity and Surgical Wound Healing
Results of a review of the literature undertaken by Pierpont and colleagues (2014) identified a number
of issues associated with obese patients and surgical wound healing. Obese patients who have a traumatic
injury are at a higher risk of developing multi-organ failure. Furthermore, they have an increased incidence
of surgical complications including atelectasis, thrombophlebitis, wound infection and wound separation.
Another aspect of wound healing for the obese patient is deficiencies in oxygen utilisation in adipose
tissue—fibroblasts’ capacity to synthesise collagen is affected by hypoxia. Overall, the studies reviewed
showed a correlation between obesity and abnormal wound healing, with knowledge of the exact mecha-
nisms still in the early stage.
SOURCE: PIERPONT ET AL. (2014).
killing and reduced heat-shock protein expression by irrigation. The aim of debridement is to provide
have been implicated in the early phase of wound a clean surface with a minimum of microorganisms
healing in diabetes. and dead tissue that provides a focus for infection
Obese patients have an increased incidence of and physically obstructs contraction of the
postoperative (PO) wound infection because of wound and closure of the wound edges. Different
poor vascularity of adipose tissue (Phillips, 2013). types of debridement materials are available
In addition, some obese patients have protein (Diefenbeck, Haustedt & Schmidt, 2013). Sharp
malnutrition, which further impedes healing. debridement has been described as what usually
Obese individuals undergoing surgery face a multi- happens in the operating room (Diefenbeck et al.,
tude of complications including skin wound infec- 2013).
tions, dehiscence, total wound failure, haematomas
and seroma formation (Pierpont et al., 2014); see SURGICAL HAEMOSTASIS
Research box 11-1.
Surgical haemostasis is the deliberate halting of
Another complication affecting wound healing blood flow. It is essential to wound management
is the formation of keloids, which are fibrotic and is a necessary and ongoing process during
tumours of the dermis that form during a pro- surgery. It is necessary to prevent the patient expe-
tracted wound-healing process and develop when riencing the physiological effects of excessive blood
the inflammatory response and fibroblast prolif- loss. Additionally, bleeding from the operative site
eration are overactive. This is an inherited trait, reduces visibility for the surgeon and is a risk factor
most common among Africans, Asians and people for developing an SSI (Camp, 2014). The mecha-
with dark skin tones or those who freckle. Keloids nisms used encourage the formation of a blood clot,
extend beyond the borders of the scar and can con- thereby stopping the flow of blood into the surgical
tinue to grow and become very large over a pro- site.
longed period after the surgical procedure. An
anti-inflammatory agent may be injected into the METHODS OF SURGICAL HAEMOSTASIS
tissue before closure for patients who have a Surgical haemostasis is achieved by several means,
history of keloids. A pressure dressing is useful in which are classed as mechanical, adjuncts to
minimising keloid formation. Application of sili- mechanical, pharmacological, chemical and energy-
cone gel sheeting over healed bulky tissue scars based; several other methods are unclassified.
for 24 hours over a period of 2 weeks can reduce
the size of the scar (Russell et al., 2010). MECHANICAL HAEMOSTASIS
Mechanical haemostasis is achieved by com-
DEBRIDEMENT pressing the ends of severed vessels, temporarily
Debridement is the removal of dead or necrotic slowing the flow of blood until the normal
tissue, dirt and foreign objects from a wound, often clotting mechanisms have sealed the vessel.
315
Various methods are used to achieve mechanical pre-cut lengths or as ligature reels, in which the
haemostasis: material is wound around a spool. See Chapter 10
• instruments for further information. Ties may be passed to the
surgeon in several ways depending on the surgery
• ligatures/ties being performed and the individual preference of
• ligating clips the surgeon. Standard length ties may be divided
• bone wax and cut into halves, thirds or quarters, depending
• packing on the depth of the tissue being ligated. Ties can be
grasped within the jaws of a haemostat/artery or
• pledgets tissue forceps or simply handed to the surgeon. Ties
• patties handed to the surgeon should be held taut like a
• tourniquets guitar string (Neveleff, 2012).
• simple digital pressure (Neveleff, 2012).
Ligating clips
Instruments Ligating clips are small, V-shaped, staple-like
Instrument clamps are used to hold a small amount devices that are designed to be pinched shut over
of tissue or the end of a blood vessel. The haemo- the ends of tissue. They are made from surgical
stat or artery forceps is the most commonly used stainless steel, titanium or absorbable polymer.
instrument for achieving haemostasis. Often, the When placed on a blood vessel and closed shut,
pressure of clamping a blood vessel is sufficient to ligating clips occlude the lumen and stop the bleed-
achieve haemostasis (Neveleff, 2012). ing from the vessel (see Fig. 11-8). Ligating clips
are available in small plastic carriers, preloaded
Ligature/ties with multiple clips, which require individual
Ligatures are made from suture material and are loading onto a sterile instrument. Ligating clips are
available in pre-packaged standard lengths, in also available in a purpose-designed, disposable,
FIGURE 11-8: Loading a clip applicator

316
preloaded instrument that delivers and closes the

clips (Neveleff, 2012).
Bone wax
Bone wax comprises small balls of processed bees
wax, which is smeared along the open edge of the
bone, acting as a barrier to stop oozing from the cut
bone surface.
Packing FIGURE 11-9: Pneumatic tourniquet

Surgical sponges or packs are used for packing a
wound site, and effectively place pressure on the
wound edges or in a body cavity to reduce bleeding.
The surgeon may require the packs to be moistened
with a warm sterile irrigating solution. Warm packs
promote haemostasis by accelerating the coagula-
tion mechanism.
Pledgets
Pledgets are small pieces of Teflon material that are
used to reinforce a suture line where bleeding may
occur through the needle holes, effectively placing
pressure on the site to reduce bleeding. The pledg-
ets remain in place as part of the suture.
Patties
Compressed, absorbent, radio-opaque cottonoid
patties are available in various sizes and are used
to absorb blood and compress delicate areas to stop
blood flow. They are commonly used in surgical
procedures on the brain, spine and spinal cord. The
FIGURE 11-10: Application of an Esmarch bandage
instrument nurse counts the patties, moistens Source: Fuller (2013).
them with normal saline, presses out excess mois-
ture and keeps them flat before use.
ADJUNCTS TO MECHANICAL HAEMOSTASIS
Tourniquets A number of products are available to provide an
A tourniquet compresses the underlying vessels, adjunct to mechanical haemostasis. The effect of
thus restricting blood flow to a limb or digit, cre these products is to speed the formation of a blood
ating a bloodless field for the procedure. A pneu- clot. Some examples of the most commonly used
matic tourniquet (see Fig. 11-9) is used when products are outlined below.
compression is required to reduce blood flow to a
limb (e.g. this might be required during open reduc- Absorbable gelatin
tion and internal fixation of a fractured ankle). Absorbable gelatin (Gelfoam) is an absorbable
An Esmarch bandage is applied to exsanguinate haemostatic agent made from porcine gelatin,
the limb before the tourniquet is inflated (see which is compressed into a pad or powder form. As
Fig. 11-10). See Chapter 9 for further information a pad, it is available in an assortment of sizes that
about care of patients when tourniquets are in use. can be cut to the desired size without crumbling.
Applying an elastic band, Penrose drain or the The gelatin sponge is not soluble and absorbs up to
finger of a glove can reduce blood flow to the toes 45 times its own weight in blood. It is frequently
and fingers (Neveleff, 2012). soaked in thrombin or adrenaline solution and is
317
handed moist to the surgeon for use. When placed application only and is never injected (Neveleff,
in an area of capillary bleeding, fibrin is deposited 2012).
in the interstices and the sponge swells, forming a
clot. Gelatin powder is mixed with sterile saline to Oxytocin
make a paste for absorbing blood (Neveleff, 2012). Oxytocin is a hormone produced in the pituitary
gland, which can also be prepared synthetically for
Absorbable collagen sponge therapeutic injection. It is commonly used in
Haemostatic sponges (Colostat) of bovine collagen obstetric and gynaecological surgery. Oxytocin
origin are applied dry to oozing or bleeding sites. causes the uterine muscle to contract, thus putting
The collagen activates the coagulation mechanism, pressure on the blood vessels, reducing bleeding
especially the aggregation of platelets, to acceler- from that organ (Begley et al., 2014).
ate clot formation. The material dissolves as
haemostasis occurs and any residual will absorb in Adrenaline
the wound. The sponge must be kept dry and should Adrenaline is a naturally occurring hormone pro-
be applied with dry gloves or instruments. It is duced by the adrenal gland. It is also prepared com-
applied directly to the bleeding surface as supplied mercially. It acts as a vasoconstrictor and is used to
from the sterile package. Absorbable collagen is reduce the flow of blood to the surgical site. Topical
contraindicated in the presence of infection or adrenaline can be applied to bleeding surfaces.
where blood or other fluids have pooled (Neveleff, Local anaesthesia often contains adrenaline to
2012). prolong its effectiveness (Grgov, Radovanović-Dinić
& Tasić, 2013).
Oxidised cellulose
Absorbable oxidised cellulose comes in the form of Fibrin glue
a knitted fabric (Surgicel) and is applied dry to Fibrin glue acts as a biological adhesive and
bleeding areas. It may be sutured to, wrapped haemostatic agent. It is composed of fibrinogen,
around or held firmly against a bleeding site, or laid cryoprecipitate from human plasma, calcium chlo-
dry on an oozing surface until haemostasis is ride and reconstituted thrombin of bovine origin
obtained. Oxidation of the cellulose acts rapidly to (Phillips, 2013). Upon application directly to tissues,
form a clot when it comes in contact with whole thrombin converts fibrinogen to fibrin to produce
blood. As it reacts with blood, it increases in size to a clot. Fibrin glue may be used in deeper tissues
form a gel. It stops bleeding in areas in which bleed- to control bleeding and approximate tissues. A
ing is difficult to control by other means of haemos- liquid gel or aerosol spray can deliver the fibrin glue
tasis. If left on oozing surfaces, it will absorb 10 (Camp, 2014).
times its own weight with minimal tissue reaction.
Oxidised cellulose is inactivated in the presence of ENERGY-BASED METHODS OF
thrombin (Neveleff, 2012). SECURING HAEMOSTASIS
There are a number of modalities that use energy
PHARMACOLOGICAL AND CHEMICAL HAEMOSTASIS to provide haemostasis throughout a surgical
There are several pharmacological and chemical procedure.
agents to reduce blood loss and the requirement for
blood transfusions in surgery. Electrosurgery
Electric current can be used to cut or coagulate
Thrombin most tissues: fat, fascia, muscle, internal organs
Thrombin (Thrombostat) is an enzyme that is and vessels. Electrosurgery is used to a greater or
extracted from dried beef blood; it is used topically. lesser extent in all surgical specialities and the
Thrombin accelerates coagulation of blood and electrosurgical unit (ESU) can be seen in all operat-
controls capillary bleeding. It unites rapidly ing rooms. The machine comes with a range of dis-
with fibrinogen to form a clot. It is available posable ‘tools’ that surgeons can use to achieve
as a powder that is reconstituted immediately ongoing haemostasis (Camp, 2014). See Chapter 6
prior to use. It can be used alone or soaked into for further information on ESUs and other energy-
a gelatin sponge. Thrombin is used as a topical based surgical modalities.
318
Laser Sclerotherapy
Laser light is used for controlling bleeding or for Sclerotherapy is the injection of a coagulant to stop
the ablation and excision of tissues. The laser con- or reduce venous bleeding. Phenol plus alcohol is a
centrates and intensifies a light beam of a single sclerotherapy agent used to thrombose external
wavelength. The thermal energy of this beam may haemorrhoids (Phillips, 2013).
simultaneously cut, coagulate and/or vaporise
tissue. The laser wound is characterised by minimal
bleeding and no PO oedema. Different lasers have
WOUND CLOSURE
selected uses, depending on the form of the wave- The goal of wound closure is to approximate the
length (Camp, 2014). wound edges, eliminate dead space, distribute
tension evenly along the suture line and maintain
Ultrasonic scalpel the tensile strength across the suture line until suf-
The titanium blades of this scalpel move by a ficient tissue tensile strength is achieved. The
rapid ultrasonic motion that cuts and coagulates closure of a surgical wound is performed after
tissue simultaneously. It generates less heat adequate haemostasis has occurred. The strength
than the ESU and therefore does not damage adja- of the wound is related to the condition of the
cent tissues. Vibrations from the tool denature tissue and the number of stitches in the edges. Care
protein molecules, producing a coagulum that seals is taken not to place more sutures than necessary
bleeding vessels. The continuous vibration of the to approximate the edges. The amount of tissue
denatured protein generates heat within the tissue incorporated into each stitch directly influences
to cause deeper coagulation. Because electricity is the rate of healing. Wound closures often include
not required to produce coagulative effects on deep and superficial sutures but may also include
tissue, a grounding pad is not required (Camp, staples, clips, tapes and glues. There are indications
2014). for each method of closure, along with advantages,
disadvantages and special considerations (Osifo &
Haemostatic scalpel Osagie, 2011).
The sharp steel blade of the haemostatic scalpel Skilful wound closure requires knowledge of
seals blood vessels as it cuts through the tissue. good surgical technique, as well as knowledge of
When the surgeon activates the handle, the blade the properties of the suture material and needle.
transfers thermal energy to tissues as the sharp edge While the actual suturing technique is largely left
cuts through them. The temperature can be adjusted to the surgeon, the perioperative nurse needs a
between 110°C and 270°C. The resultant rapid hae- broad knowledge of suture materials, their proper-
mostasis with minimal tissue damage promotes ties and how to handle the sutures safely in order
wound healing and may eliminate the need for blood to assist the surgeon. Chapter 10 has a detailed
replacement. Because electric current from the section on suture materials.
microcircuitry does not pass through the tissues, a
grounding pad is not required (Camp, 2014). WOUND CLOSURE METHODS
The traditional methods of wound closure include:
ADDITIONAL METHODS OF HAEMOSTASIS
• single layer
Embolisation
• multiple layer
Embolisation is a procedure that blocks blood flow
to a targeted area in the body. It can be used to • simple continuous sutures
prevent or stop bleeding. Various substances can be • simple interrupted sutures
used to block the blood vessel, including medical
• continuous running/locking
glue, medical putty, tiny metal coils or plastic beads.
The technique is often used in neurosurgery to • subcutaneous sutures
embolise a cerebral aneurysm or the blood supply • retention sutures
to an arteriovenous malformation, thereby negat-
ing the need for surgery, or to help the surgeon • drain suture.
control bleeding during the surgical procedure Figure 11-11 demonstrates several suturing tech-
(Jairath et al., 2012). niques for wound closure.
319
Knot placement
Interrupted stitches require individual knots and
therefore placement of the knot can influence how
well the wound heals and the cosmetic result. Prin-
ciples concerning knots and knot tying include the
following:
A B 1. The knot should be tied away from:
• vital structures, such as the eye
• sources of contamination, such as the
mouth
• potential irritants, such as the nares
C • potential sources of increased
inflammation, such as the incision line.
FIGURE 11-11: Examples of suturing techniques: A, Simple continuous.
B, Continuous locking. C, Simple interrupted 2. The knot should be tied towards:
• the better blood supply
• the area that provides the best security of
the knot
SINGLE-LAYER CLOSURE • if possible, where the mark would be less
noticeable (Phillips, 2013).
A single-layer continuous suture line is commonly
used in abdominal closure. In this technique, all of
CONTINUOUS RUNNING/LOCKING (BLANKET STITCH)
the layers of the abdominal wall except the skin and
subcutaneous tissue are sutured in one layer. The In this method, a single suture is passed in and out
skin is approximated separately with interrupted of the tissue layers and looped through the free end
sutures (Singh & Ahluwalia, 2012). It is subject to before the needle is passed through the tissue for
great pulling forces and the ‘bites’ of the needle are another stitch. Each new stitch locks the previous
deliberately large so that the force is more evenly stitch.
distributed over the area.
SUBCUTANEOUS SUTURES
MULTIPLE-LAYER CLOSURE Subcutaneous sutures are placed under the epider-
As the name suggests, the wound is closed in mul- mis of the skin. This method of closure provides
tiple layers, effectively eliminating the dead space, good cosmetic results as there is no skin perfora-
thus promoting wound healing. tion with the suture needle. It is suitable in the
absence of oedema or infection.
SIMPLE CONTINUOUS SUTURES
RETENTION SUTURES
In this method, the suture is anchored at one end
of the wound and proceeds towards the opposite Interrupted, non-absorbable retention or stay
end, taking even bites of tissue. The suture is then sutures are placed alongside the primary suture
anchored at the other end of the wound. This line to relieve lateral tension on the suture line,
method is quicker than tying several knots, as for with the aim of reducing the risk of wound dehis-
interrupted sutures (see below). cence. The tissue through which retention sutures
are passed includes skin, subcutaneous tissue and
SIMPLE INTERRUPTED SUTURES fascia, and may include the rectus abdominis
muscle and peritoneum in an abdominal incision.
With simple interrupted sutures, each suture is After abdominal surgical procedures, retention
placed and tied individually. This method is gener- sutures are used frequently in patients in whom
ally considered to be the most secure method of slow wound healing is expected because of:
suturing. Variations in the configuration of the
stitch itself are designed to exert forces in differ- • malnutrition
ent ways. • obesity
320
• carcinoma
• infection
• older age
• cortisone therapy
• respiratory problems (Phillips, 2013).
DRAIN SUTURES
Drains are often anchored to the skin by a suture to
prevent the drain being inadvertently pulled out or
slipping into the wound. Silk sutures are the most
commonly used ‘drain stitch’.
OTHER METHODS OF WOUND CLOSURE

STAPLES
Most operating suites have a large collection of
mechanical stapling devices that are used for inter-
FIGURE 11-12: Application of skin clips
nal ligation, division, resection, anastomosis and
closure of the skin and fascia layers. These dispos-
able devices provide the important benefit of reduc- Tissue adhesives provide good closure without
ing tissue handling, thereby reducing the length of causing any pain, plus there is no need to remove
the procedure. When fired, the staples take on a ‘B’ sutures at a later time. Patients are able to shower
shape, permitting nutrients to permeate the tissue because the adhesive also provides a waterproof
and promote healing. Stapling devices fire a single barrier. Synthetic adhesives are glue-like adhesives
staple, one or two straight rows or circular rows of that polymerise to bind tissue edges together. Bio-
staples. Refills are also available for some stapling logical and synthetic adhesives, such as fibrin glue
devices. Some stapling devices incorporate blades; compound (see Feature box 11-1), have great appli-
this permits the simultaneous division of tissue cation in the area of haemostasis, as previously
that has been ligated between rows of staples presented (Phillips, 2013). Tissue adhesives may
(Feese, Johnson, Jones & Lambers, 2013). be used for microsurgical anastomoses of blood
Skin staples/clips are used to close the skin vessels, nerves and fallopian tubes. They may also
layer of an incision (see Fig. 11-12). The clips are be used for reconstruction of the middle ear, to fix
made from non-corroding metal and delivered by a ocular implants, to close superficial lacerations and
preloaded disposable device. Skin staples can be fistula tracts, and to secure skin grafts.
used in the presence of infection as the strength of
the material is not affected by the increased inflam-
matory response, which can weaken some suture
WOUND CARE
materials (Feese et al., 2013). DRESSINGS
Dressings are applied to a surgical incision or
TAPES wound site for the first 24–48 hours to provide the
Skin tapes are adhesive-backed nylon or polypro- best environment for wound healing to occur. A
pylene tapes, which can be used separately or in dressing serves several purposes:
conjunction with subcuticular skin closure, provid- • protection of the wound from trauma and
ing extra strength (see Fig. 11-13). gross contamination
• keeping the wound free of microorganisms,
TISSUE ADHESIVES
both exogenous and endogenous
Tissue adhesives have been available for more than
40 years (Bryant & Knights, 2014) and have been • absorption of exudate and secretions
used most commonly in the emergency room, par- • enhancement of patient physical comfort and
ticularly for children with minor traumatic wounds. aesthetic appearance
321
A B
C D
FIGURE 11-13: How to use Steri-strip tapes on a suture line: remove the top backing (A), take one Steri-strip tape (B) and place it across the wound (C), then repeat until
the whole wound is covered (D)
Source: Adapted from Ball (2015).
FEATURE BOX 11-1 » FIBRIN GLUE COMPOUND
EQUIPMENT
• Sterile specimen cup
• Two 20-mL disposable syringes
• Two 14-gauge intravenous (IV) catheters
• 6 units thawed cryoprecipitate
• 1 ampoule calcium chloride (CaCI) (10%, 1 g)
• 50,000 units thrombin
INSTRUCTIONS
1. Mix CaCI and thrombin in the specimen cup.
2. Draw mixture into a 20-mL syringe and attach a 14-gauge IV catheter.
3. Draw cryoprecipitate into the second syringe with a 14-gauge catheter on the end.
4. Discharge both syringes over the wound at the same time. The fibrin glue will form a clot
over the wound.
SOURCE: PHILLIPS (2013).
322
• support and immobilisation of the incisional that emanate from a draining wound. It must
area and/or body part conform to body contours regardless of the site and
• provision of additional haemostasis, extent of the wound, and must stay in intimate
minimising dead space and oedema contact with the wound surface for at least 48 hours,
yet be non-adherent for painless removal. The inter-
• maintenance of a moist environment, which
mediate layer absorbs secretions that pass through
supports healing
the contact layer. It should be layered but not exces-
• application of medications (Ball, 2015). sively bulky, nor apply pressure that could compro-
When considering the most suitable dressing, mise circulation. The outer layer holds the contact
each wound is assessed in terms of the type of wound, and intermediate layers in proper position. It should
its location, depth and the patient’s comorbidities. be conforming and stretchable to avoid constriction
if oedema develops. Non-allergenic tape is the most
TYPES OF DRESSINGS frequently used material to hold the dressing in
Dressings are classified according to their main place. Depending on the site of the wound, an elastic
function: primary or secondary dressings. Primary bandage may be used because it provides gentle
dressings are placed directly over the wound. Their even pressure and gives firm support.
function is to absorb drainage, while keeping the
wound moist. This layer of dressing should be non- Pressure dressings
stick unless debridement is necessary. Secondary Bulky dressings are added to the immediate layer
dressings are placed directly over the primary of a three-layer dressing. This dressing acts to elim-
dressing. Their function includes haemostasis by inate dead space and prevent haematoma or
compression, absorption of excess drainage and oedema. It also distributes pressure evenly, absorbs
protection of the wound from trauma (Bak, 2015). extensive drainage, encourages wound healing and
minimises scarring by influencing wound tension,
One-layer dressings and immobilises a body area or supports soft tissues
One layer dressings are sterile, transparent, occlu- when muscles are being moved. A pressure dressing
sive dressings that are suitable for clean, incised helps to provide comfort to the patient postopera-
wounds. Multiple studies have shown that the use tively. These dressings are often used in plastic,
of occlusive dressings promotes wound healing two knee and breast surgery (Phillips, 2013).
to six times faster than in a wound exposed to air;
SSI rates are significantly lower under an occlusive Stent dressings
dressing compared to a non-occlusive dressing A stent dressing is a method of applying pressure
(Diana et al., 2011). and stabilising tissues when it is impossible to
dress an area, such as on the face or neck.
Skin closure dressings (island dressings)
Skin closure or island dressings consist of a non- Bolster/tie-over dressings
stick pad in the centre (to absorb drainage) and Dressing materials may be sutured in place to exert
either an occlusive-type material or adherent an even pressure over autografted wounds to
woven gauze, which anchors the dressing to the prevent haematoma or seroma formation.
skin (Walter et al., 2012).
Wet-to-dry dressings
Dry sterile dressings Wet-to-dry dressings are used when debridement
Dry sterile dressings are applied to dry incised of the wound is required; the saline-soaked gauze
wounds where there is no drainage. Dry dressings dries and debrides the wound on removal. This
are not used on denuded wounds or those with process is used to facilitate new tissue growth.
large amounts of drainage as they adhere to the These dressings are painful and their removal and/
wound, causing trauma on removal. or replacement may be conducted in the operating
room under anaesthetic.
Three-layer dressings
Three-layer dressings are used when moderate to Hydrocolloid dressings
heavy drainage is expected. The contact layer acts A hydrocolloid dressing is an occlusive dressing
as a passageway for the secretions and exudates that provides a barrier to the outside environment
323
RESEARCH BOX 11-2: Routine Abdominal Drainage versus No Abdominal Drainage for Uncomplicated
Laparoscopic Cholecystectomy
A systematic review update was undertaken in which 12 trials were included (Gurusamy et al., 2013). A
total of 1831 participants were randomised to drain (915 participants) versus ‘no drain’ (916 participants).
The authors concluded that there is currently no evidence to support the routine use of a drain after
laparoscopic cholecystectomy and suggest that further well-designed randomised clinical trials are
necessary.
and allows the body’s own phagocytic processes to DRAINS

provide debridement to the wound. Hydrocolloid Drains are often inserted during surgery to provide
dressings maintain a moist environment and are a pathway allowing blood, lymph, intestinal secre-
less painful to remove. They also need less chang- tions, bile, pus, air or urine to be transported away
ing and patients are encouraged to leave dressings from the surgical site (see Research box 11-2).
in situ until they need changing (Walter et al., Drains can be used prophylactically or therapeuti-
2012). cally. A drain is inserted prophylactically to remove
unwanted fluid, air or secretions from around the
Silver dressings surgical site, to promote wound healing, to provide
Silver is a very effective modality for the prevention a mechanism to observe for haemorrhage (Phillips,
or treatment of infection over a wide variety of bac- 2013) and to reduce PO pain. The presence of a col-
teria, viruses, fungi and moulds and has few side lection of fluid, air or secretions is thought to act
effects. It remains effective even against multi- as a medium in which microbes can grow, leading
antibiotic-resistant microorganisms (Murphy & to an SSI.
Evans, 2012). Nanocrystalline silver dressings were The use of prophylactic drains in surgery con-
developed and introduced in the late 1990s and are tinues to be controversial. Several recent studies
the latest forms of silver dressings. have found insufficient evidence to support their
use (Kęska, Paradowski & Witoński, 2014; Gurusamy,
Vacuum-assisted dressings Koti & Davidson, 2013). The presence of a wound
A vacuum-assisted dressing is a closed-system drainage system does not necessarily reduce the
dressing used for difficult-to-heal wounds with incidence of SSIs or haematoma. Indeed, in some
large amounts of drainage. The dressing comprises cases the presence of a drain is thought to increase
an absorbent sponge to draw away fluid, an occlu- the risk of SSIs by providing a route for the migra-
sive adherent dressing to seal the system, tubing to tion of bacteria around the tube into the wound
facilitate the drainage and a vacuum pump, which (Kęska et al., 2014).
gently aspirates the fluid and holds it in a storage A drain that is inserted therapeutically is used
unit. The use of vacuum-assisted dressings has to reduce the amount of an already present collec-
increased in recent years for the treatment of tion, which may be necrotic or purulent material.
wounds in patients with compromised healing. Drains are usually inserted at the time of surgery,
However, some evidence suggests that the drains primarily through a small stab incision near the
may contribute to the formation of fistulas (Mala- operative site. Drains may or may not be sutured to
hias et al., 2012; Tottle & Harris, 2014). the skin. Some drains act by directing the fluid away
through the lumen of the tube itself; other drains
APPLICATION OF DRESSINGS have a small fenestration at the tip, which drains
The application of surgical dressings is regarded as into a closed system; and yet other drains act by
part of the surgical procedure. The surgeon is ‘wicking’ the fluid away by capillary action into an
assisted by the instrument nurse and the circulat- absorbent dressing or drainage bag. The periopera-
ing nurse to dress the wound properly. tive nurse must document clearly in the patient’s
324
medical record the type of drain, its location and away from the wound site into the reservoir. Neg-
whether the drain is sutured in place, and ensure ative-pressure wound therapy (NPWT) is also called
that the drain is working properly before the patient vacuum-assisted wound closure (VAC) therapy and
leaves the operating room. refers to wound dressing systems that continuously
or intermittently apply subatmospheric pressure to
DRAIN TYPES the surface of a wound to assist healing. NPWT
Passive drains increases local vascularity and oxygenation of the
wound bed and reduces oedema by removing
Passive drains use gravity and capillary action to
wound fluid, exudate and bacteria (Rock, 2014).
move unwanted fluids away from the operative
site. A Penrose drain is a soft latex tube, of varying
sizes, often used for the superficial drainage of
Chest drains
abscesses. A Yeates drain is a soft, silicone corru- Drainage of the pleural cavity ensures complete
gated drain, which acts by capillary action and expansion of the lungs after surgery. Air and fluid
gravity to drain into a dressing or drainage bag; it must be evacuated from the pleural space after
is often used to drain post-appendicectomy wounds surgical procedures within the chest cavity (see
(Phillips, 2013). Fig. 11-15). One or more chest tubes are inserted.
If the surgeon inserts two, the upper tube evacuates
Active drains air and the lower tube drains fluid (Phillips, 2013).
Active drains are attached to an external source Care must be taken when moving and transferring
of vacuum to create a negative pressure in the the patient to ensure the drain is kept below chest
wound. Active drains include closed wound suction height.
systems, sump drains and chest drains.
Specialised drains
Closed wound drainage systems The T-tube drainage system is a soft latex drain
that is inserted into the common bile duct, allowing
Closed drainage systems, such as Jackson-Pratt or
bile to be drained away.
haemovac drains (see Fig. 11-14), are sterile, self-
contained drainage units. The closed unit mini-
mises the pathway of pathogens to the wound site.
Urinary drainage
They may be used with or without suction; that is, A urinary or ureteral catheter provides continuous
they can be active or passive drains. The negative drainage of the bladder or kidneys during and after
pressure in the reservoir acts to draw fluid gently the surgical procedure. The balloon of a urinary
catheter maintains pressure on the bladder neck,
which helps control bleeding after a transurethral
prostatectomy and can be used to facilitate bladder
irrigation. The urinary catheter is also used to
monitor the patient’s haemodynamic status.
Gastric decompression
A nasogastric tube can be used as a drain to decom-
press the stomach of flatus or gastric fluids. It is
used to drain gastric secretions, thus preventing
aspiration. It can also be used to decompress the
stomach to aid the surgeon’s view.
TECHNOLOGICAL ADVANCES IN
WOUND MANAGEMENT
The area of wound management has advanced
technologically. Implantable tissue, skin substi-
tutes and growth factors are some of the wound
FIGURE 11-14: Haemovac drain reservoir. management techniques now available.
325
Remove air
Remove fluid
A B
Water seal
chamber
To suction From patient
1900
B
1800 D Collection
800
120 chamber
Suction A 1700
control 110
chamber 1600
700 100
1500 90
600
1400 80
70
1300 500
60
1200
400 50
1100
40
Air leak C 300
monitor 1000 30
200 20
900
10
C
FIGURE 11-15: A, Placement of drains. B, Scrub person pours sterile water into the unit to create a water seal. C, Tubing attachment to three-chamber collection unitn
IMPLANTABLE TISSUE REPAIR AND prevent evaporative water loss, heat loss, protein
REPLACEMENT MATERIAL and electrolyte loss and contamination of the wound
Tissue deficiencies may require additional re (Vyas & Vasconez 2014). Sometimes, the edges of
inforcement or bridging material to obtain adequate fascia, for example, cannot be brought together
wound healing. This use of biological wound healing without excessive tension. In obese patients or older
materials permits autolytic debridement and devel- patients the fascia cannot withstand this tension
ops a granular wound bed. Biological dressings because of weakness caused by the infiltration of fat.
326
Autologous—natural Chemical—synthetic
• Skin • Glial antibiotic disc
• Cartilage • Bone cement
• Bone • Drug-eluting stent
• Muscle • Conduit graft
• Gut • Mesh graft
• Hair follicles
• Vessels
Xenograft—natural Polymerx—synthetic
• Porcine dermal collagen • Solid
• Tricalcium phosphate • Expandable
• Porcine heart valve • Shunts
• Bovine collagen matrix • Stents
• Porcine collagen matrix • Thermoplastic polymer
• Liquid
• Polyethylene
• Polyurethane
• Non-absorbable ligating clip
Allogenic—natural Metallic—synthetic
• Bone • Plates/screws
• Tendon and ligament • Rods
• Cornea • Stent
• Alloderm • Joint
• Tissue matrix: periosteal • Grid
• Saphenous veins • Clips and staples
• Heart valves • Metallic oxide, ceramic
• Ossicles • Zirconium oxide
• Chromium oxide
• Aluminium oxide
• Dental ceramic
Biomaterials—natural Mechanical—synthetic
• Biodegradable fixation S-1 (CO2 and H2O) • Pacer
• Hydroxyapatite ceramic • Penile hydraulics
• Bioengineered stent, endothelial • Medication pump
• Bovine collagen polyester graft • Cochlear components
• Heart assist device
• Internal defibrillator
• Nerve stimulator
FIGURE 11-16: Implants: tissue repair and replacement material—natural (biological) and mechanical (synthetic)
Biological or synthetic mesh materials are used to autologous engineered skin, are available to provide
fill congenital, traumatic or acquired defects in the temporary or permanent coverage. Acellular prod-
fascia or a body wall and to reinforce the fascia, as ucts such as cadaveric human dermis with removed
in hernia repair (Phillips, 2013). Implants must be cellular components contain a scaffold or matrix of
sterile and compatible with the recipient. They hyaluronic acid, collagen or fibronectin. Cellular
should not be handled excessively to prevent damage products contain living cells such as keratinocytes
to the surface or contamination from the field. Im- and fibroblasts within a matrix (Vyas & Vasconez,
plants can be permanent or temporary and com- 2014). These products have the advantage of being
posed of many materials. Some implants used are available in large quantities and have negligible
mechanical. See Figure 11-16. risk of infection or immunological issues (Murphy
& Evans, 2012). There are three types of skin
SKIN SUBSTITUTES substitutes:
Burns are the major indicator for the use of
skin substitutes. Bioengineered skin substitutes, • epidermal equivalents only
both biosynthetic skin substitutes and cultured • dermal components from processed skin
327
• distinct dermal and epidermal components, to greater than 1 atmosphere absolute (ATA).
referred to as composite skin (Augustine, Hyperoxygenation is valuable in the management
Kalarikkal & Thomas, 2014). of crush injury, compartment syndrome, flap
salvage and acute blood loss anaemia. Oxygen is
GROWTH FACTORS AND BIOLOGICAL vital for hydroxylation of lysine and proline resi-
WOUND PRODUCTS dues during collagen synthesis and for cross-linking
These products aim to accelerate healing by aug- and maturation of collagen, which is required for
menting or modulating inflammatory mediators. strong wound healing. Lack of oxygen is corrected
Growth factors mainly stimulate fibroblasts and during HBOT, leading to adequate amounts of
keratinocytes (Murphy & Evans, 2012). mature collagen formation. Hypoxia is a vital stim-
ulant for angiogenesis, but the development of
SCAFFOLDS an adequate capillary network requires adequate
amounts of tissue oxygen concentration. HBOT also
Hybrid scaffolds are comprised of polymeric sub-
increases the oxygen gradient between the centre
strates coated with bioactive materials, collagen
and the periphery of the wound, thus creating a
and silk fibroin. They also contain advanced tissue
strong angiogenic stimulus. This, along with fibro
engineering substrates impregnated with endothe-
blastic proliferation, leads to increased neovascu-
lial progenitor cells. Nanomaterial-based scaffolds
larisation (Murphy & Evans, 2012).
may be employed as advanced wound dressings to
initiate and expedite wound healing (Vyas & Vas-
conez, 2014). Vyas and Vasconez (2014) suggest that CONCLUSION
both surface and deep wounds of the epidermis may Wound healing is a complex process that involves
be expedited by the application of active biological, the activation and synchronisation of intracellular,
biomembrane or scaffold-based wound dressings. intercellular and extracellular elements. Advance-
ment of the clinical understanding of wounds and
HYPERBARIC OXYGEN THERAPY their pathophysiology has evolved over the past
While hyperbaric oxygen is not a wound closure two decades. This chapter has explored types of
technique per se, it is useful for the operating room wound healing, surgical haemostasis and wound
nurse to have an understanding of hyperbaric closure. Recent advances in wound closure have
oxygen therapy (HBOT). HBOT uses 100% oxygen also been presented. The perioperative nurse must
at pressures greater than atmospheric pressure: the show sound assessment, planning, implementation
patient breathes 100% oxygen intermittently while and evaluation of all aspects of wound manage-
the pressure of the treatment chamber is increased ment during the perioperative period.

1. Potential wound problems
Miss Brown is scheduled for a right below-knee amputation on tomorrow’s list. She weighs 120 kg, is
160 cm tall and has type 2 diabetes.
• Identify three potential problems that Miss Brown may encounter. Provide rationales for your
answers.
2. Wound classification
Mrs Edwards is a 58-year-old mother of three children who is being admitted on the morning of
surgery for a vaginal hysterectomy with a diagnosis of benign myoma of the uterus. Mrs Edwards
underwent a bilateral total hip replacement for osteoarthritis 2 years ago.
• How would you classify Mrs Edwards’ wound?
• What actions should the surgical team take to optimise her wound healing?
328
3. Wound closure
• Apart from sutures and staples, identify four other methods of wound closure and outline when
these methods would be used.
4. Wound healing
• Identify factors that impinge on wound healing.
• Discuss three advances that promote wound healing and outline their advantages.
Centers for Disease Control and Prevention (CDC). (1999).

RESOURCES Guideline for prevention of surgical site infection, 1999.
Skin integrity in the elderly in hospital Retrieved from <www.cdc.gov/hicpac/SSI/001_SSI.html>.
www.health.vic.gov.au/older/toolkit/10SkinIntegrity/ Diana, M., Hübner, M., Eisenring, M., Zanetti, G., Troillet, N.,
index.htm & Demartines, N. (2011). Measures to prevent surgical site
Wounds International infections: What surgeons (should) do. World Journal of
www.woundsinternational.com/other-resources/view/ Surgery, 35(2), 280–288. doi:10.1007/s00268-010-0862-0.
patient-safety-surgical-site-infections-quick-guide Diefenbeck, M., Haustedt, N., & Schmidt, H. (2013). Surgical
debridement to optimise wound conditions and healing.
VIDEO RESOURCES International Wound Journal, 10(Suppl. 1), 43–47. doi:10.1111/
iwj.12187.
Burn management in the OR Feese, C. A., Johnson, S., Jones, E., & Lambers, D. S. (2013). A
https://youtu.be/lFPHYjjKJVs randomized trial comparing metallic and absorbable staples
Wound debridement for closure of a Pfannenstiel incision for cesarean delivery.
https://youtu.be/2DBWtPwcNag American Journal of Obstetrics and Gynecology, 209(6), e1–e5.
doi:10.1016/j.ajog.2013.08.001.
REFERENCES Fuller, J. (2013). Surgical technology principles and practice
Augustine, R., Kalarikkal, N., & Thomas, S. (2014). Advance- (6th ed.). St Louis: Elsevier.
ment of wound care from grafts to bioengineered smart Gethin, G. (2012). Understanding the inflammatory process
skin substitutes. Progress in Biomaterials, 3, 103–113. in wound healing. British Journal of Community Nursing, 17(3
Bak, J. (2015). Wound healing, dressings and drains. In J. C. Suppl.), S17–S22.
Rothrock & D. R. McEwen (Eds.), Alexander’s care of the Grgov, S., Radovanović-Dinić, B., & Tasić, T. (2013). Could
patient in surgery (15th ed., pp. 253–269). St Louis: Elsevier application of epinephrine improve hemostatic efficacy of
Saunders. hemoclips for bleeding peptic ulcers? A prospective rand-
Ball, K. (2015). Surgical modalities. In J. C. Rothrock & D. R. omized study. Vojnosanitetski Pregled: Military Medical &
McEwen (Eds.), Alexander’s care of the patient in surgery Pharmaceutical Journal of Serbia & Montenegro, 70(9), 824–
(15th ed., pp. 211–252). St Louis: Elsevier Saunders. 829. doi:10.2298/VSP110411009G.
Begley, M., Gross, M., Denckar, A., Benstoem, C., Berg, M., & Gurusamy, K. S., Koti, R., & Davidson, B. R. (2013). Routine
Devane, D. (2014). Outcome measures in studies on the use abdominal drainage versus no abdominal drainage for
of oxytocin for the treatment of delay in labour: A system- uncomplicated laparoscopic cholecystectomy. Cochrane
atic review. Midwifery, 30(9), 975–982. Database of Systematic Reviews, 9, CD006004, doi:10.1002/
Bhangu, A., Singh, P., Lundy, J., & Bowley, D. M. (2013). Sys- 14651858.CD006004.pub4.
temic review and meta-analysis of randomized clinical Jackson, D. (2015). Gastrointestinal surgery. In J. Rothrock &
trials comparing primary vs delayed primary skin closure in D. McEwen (Eds.), Alexander’s care of the patient in surgery
contaminated and dirty abdominal incisions. JAMA Surgery, (15th ed., pp. 295–347). St Louis: Elsevier Saunders.
148(8), 779–786.
Jairath, V., Kahan, B. C., Logan, R. F., Hearnshaw, S. A., Dore,
Brandl, A., Laimer, E., Perathoner, A., Zitt, M., Pratschke, J., & C. J., Travis, S. P., et al. (2012). National audit of the use of
Kafka-Ritsch, R. (2014). Incisional hernia rate after open surgery and radiological embolization after failed endo-
abdomen treatment with negative pressure and delayed scopic haemostasis for non-variceal upper gastrointestinal
primary fascia closure. Hernia: The Journal of Hernias and bleeding. British Journal of Surgery, 99(12), 1672–1680.
Abdominal Wall Surgery, 18(1), 105–111. doi:10.1007/ doi:10.1002/bjs.8932.
s10029-013-1064-0.
Kęska, R., Paradowski, T. P., & Witoński, D. (2014). Outcome
Bryant, B., & Knights, K. (2014). Pharmacology for health in primary cemented total knee arthroplasty with or without
professionals (4th ed.). Sydney: Elsevier. drain: A prospective comparative study. Indian Journal of
Camp, M. (2014). Hemostatic agents: A guide to safe practice Orthopaedics, 48(4), 404–409. doi:10.4103/0019-5413
for perioperative nurses. AORN Journal, 100(2), 131–147. .136285.
329
Malahias, M., Hindocha, S., Saedi, F., & McArthur, P. (2012). Tsourdi, E., Barthel, A., Rietzsch, H., Reichel, A., &
Topical negative pressure therapy: Current concepts and Bornstein, S. R. (2013). Current aspects in the pathophysiol-
practice. Journal of Perioperative Practice, 22(10), 325–332. ogy and treatment of chronic wounds in diabetes mellitus.
McLafferty, E., Hendry, C., & Farley, A. (2012). The integu BioMed Research International, 1–6. doi:10.1155/2013/
mentary system: Anatomy, physiology and function of skin. 385641.
Nursing Standard, 27(3), 35–42. Turrentine, F. E., Giballa, S. B., Shah, P. M., Jones, D. R., Hedrick,
Murphy, P. S., & Evans, G. R. D. (2012). Advances in wound T. L., & Friel, C. M. (2015). Solutions to intraoperative wound
healing: A review of current wound healing products. Plastic classification miscoding in a subset of American College of
Surgery International, 1–8. doi:10.1155/2012/190436. Surgeons National Surgical Quality Improvement Program
patients. The American Surgeon, 81(2), 193–197.
Neveleff, D. (2012). Optimizing hemostatic practices: Match-
ing the appropriate hemostat to the clinical situation. AORN Vyas, K. S., & Vasconez, H. C. (2014). Wound healing: Biolog-
Journal, 96(5), S4–S17. doi:10.1016/j.aorn.2012.08.005. ics, skin substitutes, biomembranes and scaffolds. Health-
care, 2, 356–400.
Ortega, G., Rhee, D. S., Papandria, D. J., Yang, J., Ibrahim, A. M.,
Shore, A. D., et al. (2012). An evaluation of surgical site infec- Walter, C. J., Dumville, J. C., Sharp, C. A., & Page, T. (2012).
tions by wound classification system using the ACS-NSQIP. Systematic review and meta-analysis of wound dressings in
Journal of Surgical Research, 174(1), 33–38. doi:10.1016/j. the prevention of surgical-site infections in surgical wounds
jss.2011.05.056. healing by primary intention. British Journal of Surgery, 99(9),
1185–1194. doi:10.1002/bjs.8812.
Osifo, O. D., & Osagie, T. O. (2011). Outcomes of skin closure
with suture materials in clean paediatric surgical proce- Zinn, J. L. (2012). Surgical wound classification: Communica-
dures. African Journal of Medicine and Medical Sciences, 40(2), tion is needed for accuracy. AORN Journal, 95(2), 274–278.
147–152. doi:10.1016/j.aorn.2011.10.013.
Phillips, N. (2013). Berry & Kohn’s operating room technique

(12th ed.). St Louis: Elsevier Mosby. FURTHER READING
Pierpont, Y. N., Dinh, T. P., Salas, R. E., Johnson, E. L., Wright, Berg, A., Fleischer, S., Kuss, O., Unverzagt, S., & Langer, G.
T. G., Robson, M. C., et al. (2014). Obesity and surgical wound (2012). Timing of dressing removal in the healing of surgi-
healing: A current review. ISRN Obesity, Feb, 1–13. cal wounds by primary intention: Quantitative systematic
doi:10.1155/2014/638936. review protocol. Journal of Advanced Nursing, 68(2), 264–270.
doi:10.1111/j.1365-2648.2011.05803.x.
Pommerening, M. J., Kao, L. S., Sowards, K. J., Wade, C. E.,
Holcomb, J. B., & Cotton, B. A. (2015). Primary skin closure Gurusamy, K. S., Allen, V. B., & Samraj, K. (2012). Wound
after damage control laparotomy. The British Journal of drains after incisional hernia repair. Cochrane Database of
Surgery, 102(1), 67–75. doi:10.1002/bjs.9685. Systematic Reviews, 15, 2, doi:10.1002/14651858.CD005570.
pub3.
Rock, R. (2014). Guidelines for safe negative-pressure wound
therapy. Wound Care Advisor, 3(2), 29–33. Ibrahim, M. I., Moustafa, G. F., Abd Al-Hamid, A. S., & Hussein,
M. R. (2014). Superficial incisional surgical site infection rate
Russell, S. B., Russell, J. D., Trupin, K. M., Gayden, A. E., Opal- after cesarean section in obese women: A randomized con-
enik, S. R., Nanney, L. B., et al. (2010). Epigenetically altered trolled trial of subcuticular versus interrupted skin suturing.
wound healing in keloid fibroblasts. Journal of Investigative Archives of Gynecology and Obstetrics, 289, 981–986.
Dermatology, 130, 2489–2496. doi:10.1038/jid.2010.162.
Mioton, L. M., Jordan, S. W., Hanwright, P. J., Bilimoria, K.,
Salkind, A. R., & Rao, K. C. (2011). Antibiotic prophylaxis to & Kim, J. (2013). The relationship between preoperative
prevent surgical site infections. American Family Physician, wound classification and postoperative infection: A multi-
83(5), 585–590. institutional analysis of 15,289 patients. Archives of Plastic
Scott-Conner, C. (2013). Scott-Conner & Dawson essential Surgery, 40(5), 522–529. doi:10.5999/aps.2013.40.5.522.
operative techniques and anatomy (4th ed.). Philadelphia: Rothrock, J., & McEwen, D. (Eds.), (2015). Alexander’s care
Lippincott Williams & Wilkins. of the patient in surgery (15th ed.). St Louis: Elsevier
Singh, G., & Ahluwalia, R. (2012). A comparison between Saunders.
mass closure and layered closure of midline abdominal inci- Voigt, J., & Driver, V. R. (2012). Hyaluronic acid derivatives
sions. Medical Journal of Dr D.Y. Patil University, 5, 23–26. and their healing effect on burns, epithelial surgical wounds,
Tottle, A., & Harris, S. (2014). The use of negative pressure and chronic wounds: A systematic review and meta-analysis
wound therapy in a non-healing breast wound. Wound Prac- of randomized controlled trials. Wound Repair and Regenera-
tice & Research, 22(3), 142–144. tion, 20, 317–331.
330
Chapter 12
POSTANAESTHESIA NURSING CARE
PAULA FORAN
LEARNING OUTCOMES
• Discuss the design and purpose of the postanaesthesia care unit (PACU)
• Describe the handover process from the anaesthetist to the nurse and the nursing responsibility for
accepting the care of a patient
• Explain the initial assessment and management of an immediate postanaesthesia patient and the
ongoing assessment and interventions required for safe care
• Discuss common postanaesthesia complications, including the recognition of deteriorating patients and
their management
• Discuss pain management of the postanaesthesia patient and describe common pharmacological and
non-pharmacological treatments
• Describe the management of special patient populations
• Discuss the discharge criteria for postanaesthesia patients and describe the handover procedure from
the PACU to the ward
KEY TERMS
airway
bronchospasm
complications
deterioration
discharge criteria
handover
laryngospasm
pain management
331
complications are likely for each patient. There are

INTRODUCTION general complications that can occur in all patients;
The purpose of the postanaesthesia care unit however, each anaesthetic or surgical procedure
(PACU) is to monitor and stabilise patients imme- may have its own explicit complications. It is there-
diately postoperatively. The first documented PACU fore essential that the PACU nurse has knowledge of
was set up in Britain in the 1700s following a reali- both general and specific complications associated
sation that in the immediate postoperative (PO) with anaesthesia and surgical procedures when
period patients were vulnerable (American Society caring for patients postoperatively.
of Peri-Anesthesia Nurses, 2012). At this time there Many patients present for surgery with several
was a new understanding of the susceptibility of comorbidities which, combined with the stress of
patients when they first recovered from anaes anaesthesia and surgery, can affect their immediate
thesia, not the surgery, and that it was essential to PO management. The PO patient is vulnerable
provide a room close to the theatre where patients because of altered physiological, psychological and
could be cared for by nurses to reduce deaths cognitive function. This places patients in a state of
from respiratory failure immediately after surgery reliance on nursing and medical staff to ensure
(American Society of Peri-Anesthesia Nurses, 2012). their safety, privacy, dignity and comfort during a
Surgical and anaesthetic techniques have devel- phase when they are unable (or inadequately able)
oped enormously since then but the main focus to advocate or care for themselves (Callaghan,
of patient care in the PACU has remained the same; 2011).
that is, critical evaluation and stabilisation of
patients following surgery, with a strong emphasis
on anticipation, prevention and treatment of com- PACU DESIGN FEATURES
plications arising from anaesthesia and/or surgery For safety reasons the PACU is located within the
(Schick, 2013). operating suite. However, patients also undergo pro-
This chapter presents the role and function of cedures that require sedation or anaesthesia in other
the PACU and the assessment and management of departments, such as endoscopy, radiology and
the postsurgical, postprocedural and postanaes cardiac investigation laboratories. These depart-
thesia patient. The chapter examines many impor- ments require an area where patients can be safely
tant complications, as well as the nurse’s role in monitored post-procedure. Free-standing day
managing PO patients’ pain. Finally, the chapter surgery units also have a PACU.
discusses discharge criteria. Staffing guidelines exist for the care of recover-
ing patients and suggest that:
THE ROLE OF THE NURSE AND • staff trained in the care of patients recovering
from anaesthesia must be present at all times
FUNCTION OF THE PACU
• a registered nurse (RN) trained in PACU
All patients who have undergone anaesthesia and nursing should be in charge of this specialist
surgery must be closely monitored in the PACU area
during the immediate PO period. During this time
the nurse looks for alterations in vital signs, reports • nursing students and RNs who are not
them and initiates corrective treatment when experienced in the care of patients recovering
required. The PACU is staffed by nurses who are spe- from anaesthesia must be supervised
cially trained to manage and care for patients during (Australian and New Zealand College of
this vulnerable period and to promptly summon Anaethetists [ANZCA], 2006).
assistance from expert medical staff (the anaesthet- The Australian College of Operating Room
ist or surgeon) when required. The role of the PACU Nurses (ACORN) Standards indicate that there
nurse (see Chapter 1) is to provide a high standard of must be a minimum of one nurse to one patient for
expert nursing care to patients in this specialist area patients who are unconscious, paediatric patients
until their condition has stabilised to a point where or patients receiving the initial phase of IV pain
they are considered ‘ward ready’. In order to antici- protocol, while complex patients may require two
pate the complications of surgery and anaesthesia, nurses per patient (ACORN, 2016). Staffing per
it is essential that the nurse understands what patient must be flexible. Even when patients have
332
CHAPTER 12 | Postanaesthesia nursing care
regained consciousness, in the immediate PO phase The PACU is a semi-restricted area within the
they must never be left unattended. If the treating operating suite, meaning that ward nurses collect-
nurse needs to obtain medications that are not at ing PO patients and other healthcare workers can
the bedside, another PACU nurse must be asked to enter in their street clothes. However, general
monitor the patient. Figure 12-1 shows a typical access should be restricted as practicable to mini-
PACU that may be found in Australia and New mise the introduction/transfer of microorganisms
Zealand. (ACORN, 2016).
The location and design of the operating Each patient bay should be at least 9 square
suite should enable quick and easy access between metres, with easy access to the patient’s head
each operating room (OR) and the PACU to allow (ANZCA, 2006). Other provisions include at least
surgeons/anaesthetists to respond immediately 1.2 metres between each patient’s bed/trolley,
when summoned to assist in the management of and a system in place, or an area set aside, for
PO complications (ANZCA, 2006). The PACU should the recovery of patients with infectious diseases
promote comfort and reduce anxiety, so design that supports infection prevention and control
features such as indirect lighting, soft colours, good guidelines (Australian Commission on Safety and
ventilation and soundproofing to reduce noise Quality in Health Care [ACSQHC/the Commission],
should be considered. The three most critical design 2012a).
features of the PACU are shown in Figure 12-2. In To accommodate patients during peak periods,
some hospitals, particularly day surgery facilities, the number of allocated patient bays within the
the PACU includes stage 2 and stage 3 recovery unit should be at least 1.5 bays per operating room;
areas, as well as stage 1 (Burden, 2013); see for example, a four-room operating suite should
Figure 12-3. have six available bays (ANZCA, 2006).
EQUIPMENT REQUIREMENTS
The set-up of each bay should be standardised,
with devices that are used regularly at the bedside
and emergency and other essential equipment
centrally located for easy access. Each bay should
have:
• an oxygen outlet with flow meter
• airway equipment such as Hudson masks,
oral airways, t-pieces for laryngeal mask
airways (LMAs) and a selection of suction
catheters
• medical suction complying with relevant
FIGURE 12-1: Design of a PACU national standards
Source: Aitkinhead, Moppett & Thompson (2013).
• at least two general power outlets
• appropriate lighting and wall colour to allow
1. Close proximity to the procedure or operating rooms accurate assessment of skin colour
• emergency lighting
2. An open area that enables unobstructed observation and • automatic and manual blood pressure (BP)
constant visualisation of each patient
monitoring apparatus, including a range of
cuffs suitable for all patient sizes
3. Essential monitoring and resuscitation equipment • call bell and emergency bell system
available to meet the needs of the surgical population
served • personal protective equipment (non-sterile
gloves, eyewear, facemasks)
FIGURE 12-2: Critical PACU design features
Source: ANZCA (2006). • emesis bowls or bags
333
Stage 1
• Patients are admitted directly from the operating/procedure room and are, or
have the potential to become, physiologically unstable
• Staff must be proficient in advanced life support and resuscitation equipment
must be immediately available
• While there is a risk of harm, patients must remain in stage 1
• Patients are closely observed until they are haemodynamically stable and meet
appropriate discharge criteria
• They are then transferred to stage 2
Stage 2
• Patients are conscious and fully awake and able to maintain their own airway
• Staff must be proficient in basic life support
• Patients must be within physiological limits that are defined by their baseline
observations
• From stage 2, patients may be discharged to either stage 3 (day case) or ward
areas
Stage 3
• Patients remain in stage 3 until they are fully recovered from their
procedure and no longer require any hospital care
• Following day-case procedures, patients may be discharged home
with a responsible adult
FIGURE 12-3: Three stages of recovery

Source: Adapted from Burden (2013).
• appropriate facilities for mounting and • neuromuscular function monitor

operating any necessary equipment and for
• blood and electrolyte monitoring equipment
the patient’s observation and assessment
(ANZCA, 2006). • warming cupboard
Equipment for the whole PACU includes: • refrigerator for drugs/blood
• emergency equipment and drugs for difficult • diagnostic imaging services (ANZCA, 2006).
airway management and endotracheal
intubation (see Chapter 8)
• core temperature measuring devices CLINICAL HANDOVER FROM
• forced-air warming devices ANAESTHETIST TO NURSE
• blood glucose measuring devices (ANZCA, Patients should be transported to the PACU by the
2006). anaesthetist and the instrument or circulating
nurse. Patients must be observed continuously
Additionally, there must be easy access to the
during transfer as complications may occur, includ-
following:
ing apnoea, respiratory obstruction, hypoxaemia
• defibrillator and resuscitation trolley leading to hypoxia or vomiting. Research suggests
• 12-lead ECG machine that oxygen therapy should be administered during
transport (Parker, Webb, Albers & Clarke, 2011;
• patient ventilator Sear, 2013), and if given, it should be via a Hudson
• devices for measuring expired carbon dioxide mask (Hatfield, 2014). The patient’s conscious state
(if not available in each monitor) will vary from unconscious to semi-conscious (with
334
• Patient’s name, checked and confirmed with patient wristband

Identification
• Patient’s medical history, including allergies
• Type of anaesthesia and any other drugs administered

Situation
• Operative procedure
• Patient observations preoperatively, operatively

Observations • What is expected
• Reportable parameters for the postoperative (PO) period
• Significant intraoperative events/actions (e.g. significant blood loss)

Background and history
• Intravenous (IV) access and fluid orders
• Postoperative orders for the administration of analgesia,

Assessment and action
antiemetics and any other medications
to establish an agreed
• Any specific, relevant PO issues, such as airway,
management plan
intra-arterial devices, epidural catheters in situ or drug infusions
• Ongoing management such as who needs to be contacted should

Responsibility and risk
help be required (the treating anaesthetist or the on-call
management
anaesthetist)
FIGURE 12-4: Application of ISOBAR in the PACU
the possibility of an unprotected airway), to awake Identification, Situation, Background, Assessment,

and alert. Recommendations. ANZCA suggests using a tool
based on ISOBAR, as this includes ‘observations’
Research suggests that PO patient handover
(ANZCA, 2013):
from anaesthetist to nurse in the PACU may be
affected by technical and communication errors Identification to ensure that the patient is correctly
identified
and if not done appropriately may have potentially
negative impacts for patient safety (Segall et al., Situation, including current clinical status and patient-
centred care requirements
2012). While consensus on a specific anaesthetic
handover tool has not yet been reached, and no Observations—preoperative, operative and what may be
expected postoperatively
specific tool has been mandated, what has been
agreed is that some form of standard process is Background and history
essential (ACSQHC/the Commission, 2012a; Segall Assessment and action to establish an agreed
et al., 2012). A formal clinical handover is provided management plan
by the treating anaesthetist to the nurse who Responsibility and risk management (ANZCA, 2013).
is caring for the patient at the time of transfer Figure 12-4 illustrates application of ISOBAR in the
(see Fig. 12-4). It is important for nurses to under- PACU.
stand this process, knowing what information
needs to be extracted from the clinical handover,
as the nurse is taking responsibility for the
PATIENT MANAGEMENT IN
patient’s care (Foran & Marshall, 2015). In addi- THE PACU
tion, in some hospitals there is also a nursing INITIAL PATIENT MANAGEMENT
handover from one of the perioperative nurses who
The treating anaesthetist is required to remain with
participated in the surgical procedure, providing
the patient until the PACU nurse assigned to the
information about the operative process, dressings,
patient is available to receive handover; in some
drain tubes and any notable intraoperative events;
hospitals, the nurse who has assisted in patient
see Figure 12-5.
transfer will remain and accept the handover (and
Anaesthetic colleges worldwide recommend thus care of the patient) until a PACU nurse is avail-
slightly different handover tools but these are gen- able. It is important that PACU nurses do not take
erally a variation on a similar theme. A commonly extra patients until they are able to do so as these
used handover tool in Australian ward settings and patients are unstable and require the nurse’s full
some operating suites is ISBAR, which stands for attention (one nurse to one patient) on admission.
335
• Patient’s name, checked with the patient wristband

Identification • May be done at the same time as with the anaesthetist
• Preferred name of the patient, if applicable
• Relevant preoperative status

• Details of surgery or procedure
• Skin prep if used
• Size and location of incision; tension sutures, if used
• Dressings, drains and catheters
Situation • If used, local anaesthetic injected at the end of the procedure
• Bromage score, if appropriate, to indicate the intensity of motor
block following spinal anaesthesia; the Bromage score ranges
from 0 (full movement of legs) to 3 (unable to move legs)
• Pain level of the patient
• Emotional status of the patient on arrival
• Duration in intraoperative position and aids used

• Tourniquet time, if used
• Forceful retraction devices or surgical manipulation
• Tissue specimens
• Wound/bladder irrigation
• Blood loss
Background • Immediate postoperative (PO) skin integrity; whether the patient is
clean and dry
• Potential issues such as skin tears or indications of pressure injuries
requiring further assessment and/or treatment
• Specific patient care details that may be noted on the anaesthetic
check-in list
• Physical impairments, such hearing, eyesight or movement
difficulties
• Sufficient PO orders for the administration of analgesia, antiemetics

Assessment and action and any other medications
to establish an agreed • Specific management of airway, intra-arterial devices, epidural
management plan catheters in situ or drug infusions
• Management of drains, catheters, wound dressing
• Comfort measures
• Whereabouts of patient belongings such as teeth, hearing aids or
Responsibility and risk glasses
management • Whereabouts of relatives for paediatric or special needs patients
(most PACUs allow parents to visit and remain with their child/
special needs adult in the immediate PO period)
FIGURE 12-5: The nursing handover

Source: ACSQHC/the Commission (2012a).
ASSESSMENT OF AIRWAY AND BREATHING RESPIRATIONS

The PACU nurse makes an initial assessment of the In order to accurately measure a patient’s respira-
patient’s airway, breathing and colour. If it is tory rate, it needs to be taken over one full minute,
apparent that the patient is unable to maintain her making this the vital sign that is most often
or his own airway, the nurse must remain with the neglected in clinical practice (Subbe, 2013). This is
patient and provide airway support. A second nurse despite the knowledge that the respiratory rate is
may assist by assessing and documenting BP, heart often considered to be the single most important
rate, saturation of oxygen (SO2), level of conscious- vital sign in deteriorating patients (Subbe, 2013).
ness and pain status, all of which are priorities at Normal respiratory rates vary enormously between
this time (ACORN, 2016). A systematic approach to patients, which is why it is essential to have a set
airway assessment follows a look, listen and feel of baseline observations for comparison postopera-
approach; any untoward findings require immedi- tively. The normal adult respiratory rate is between
ate action (see Feature box 12-1). 12 and 20 respirations per minute (Schick, 2013)
336
FEATURE BOX 12-1 » AIRWAY ASSESSMENT
LOOK
Assessment of the patient’s airway includes the following:
• Look for misting and demisting of the oxygen mask (or if an LMA is in situ, that the t-piece
bag is inflating and deflating), indicating that effective respiration is taking place.
• The patient’s colour should be pink, indicating that the patient is receiving adequate
oxygen.
• Chest movement should be symmetrical as the chest rises and falls, indicating effective
respiration.
• The patient should not be using the accessory muscles of respiration, indicating ineffective
respiratory effort or possible upper airway obstruction.
• The respiratory rate should be normal, not shallow or laboured.
• The patient should be conscious and able to respond to commands to take a deep breath.
• Pulse oximetry should show good oxygen saturation levels. Normal saturation levels are
between 97% and 100% (Drain, 2013); however, it is important to remember that if patients
are receiving O2 this may disguise decreased respiratory function.
It is also important to review the patient’s baseline observations and to immediately report to
the treating anaesthetist patients who are not meeting the above criteria.
LISTEN
• Breath sounds should be present but not noisy (e.g. gurgling, snoring). If the patient is
making abnormal noises as she or he breathes, these may indicate an upper airway
obstruction, which could be caused by the tongue falling backwards, or by laryngospasm.
• A wheeze should not be heard as this indicates a lower airway obstruction
(e.g. bronchospasm).
FEEL
• Place a hand on the patient’s chest to assess whether chest movements are symmetrical,
indicating effective respiration.
(commonly 18–20). Anaesthetic agents and analge- recovering from neuromuscular blockade, have
sics can slow the respiratory rate from the preop- generally been given narcotics and are sedated.
erative baseline; however, a respiratory rate of less
than 8 or above 30 respirations per minute should PATIENT OBSERVATIONS AND MONITORING
activate an immediate emergency response and Once the initial priorities have been met and
‘escalation of care’ for a deteriorating patient in the the patient is maintaining his or her own airway,
PACU. If medical staff are not immediately availa- a more thorough assessment can be undertaken
ble, a medical emergency team (MET) response using a head-to-toe approach, including wound
will be triggered by this level of patient deteriora- status, dressings, location of drain tubes and
tion. Patients who have undergone general anaes- nature of drainage, presence of catheters, IV fluid
thesia are particularly vulnerable as they are often therapy and temperature measurement. This initial
337
assessment is known as the ABCDE method: airway, or vascular surgery patients and patients with
breathing, circulation, dressing/drain tubes and plaster casts. Peripheral return is assessed by
everything else (IVs, catheters, temperature). The pushing on the patient’s fingertip to decrease vas-
patient should be continuously observed by the cularity and then observing its return: if it returns
nurse watching the patient’s respirations and very quickly, this is referred to as brisk; if it returns
colour. In a stable patient, continuous monitoring very slowly, this is referred to as sluggish. In a patient
such as ECG, pulse oximetry and automatic or who is becoming peripherally shut down, there
manual BP readings every 5 minutes should be taken may be no vascular return and, if so, this must
throughout the patient’s stay and accurate docu- be reported. Bariatric patients have specific issues
mentation is imperative. Haemodynamic status is with airway management as identified in Feature
determined via assessment and documentation of box 12-2.
vital signs, including: When receiving PO patients, it is essential that
• ECG, recommended in stage 1 recovery the nurse has a full understanding of the possible
(Peterson, 2013) complications of each procedure that has been per-
• end-tidal carbon dioxide (ETCO2)—this is formed (Foran & Marshall, 2015). Some examples
increasingly being used in PACU (Peterson, of specific complications include:
2013) • upper airway obstruction following surgery
• arterial oxygen saturation (SaO2) level under the muscle layer of the neck such as
thyroidectomy, parotid cyst
• respiratory rate and depth
• water intoxication and/or sodium depletion in
• heart rate surgery that flushes large amounts of saline
• BP solution or water under pressure, such as in
• temperature transurethral resection of the prostate (TURP)
and endometrial ablation—hyponatraemia can
• urine output occur in any procedure where water or glycine
• conscious state. is used as an irrigating fluid, as these fluids
Unstable patients require prolonged assess- exit the body taking sodium with them;
ment, intervention and documentation according to water intoxication may occur in any
the individual’s condition (ACSQHC/the Commis- procedure where irrigating fluid is absorbed
sion, 2012b). Specific observations are undertaken in sufficient amounts to produce systemic
when required, such as neurological observations manifestations (Harvey, Mukhtar, Sinclair &
assessed using the Glasgow Coma Scale for neuro- Pearce, 2009)
logical patients or those with a head injury; blood • specific vascular observations for patients
glucose levels for diabetic patients; and vascular following free-flap surgery such as deep
observations (colour, warmth, sensation, movement inferior epigastric perforators (DIEP) or
and peripheral return) for all limb surgeries, plastic transverse rectus abdominis myocutaneous
FEATURE BOX 12-2 » AIRWAY MANAGEMENT OF BARIATRIC PATIENTS
In bariatric patients, airway management may be difficult and hazardous due to anatomical fea-
tures, such as a large tongue and excessive pharyngeal and palatal soft tissue, impairing neck
movement and making mask ventilations awkward. There is a direct correlation between the
degree of obesity a patient suffers and the risk and rate of pulmonary complications (Clifford,
2013). Functional residual capacity may also decline, particularly if the weight of the chest wall
exceeds the closing capacity of the alveoli, leading to a resultant small airway closure, ventilation/
perfusion (V/Q) mismatch and subsequent hypoxia (Pereiraa, Xaráa, Santosa & Abelhaa, 2014).
338
(TRAM ) flaps—observing not just for arterial HEART RATE

vascularity but also for venous engorgement Although the use of pulse oximetry or ECG moni-
• postpartum haemorrhage following lower toring provides a numerical value for the heart rate,
segment caesarean section (LSCS) requiring it is essential to palpate the patient’s pulse as well,
assessment with fundal height measurements as this gives information not provided by monitor-
ing devices, such as the strength of the pulse (e.g.
• cervical shock causing a fall in both heart rate
thready, bounding). Touching the patient to palpate
and BP in gynaecological patients (Foran &
the pulse also allows an opportunity to assess skin
Marshall, 2015).
temperature (cool, clammy) and provide reassur-
ance to the patient.
CARDIOVASCULAR ASSESSMENT
PO patients are at risk of developing cardiovascular BLOOD PRESSURE
complications as they may have experienced some BP is measured using automatic non-invasive
degree of blood loss, have been administered anaes- equipment that cycles at least every 5 minutes or
thetic medications or have undergone temperature by manual readings. If the nurse has concerns about
changes that may have altered vascularity (inad- a patient’s automatic BP reading, a manual reading
vertent hypothermia will cause vasoconstriction). should be taken to confirm the findings. The
In addition, an anaesthetic block may have caused patient’s preoperative BP readings should be noted
vasodilation and/or interference to the body’s sym- to provide a baseline comparison for the PO read-
pathetic responses, and the patient may be in pain ings. A BP reading 20% above or below the patient’s
(Foran & Marshall, 2015). normal reading may be considered abnormal and
Cardiovascular complications are commonly corrective measures should be undertaken. Such
seen in the PACU and range from benign ectopic levels can be attributed to a number of factors such
beats to life-threatening haemodynamic collapse as pain, haemorrhage and alterations to vascularity
(O’Brien, 2013). When making a cardiovascular (O’Brien, 2013).
assessment, it is important for the nurse to remem-
ber and evaluate three vital components of the cir- LEVEL OF CONSCIOUSNESS
culatory system: the heart as a pump; the circulating Assessing a patient’s emergence from general
blood volume; and the arteriovenous system (Peter- anaesthesia and awareness of self and surround-
son, 2013). This is completed by assessing vital ings requires close monitoring; it is also an excel-
signs including the ECG, heart rate, BP, skin and lent indicator of airway, breathing and cardiac
peripheral tissue return (e.g. hands and feet) and sufficiency, and neurological function (O’Brien,
level of consciousness (Foran & Marshall, 2015). 2013). The patient’s level of consciousness is usually
Together these factors ensure adequate tissue per- assessed concurrently with airway, breathing and
fusion, which in turn is reliant on a satisfactory circulation, using verbal or gentle tactile stimula-
cardiac output (Peterson, 2013). tion. It includes determining the patient’s:
• orientation and alertness
ECG
• ability to follow commands (e.g. ‘take a deep
Dysrhythmias can occur as a result of common com-
breath’)
plications such as hypoxaemia leading to hypoxia,
hypercarbia, inadvertent perioperative hypother- • ability to move all limbs as per preoperative
mia (IPH) or pain (O’Brien, 2013). Other alterations status (O’Brien, 2013).
to ECGs may be caused by acid–base or electrolyte
imbalance, cardiac ischaemia (seen in ST segment CENTRAL NEURAL BLOCKADE
changes), bladder distension, hypovolaemia or the Central neural blockade or neuraxial anaesthesia is
effects of anaesthetic medications (O’Brien, 2013). a generic term for epidural, spinal, epidural–spinal
Thus it is important for vulnerable postanaesthetic or caudal anaesthesia (Moos, 2013), which blocks
patients to be connected to an ECG monitor during pain during a surgical procedure. Many of the medi-
stage 1 recovery to aid in monitoring for the onset cations used in epidural or spinal anaesthesia
of some of these conditions (Daley & Huff, 2010; continue to provide pain relief in the PO period,
Peterson, 2013). with local anaesthetic agents having differing
339
durations of action. Local anaesthetic agents with TEMPERATURE CONTROL

adrenaline may be given if a longer duration of In locations such as the PACU where patients are
action is required (Moos, 2013). Care of the patient likely to be haemodynamically unstable, it is vital
following epidural or spinal anaesthesia requires an to obtain an accurate ‘core’ temperature reading
understanding of the possible complications asso- (Bender, Self, Schroeder & Brandon, 2015). Core
ciated with this type of anaesthesia. These compli- temperature refers to the temperature in parts of
cations are wide ranging, from minor irritations to the body that are protected by thermal regulation
possibly life-threatening conditions (Moos, 2013), to ensure survival in extreme conditions: the
and include spinal and epidural haematoma, post- cranium, thoracic cavity and abdominal cavity
dural puncture headache, high spinal block, hypo- (Bender et al., 2015). The core temperature pro-
tension, bradycardia, nausea and vomiting, urinary vides important information to guide clinical
retention and transient neurological symptoms judgement; for example, a patient who is hypother-
(Moos, 2013). mic may, as a consequence, be vasoconstricted—
Patients who have had local anaesthetic blocks this can falsely elevate the BP, even in the presence
must have their anaesthetised body parts protected. of hypovolaemia. Similarly, a hyperthermic patient
Care must be taken with cot sides and bed rails to may be vasodilated; this can cause the BP to fall.
prevent jamming the patient’s anaesthetised body Currently, new-generation infrared tympanic mem-
parts. Care is also required when using warm packs, brane thermometry is hypothesised to provide
as sensation is impeded. As well as normal PO the most accurate reflection of core temperature
observations, continual assessment for possible (Haugan et al., 2013).
complications should be maintained including:
• discussions with the patient regarding the GENERAL COMFORT MEASURES
onset of pain or tenderness at the catheter Nursing care initiated in the operating suite such
site as prevention of venous thromboembolism with
sequential compression devices or arteriovenous
• observation of the epidural catheter site for foot pumps continues in the PO phase. Any associ-
bleeding, swelling or redness ated single-use products should remain in place
• catheter migration (Moos, 2013). during transfer from the OR to the PACU.
Patients who received a spinal block will have a Psychological care is important as the patient
greater motor block than those who received an epi- may be anxious about the outcome of surgery;
dural. This is because the local anaesthetic is injected the presence of a nurse speaking gently, reassuring
into the subarachnoid space with the cerebrospinal and reorienting the patient to time and place can
fluid where the spinal nerves are not myelinated, be very comforting. Most PACUs allow family
providing a denser motor block. Caution must be members to visit, particularly for paediatric patients
taken when the block appears to have worn off and or special needs patients, and the presence of a
the patient is about to ambulate as the patient may family member or carer can reduce patient anxiety
have residual motor block. The nurse should estab- and make the patient feel more secure (O’Brien,
lish when walking is required and provide support 2013).
until full motor function has returned. The Bromage General comfort measures for the patient
scale measures the intensity of motor block by include:
assessing the patient’s ability to move his or her • position changes
lower extremities (Anaesthesia UK, 2004):
• providing extra pillows
• Bromage 3 (complete): unable to move feet or
• providing active warming devices if the patient
knees
is hypothermic; otherwise, providing a warm
• Bromage 2 (almost complete): able to move blanket
feet only • washing off excess skin preparations and
• Bromage 1 (partial): able to move knees providing a face washer for the patient’s use
• Bromage 0 (none): full flexion of knees and • assisting with range-of-motion exercises
feet. • encouraging deep breathing
340
• providing mouth care with moistened swabs oxygenation and possible hypoxaemia. The latter is
and ice chips to suck for patients who can evident when the partial pressure of oxygen in
tolerate fluids arterial blood (PaO2) is less than 60 mmHg. Normal
• offering toileting—a bottle or a bedpan PaO2 in healthy adults is 97 mmHg, although
the PaO2 declines with age (Hatfield, 2014). These
• returning the patient’s spectacles and/or
complications can result from an upper airway
hearing aid, as appropriate.
obstruction (such as obstruction by the tongue or
secretions, laryngospasm or subglottic oedema) or
POSTANAESTHESIA AND a lower airway obstruction (such as bronchospasm
POSTSURGICAL COMPLICATIONS or non-cardiogenic pulmonary oedema). They may
be caused by a simple problem (such as poor man-
There is a range of complications that surgical dibular positioning where the tongue falls back,
patients may experience. These are associated with obstructing the airway) or complete laryngospasm
the use of anaesthetic agents, the surgical interven- with no air entry (O’Brien, 2013), or as a result
tion or patient characteristics, or any combination of hypoventilation. Any of these problems can
thereof. cause life-threatening hypoxia if not rectified
immediately.
THE DETERIORATING PATIENT
The Australian national consensus statement on Hypoxia (of whatever cause) is a medical emer-
essential elements for recognising and responding gency; if suspected, the PACU nurse should press
to clinical deterioration states that measurable the emergency bell and summon medical assist-
physiological abnormalities occur prior to adverse ance immediately. Treatment will range from ele-
events such as cardiac arrest and death, and that vating the mandible, to providing positive pressure
early recognition of changes in a patient’s condi- ventilation with a bag and mask, intubation, crico-
tion, followed by prompt and effective treatment, thyroid puncture or, if all else fails, creating a surgi-
can minimise poor outcomes. Surgical patients are cal airway (tracheostomy). It is imperative that the
prime candidates for possible deterioration, with nurse is familiar with all of the emergency airway
complications in this cohort accounting for 50–75% equipment in the department.
of all adverse medical events (Pinney, Pearce &
Feldman, 2010). OBSTRUCTION BY THE TONGUE
Relaxation of the tongue may occur in patients who
AIRWAY AND BREATHING COMPLICATIONS have not fully recovered from anaesthetic agents
One of the most common airway complications in such as narcotics, sedatives or muscle relaxants
the immediate PO period is airway obstruction (O’Brien, 2013). The signs and symptoms of tongue
(O’Brien, 2013). The depressant effects of anaes- obstruction are noisy, gurgling, choking sounds;
thesia can mean that PO patients are unable to irregular respirations; and decreased arterial oxygen
protect their airway. Signs that the patient might saturation readings—with a pulse oximetry reading
have an airway obstruction include increased res- of 90% or less indicating hypoxaemia (Hatfield,
piratory effort, use of the accessory muscles of 2014). In many cases the PACU nurse can open the
respiration, and noisy or abnormal breathing, patient’s airway by providing jaw support (if not
along with signs of altered gas exchange as seen contraindicated), which can help restore airway
in pulse oximetry and capnography readings. patency (see Fig. 12-6). However, in some cases an
Note: capnographs measure carbon dioxide (CO2) artificial airway may be required to prevent obstruc-
concentrations in the expired air. See Table 12-1 tion that occurs when the patient’s tongue and epi-
for a summary of common PO respiratory glottis fall back on the posterior pharyngeal wall. If
complications. a patent airway cannot be established, the PACU
nurse should call for urgent medical assistance.
HYPOXAEMIA
Hypoxaemia is an abnormally low concentration of OBSTRUCTION BY SECRETIONS/BLOOD
oxygen in arterial blood (Drain, 2013). All airway The upper airway can be obstructed by the presence
and breathing complications are serious in varying of secretions such as mucus or blood. The signs
degrees as they put the patient at risk of decreased and symptoms of this complication include noisy,
341
TABLE 12-1: Common Immediate PO Respiratory Complications
COMPLICATIONS
AND CAUSES MECHANISMS MANIFESTATIONS INTERVENTIONS
Tongue falling Muscular flaccidity associated Use of accessory muscles Patient stimulation
back with decreased Snoring respirations Jaw thrust
consciousness and muscle Decreased air movement Chin lift
relaxants Artificial airway
Retained thick Secretion stimulation by Noisy respirations Humidified O2

secretions anaesthetic agents Rhonchi Suctioning
Dehydration of secretions Deep breathing and coughing
IV hydration
IPPV with mucolytic agent
Chest physiotherapy
Laryngospasm Irritation from secretions, Inspiratory stridor (crowing on High-flow O2 therapy

endotracheal tube or inspiration) Reassurance
anaesthetic gases Sternal retraction Positive pressure ventilation
Most likely to occur after Acute respiratory distress Possible intubation
removal of endotracheal
tube
Laryngeal oedema Allergic drug reaction Barking respirations (like a O2 therapy

Mechanical irritation from seal) on expiration Antihistamines
intubation Corticosteroids
Fluid overload Sedatives
Possible intubation
Bronchospasm Increased smooth muscle tone Wheezing O2 therapy

with closure of small Dyspnoea Bronchodilators
airways Tachypnoea
↓ SaO2
Atelectasis Bronchial obstruction caused Noisy breath sounds CPAP

by secretions or decreased ↓ SaO2 Humidified O2
lung volumes Deep breathing
Incentive spirometry
Early mobilisation
Aspiration Inhalation of gastric contents Bronchospasm O2 therapy

Atelectasis Chest X-ray
Crackles Antibiotics
Respiratory distress ? intubation
↓SaO2
SOURCE: BROWN & EDWARDS (2014).
gurgling, choking sounds; coughing; irregular res- • repositioning patients on their left side to
pirations; and decreased oxygen saturation readings assist in draining secretions from the mouth
—with a pulse oximetry reading of 90% or less indi- and careful monitoring (the left side is the
cating hypoxaemia, which can rapidly lead to position of choice as it allows the stomach to
hypoxia. Management includes: be dormant and has a lower risk of aspiration).
• gentle suctioning of the mouth and If hypoxaemia continues, the PACU nurse should
oropharynx using a Yankauer sucker or suction call for urgent medical assistance by pressing the
catheter emergency bell.
342
• distress/sweating
• an upper airway noise heard on auscultation.
As PO patients generally have oxygen therapy,
these symptoms may or may not include a decrease
in oxygen saturation levels.
Initial management by the nurse includes:
• immediately informing the treating
anaesthetist or medical staff
• sitting the patient up, as this facilitates better
ventilation (provided the patient is not
hypotensive and it is not contraindicated by
the nature of the surgery)
• giving oxygen by mask, if not already
in situ
FIGURE 12-6: Opening the airway with the head-chin-lift manoeuvre • gently suctioning the upper airway
Source: Odom-Forren (2013).
• providing airway support as required (Drain,
2013).
Laryngospasm is terrifying for an awake patient:
reassurance and a calm demeanour from nurses and
LARYNGOSPASM
doctors are of the utmost importance as patient
Laryngospasm is an involuntary forceful spasm of anxiety can exacerbate the condition. If the oxygen
the laryngeal musculature that is caused by stimu- saturation is falling, it is necessary to summon
lation of the superior laryngeal nerve (Butterworth, urgent medical assistance. If the above actions are
Mackey & Wasnick 2013a). Although it can occur in unsuccessful, the following may be required:
patients of any age, it occurs more commonly in
young patients and is most common in infants 1–3 • gentle positive-pressure ventilation (place a
months old (Butterworth et al., 2013a). Laryngo bag-valve mask with a reservoir bag connected
spasm can result in either incomplete or complete to oxygen firmly over the patient’s nose and
airway obstruction (Drain, 2013), with the latter mouth and gently bag)
fortunately being less common. Laryngospasm may • forward jaw thrust
be avoided by extubating the patient either while • IV lignocaine
awake and reversed or while deeply anesthetised
and paralysed; both techniques have advocates • if hypoxia develops, paralysis of the patient
(Butterworth et al., 2013a). Extubation during the with IV suxamethonium or rocuronium and
interval between these two extremes is generally use of controlled ventilation (Butterworth
recognised as more hazardous (Butterworth et al., et al., 2013a).
2013a). The presence of secretions in the orophar-
ynx may also cause laryngospasm. Closure of the POST-INTUBATION CROUP/SUBGLOTTAL OEDEMA
cords in response to these stimuli is a protective Post-intubation croup or subglottal oedema is a
reflex but it can become a life-threatening event as complication that occurs later than laryngospasm,
the airway is compromised. but usually appears within 3 hours of extubation
Partial closure of the vocal cords results in a (Butterworth et al., 2013a). It may occur in adults
crowing-like noise on inspiration, known as an but is most commonly seen in patients aged 1–4
inspiratory stridor. The patient may be awake when years (O’Brien, 2013) and is due to glottic or tra-
this occurs and will show signs of distress as this is cheal oedema, which can be lessened in children
a very frightening experience. Signs and symptoms with endotracheal tubes without a cuff that allow a
of laryngospasm include: slight gas leak at 10–25 cm H2O as the tube does
not touch the tracheal walls (Butterworth et al.,
• inspiratory stridor 2013a). The manufacturers of newer types of cuffed
• dyspnoea paediatric endotracheal tubes suggest they allow a
343
cuffed tube with reduced tracheal trauma. Signs intubation and intermittent positive pressure ven-
and symptoms of this PO complication include: tilation may be required, and antihistamines, anti-
• inspiratory stridor biotics and steroids may also be considered (O’Brien,
2013).
• chest retractions
• hoarseness INADEQUATE REVERSAL OF MUSCLE RELAXANTS
• a croup-like cough Initial airway assessment may reveal that a patient
• apprehensiveness is not moving an adequate tidal volume, has weak
breathing and shallow respirations. This can be an
• restless. indication that the muscle relaxants have not been
As in all respiratory conditions, the PACU nurse adequately reversed. These patients may exhibit
should sit the patient up (provided the patient dyspnoea and paroxysmal breathing (forward to
is not hypotensive), provide oxygen and call for backward abdominal breathing) and may be dis-
medical assistance. tressed. Treatment will depend on the severity of
the symptoms and may include providing oxygen
BRONCHOSPASM therapy, sitting the patient up (if he or she is not
hypotensive), assessing the CO2 and O2 saturations
Bronchospasm is a lower airway obstruction, char-
and reassuring the patient. In compromised patients
acterised by spasmodic smooth muscle contraction
the anaesthetist must be summoned and further
that causes narrowing of the bronchi and bronchi-
reversal drugs may be given.
oles (O’Brien, 2013). It is more common for bron-
chospasm to occur in patients with a pre-existing
pulmonary illness such as asthma or chronic HYPOVENTILATION
obstructive pulmonary disease, but it may also Hypoventilation may occur in the PO period due to
develop in healthy patients in the presence of the effects of sedation, narcotics, residual anaes-
allergy, anaphylaxis or pulmonary aspiration. If thetic agents or neuromuscular blocking agents,
a patient without pulmonary pathology develops and thoracic or abdominal incisions causing pain
bronchospasm the underlying cause may be an (O’Brien, 2013). Symptoms include a decreased res-
allergy or pulmonary aspiration. Signs and symp- piratory rate, shallow respirations and an increase
toms of bronchospasm include: in end-tidal CO2. The PACU nurse should provide
oxygen and call for medical assistance. Treatment
• coughing
includes identifying the cause (e.g. pain, narcot-
• distinct wheeze upon auscultation ics); management will depend on the causative
• noisy shallow respirations factor.
• chest retractions
GENERAL COMPLICATIONS
• use of the accessory muscles of breathing PO NAUSEA AND VOMITING
• prolonged expiratory phase of respiration PO nausea and vomiting (PONV) is the most
• hypertension common and most undesirable PO complication
seen in the PACU (Peterson, 2013). All immediate
• tachycardia.
PO patients with emesis are at risk of aspiration as
Nursing care includes sitting the patient up (if they may also have a decreased state of conscious-
he or she is not hypotensive), providing oxygen, ness and obtunded airway reflexes. PONV can be
calling for medical assistance and reassuring the prevented by:
patient. Initial management will include removing
• avoiding hypotension
the identified cause if possible (O’Brien, 2013),
with treatment depending on the cause, specific • giving a high concentration of oxygen
symptoms and severity of the bronchospasm. The • treating pain
PACU nurse should carry out instructions from the
medical staff, which may include giving the patient • avoiding sudden movement (Hatfield, 2014).
humidified oxygen and administering a beta2- Generally nausea precedes vomiting; in this
adrenergic agonist (O’Brien, 2013). In severe cases, case the PACU nurse should provide the patient
344
with oxygen and administer an antiemetic. The (Billeter, Hohmann, Druen, Cannon & Polk, 2014).
patient must be observed by a PACU colleague while It is essential to re-warm hypothermic patients
the medications are being accessed. If an antiemetic prior to discharge from the PACU (temperature at
has not been prescribed, the anaesthetist should be discharge should be 36°C) and active warming
contacted so that this can be addressed. If vomiting devices such as forced-air convection warmers have
occurs, the PACU nurse should swiftly place the been shown to be the most effective (Moola &
unconscious or semi-conscious patient in a left Lockwood, 2011). See Chapter 9 for further infor-
lateral position. Suction must be ready for the nurse mation on the management of IPH.
to remove any gastric aspirate from the mouth and
oropharynx. The nurse should administer oxygen
where possible as this helps reduce nausea. The HYPERTHERMIA
fully awake patient with a satisfactory BP and gag Possible causes of hyperthermia in perioperative
reflex may be sat upright by the nurse and provided patients include a pre-existing febrile state (where
with an emesis bag. A vomiting patient must never infection was present preoperatively, such as in an
be left alone. appendectomy), malignant hyperthermia, thyroid
Common pharmacological agents for the man- crisis, a blood transfusion reaction, overheating in
agement of nausea and vomiting include serotonin infants and neurological damage post head injury
receptor blockers (ondansetron) and dopamine or neurosurgery. The PACU nurse should investi-
receptor blockers (droperidol). Alternative non- gate the cause of hyperthermia; treatment will
pharmacological measures such as pressure point include leaving just a sheet to cover the patient and
therapy may be useful in patients who have received applying a cool face washer to the patient’s fore-
medication and still feel nauseated. head (being cautious not to induce shivering as this
increases temperature). If the cause of the hyper-
thermia is known, the PACU nurse will give antipy-
ASPIRATION PNEUMONITIS retic agents as ordered and continue to monitor the
Aspiration pneumonitis is severe inflammation of temperature every 5 minutes to ensure that the
the lungs caused by the aspiration of gastric con- patient does not become cold. In severe cases such
tents. Preoperative patient fasting is aimed at mini- as a septic shower (which is the sudden systemic
mising the risk of aspiration. Pregnant women, influx of pathogens) or malignant hyperthermia,
those with gastro-oesophageal reflux disease, and when the temperature is close to the human critical
obese and non-fasting patients are all at increased thermal maximum of 41.6°C, the nurse must
risk of aspiration pneumonitis (Wetsch, Spöhr, Hin- immediately contact medical staff and consider
kelbein & Padosch, 2012). placing ice packs on the axilla and groin (Larach,
Gronert, Allen, Brandom & Lehman, 2010). See
Clinical progression after aspiration varies
Chapter 8 for further information on malignant
widely, from no symptoms to very mild symptoms,
hyperthermia.
bronchopneumonia and possibly development of
acute pulmonary oedema. The severity is deter-
mined by several factors including the aspirate HIGH SPINAL/EPIDURAL BLOCK
pH, the quantity of aspirate and the presence of
solid particles (Wetsch et al., 2012). Symptoms The PACU nurse should assess dermatomes after
include tachypnoea, tachycardia, cough and possi- spinal and epidural anaesthesia to identify the
ble bronchospasm (O’Brien, 2013). While this con- exaggerated dermatome spread that can occur.
dition may be dramatic on onset it can also be Signs and symptoms may include dyspnoea, numb-
insidious in nature. Bronchospasm that occurs in a ness or weakness in the upper extremities, nausea
healthy patient should raise the PACU nurse’s sus- (which often precedes hypotension) and bradycar-
picion of a possible aspiration (Foran & Marshall dia (Butterworth, Mackey & Wasnick, 2013b). A
2015). high block may also cause blocking of the cardiac
sympathetic fibres from T1 to T4, which in turn can
cause loss of chronotropic and inotropic drive and
INADVERTENT PERIOPERATIVE HYPOTHERMIA a fall in cardiac output, leading to hypotension and
IPH has been associated with increased mortality bradycardia. In this instance, medical assistance
and morbidity among elective surgical patients must be summoned immediately.
345
URINARY RETENTION decrease from the patient’s baseline) and an increase

Epidural opioids can interfere with normal voiding in heart rate, and it is not an uncommon occurrence
and a regional block at the level of the S2–S4 root in PO patients (O’Brien, 2013). This is because sur-
fibres decreases urinary bladder tone and may gical patients may have had significant blood loss
inhibit a patient’s ability to void (Butterworth et al., leading to hypovolaemic shock, or may have had
2013b). In caring for a patient who is unable to void misdistribution of circulation from vasodilation
or where urinary retention is suspected, the PACU due to central neural blockade (Foran & Marshall,
nurse should perform a bladder scan. If the bladder 2015).
is full and the patient is unable to void, the nurse In caring for the patient suffering from shock,
should insert an indwelling catheter until normal the PACU nurse should lie the patient flat with the
bladder muscle function has returned. The inability legs elevated and provide supplemental oxygen (if
to void is more pronounced in men, thus urinary not already in use). The nurse should call for
bladder catheterisation should be routinely used medical assistance and check the patient’s periph-
for all but the shortest-acting blocks (Butterworth eral return at the fingernail beds to assess whether
et al., 2013b). In some types of surgery (e.g. joint peripheral shutdown has occurred, signalling com-
replacements) surgeons are reluctant to leave cath- pensation (Foran & Marshall, 2015). Depending on
eters in situ, although they may allow a catheter to the type and cause of shock, medical management
be passed to empty the bladder—then the catheter may include fluid resuscitation therapy; in the case
must be withdrawn (Hatfield, 2014). of misdistribution of circulation from an epidural
or spinal injection of local anaesthetic, medications
HYPOTENSION such as metaraminol (a potent sympathomimetic
Hypotension in the immediate PO period is a agent) may be used to provide some vasoconstric-
common occurrence and may be due to a number tion to increase the BP (Foran & Marshall, 2015). If
of factors including blood loss, vasodilation causing haemorrhage is the cause, resuscitation of the
pooling of blood in the extremities, anaesthetic patient is commenced. Unresolved haemorrhage
agents or narcotics. As the patient recovers from may require the patient to be returned to the oper-
surgery and the BP returns to normal, a rise in BP ating room to find the cause of the bleeding and to
may cause resected tissue to ooze blood. Often, the initiate surgical haemostasis.
patient’s natural haemostatic mechanisms will
control the bleeding, but occasionally haemorrhage HYPERTENSION
will occur. Active bleeding may be seen through a Hypertension may be pre-existing in some patients
wound dressing or in drains. It may also occur or it may be indicative of a patient who has pain or
insidiously or be hidden, for example in the uterus is anxious. It is vital for the PACU nurse to compare
after LSCS, resulting in the patient exhibiting the PO observations with the patient’s baseline obser-
signs and symptoms of hypovolaemic shock. Careful vations. If the patient’s BP is more than 20% higher
assessment by the PACU nurse of the patient’s than the baseline readings, the nurse should obtain
wound, drains and catheters, and fundal height in medical assistance.
LSCS patients, is essential, as is the frequent moni-
toring of vital signs. EMERGENCE DELIRIUM
Sustained hypotension or untreated hypoten- Emergence delirium is a well-known phenomenon
sion can lead to the development of shock in rela- that may occur in postanaesthetic patients (Munk,
tion to blood loss or an altered vascularity that Andersen & Gögenur, 2013). In its mild form
occurs secondary to sympathetic blockade and an awake patient may exhibit disorientation, rest-
vasodilation after regional anaesthesia. lessness, irrational conversations and inappropri-
ate behaviour, and this is often referred to as
SHOCK emergence excitement (O’Brien, 2013). Patients
Shock is a condition of circulatory impairment with emergence delirium, in addition to the symp-
leading to inadequate vital organ perfusion and toms just discussed, may also have hallucinations,
oxygen delivery relative to the individual’s hypersensitivity to external stimuli and hyperactiv-
metabolic needs (Anderson & Watson, 2013). Shock ity, with the patient often screaming and thrashing
is characterised by a decrease in BP (a 20–30% (Munk et al., 2013; O’Brien 2013). Emergence
346
delirium is a serious PO complication raising safety can alter the body’s metabolic responses and lead
concerns for both the patient and staff; thus pre- to increased morbidity rates, delayed recovery,
vention of injury is vital in both groups (Munk longer periods of hospitalisation and the develop-
et al., 2013). ment of a chronic pain state (Kiekkas et al., 2015;
Children have a higher incidence of emergence Samaraee et al., 2010). In contrast, effective pain
delirium than adults. Adults who have received control reduces PO complications, facilitates reha-
certain medications including ketamine, droperi- bilitation and provides a more rapid recovery from
dol, opioids, benzodiazepines, scopolamine, atro- surgery (Samaraee et al., 2010). Despite the finding
pine or large doses of metoclopramide are also that experiencing PO pain is the most common
susceptible. In addition, patients who have suffered patient fear (Samaraee et al., 2010) and the great
a recent tragedy or bereavement, patients with advancements seen in acute pain management, PO
severe preoperative anxiety and patients with a pain relief still continues to be undermanaged
history of drug dependency or psychiatric illness and inadequate (Hartog, Rothaug, Goettermann,
are likely to suffer emergence delirium (O’Brien, Zimmer & Meissner, 2010; Kiekkas et al., 2015).
2013). The patient’s eyes will look glazed and he or It is essential for the PACU nurse to manage the
she will appear not to have any response to verbal PO patient’s pain before the patient leaves the
dialogue. Speaking to the patient in a raised voice operating suite; this is because on the ward, where
tends to worsen the situation. Calm, confident reas- patient-to-nurse ratios are lower, it may be more
surance by the PACU nurse is advised. Emergence difficult for the ward nurse to treat a patient’s
delirium may last about 20 minutes, with the severe or unmanageable pain effectively.
patient eventually falling back to sleep and waking
with no recollection of the incident. PAIN ASSESSMENT AND MANAGEMENT
Initial management of the patient with emer- Pain assessment and pain management can be
gence delirium by the PACU nurse involves: difficult in the emergence phase of anaesthesia due
to the impaired conscious state of patients and
• ensuring the patient’s safety and calling for
their difficulty communicating their perception of
assistance
pain to the nurse. In addition, normal haemody-
• ruling out hypoxia and hypoglycaemia namic responses to pain, such as tachycardia and
• treating the cause, if known hypertension, may be depressed due to the ongoing
effects of the anaesthesia (Pasero, 2013). Doses of
• considering sedation
analgesia must be titrated to the individual patient
• importantly, protecting these vulnerable (ANZCA & Faculty of Pain Management, 2013) and
patients from accidental self-injury (O’Brien, are dependent on the patient’s age, tolerance to
2013). analgesics, pain level, sedation score and medical
If the nurse knows that a patient is prone to emer- history. Patients who present with a drug depend-
gence delirium, preparations can be made for the ency may require much larger doses of analgesia
person’s safe recovery by obtaining a protective cot and may be greatly advantaged by assistance from
or bed sides to prevent injury, and ensuring that an acute pain service.
security staff are available in the case of a strong As pain differs in patients and is subjective, it is
adult. essential to use an assessment tool to measure a
patient’s pain level. One assessment tool that is
commonly used in the PACU is the verbal analogue
MANAGEMENT OF PAIN IN THE PACU score (VAS), which assesses pain severity on a scale
Effective treatment of acute pain is a fundamental of 0 to 10, with 0 being no pain and 10 being
component of quality patient care (ANZCA & the worst pain imaginable. By inviting patients
Faculty of Pain Management, 2013). Pain was to quantify their pain level numerically, the VAS
once thought to be an unfortunate but normal side enables the nurse to assess whether analgesic med-
effect of surgery that would have no detrimental ications are required or have been effective for
effects to the sufferer (Samaraee, Rhind, Saleh & the individual patient. For children or those who
Bhattachacharya, 2010). Research has proved this may otherwise be unable to communicate their
to be incorrect, finding that inadequate pain relief pain (e.g. cognitively impaired patients), the
347
Numerical rating scale
0 1 2 3 4 5 6 7 8 9 10
No Moderate Worst
pain pain possible
pain
0 2 4 6 8 10
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE LITTLE EVEN WHOLE LOT WORST
BIT MORE MORE
Wong-Baker FACES Pain Rating Scale

FIGURE 12-7: Visual scales for assessing pain
Source: Odom-Forren (2013).
Wong-Baker FACES Pain Rating Scale can be used; immediate PO period requires a delicate balance
see Figure 12-7. between relieving acute pain and avoiding over-
sedation. Many PACUs use a pain protocol in the
PHARMACOLOGICAL INTERVENTIONS form of an algorithm (flow chart) to enable the
Pain is a complex phenomenon and since there are PACU nurse to assess pain and administer the pre-
different mechanisms that cause pain, using one scribed analgesics by means of intermittent IV
method to relieve pain may not be adequate (Pasero, bolus doses of opioids (e.g. morphine or fentanyl).
2013). Different combinations of selected analge- Standard pain protocols for adult patients require
sics and methods are employed by anaesthetists; the elderly to receive smaller opioid doses due to
this is known as multimodal analgesia and the their reduced tolerance and increased susceptibility
PACU nurse should understand the regimens to side effects, particularly respiratory depression
used. Analgesic medications may include opioids, and sedation (ANZCA & Faculty of Pain Manage-
non-steroidal anti-inflammatory drugs (NSAIDs) ment, 2013). Because of these adverse effects all
and local anaesthetics, as well as adjuvant agents patients’ vital signs must be monitored carefully by
including gabapentinoids such as gabapentin (orig- the PACU nurse during administration (Pasero,
inally developed as an anti-epileptic treatment but 2013). In the event of increasing sedation or respi-
also very effective in treating chronic neuropathic ratory depression, the PACU nurse must summon
pain), clonidine and selected antidepressants, and medical staff such as the treating anaesthetist. An
anticonvulsants (ANZCA & Faculty of Pain Man- opioid antagonist such as naloxone may need to be
agement, 2013). Non-pharmacological therapies administered by the PACU nurse to reverse these
must be considered as complementary to pharma- serious adverse effects (Pasero, 2013).
cological therapies (ANZCA & Faculty of Pain Man-
agement, 2013). Morphine
Morphine has a slower onset and peak but longer
Opioid analgesics duration of action compared to other first-line
Opioid analgesics provide a rapid onset of pain opioids such as fentanyl. Given intravenously, its
relief and first-line opioids include morphine and peak analgesic effect is felt in 20 minutes and lasts
fentanyl (Pasero, 2013). Titrating IV opioids in the approximately 2 hours (Pasero, 2013). It remains
348
the most widely used opioid in the management of tor (ANZCA & Faculty of Pain Management, 2013).
acute pain and is the gold standard against which Tramadol causes significantly less respiratory
other opioids are compared (ANZCA & Faculty of depression and less impairment to gastrointestinal
Pain Management, 2013). motor function at equivalent analgesic doses com-
pared with morphine. However, severe respiratory
Fentanyl depression has been described in patients with
Fentanyl has a fast onset and its peak analgesic severe renal failure (ANZCA & Faculty of Pain
effect is felt within 5–6 minutes but it has a shorter Management, 2013). Although tramadol is an effec-
duration of action than morphine (20–40 minutes). tive analgesic, it may not provide adequate pain
Given intravenously, its analgesic properties are 80 relief if used as the sole agent for moderate to
to 125 times more potent than morphine (Pasero, severe acute pain. In addition, while it has been
2013). known for some time that tramadol is a contribut-
ing factor in the development of PO delirium, there
Pethidine is now evidence from Stephens and colleagues
(2015) that there is a drug interaction between
Pethidine has many properties similar to morphine tramadol and ondansetron (an antiemetic) in the
but it is faster acting—within 2–3 minutes. When early PO period that decreases the effectiveness of
given intravenously pethidine causes more hypo- tramadol.
tension and tachycardia than morphine and so is
used infrequently (Stephens, Woodman & Owen, Non-steroidal anti-inflammatory drugs
2015). However, when surgery causes smooth
muscle spasm, for example on the fallopian tubes, The term non-steroidal anti-inflammatory drugs
pethidine may be considered more effective than (NSAIDs) refers to a range of drugs that include
morphine. coxibs (COX-1 and COX-2 inhibitors) (Bryant
& Knights, 2014). NSAIDs have analgesic, anti-
inflammatory and antipyretic effects and are effec-
Targin®
tive for a variety of acute pain states (ANZCA &
Targin® is a controlled-release tablet containing Faculty of Pain Management, 2013). NSAIDs may
a combination of oxycodone–hydrochloride and produce renal, gastrointestinal and some platelet-
the opioid antagonist naloxone hydrochloridedihy- related adverse effects, which precludes their use in
drate (Ruetzler et al., 2014). See Research box 12-1 some surgical patients. The coxibs available at
for more information. present include celecoxib, etoricoxib and parecoxib,
the injectable precursor of valdecoxib (ANZCA &
Tramadol Faculty of Pain Management, 2013). Coxibs offer
Tramadol is an atypical centrally acting analgesic the potential for effective analgesia with fewer side
due to its combined effects as an opioid agonist effects than other classes of NSAIDs (ANZCA &
and a serotonin and noradrenaline reuptake inhibi- Faculty of Pain Management, 2013).
RESEARCH BOX 12-1: Targin®
A randomised trial of oral versus intravenous opioids compared pain levels of post-cardiac surgery
patients. Patients were randomised into one of two groups receiving different types of analgesia: oral
Targin or patient-controlled IV morphine. The results showed that doses of oral Targin were significantly
lower compared with IV morphine (in the presence of similar pain scores), revealing promising results for
this oral opioid even in painful PO procedures.
SOURCE: RUETZLER ET AL. (2014).
349
Diclofenac treating individual symptoms and possibly admin-

Diclofenac is a NSAID that is useful for pain relief istration of serotonin antagonists such as methy-
following pelvic gynaecological surgery, insertion sergide and cyproheptadine (Hatfield, 2014).
of ureteric stents and ureteric colic. It is absorbed
rapidly by the gut and has a half-life of 1–2 hours CODEINE IN CHILDREN
(Hatfield, 2014). The American Food and Drug Administration (FDA)
recommends avoiding use of codeine in children,
Ibuprofen particularly after tonsillectomy and adenoidectomy
Ibuprofen has the least number of side effects of for obstructive sleep apnoea, due to the possible
the NSAIDs and is an effective analgesic but a risk of respiratory depression (DeDea & Bushardt,
weaker anti-inflammatory. It is known to be useful 2013).
for pain relief following dental extractions and
laparoscopy (Hatfield, 2014). PATIENT-CONTROLLED ANALGESIA
The major goal of patient-controlled analgesia
Ketamine (PCA) is to avoid the peaks and troughs of analge-
The principal effect of ketamine is as an anti- sia by enabling patients to administer their own
hyperalgesic, anti-allodynic and anti-tolerance analgesia as they need it, in order to control their
agent, not as a primary analgesic. Its main role is pain (Pasero, 2013). Patients are able to anticipate
as an adjuvant in the treatment of pain associated activities such as coughing or movement that
with central sensitisation, such as in severe acute are associated with increased pain and provide
pain, neuropathic pain and opioid-resistant pain. It themselves with an opioid bolus in advance. The
is also known to reduce the incidence of chronic PCA device is programmed to a pre-determined
postsurgical pain and attenuate opioid-induced maximum dose as a bolus and there is a lock-out
tolerance and hyperalgesia (ANZCA & Faculty of period after each bolus to prevent overdose. PCA
Pain Management, 2013; Hatfield, 2014). devices are programmed based on the patient’s
needs and the pharmacokinetics of the drug being
Paracetamol administered (Pasero, 2013). PCA works effectively
Paracetamol is an important and well-tolerated if commenced when the patient is pain-free or has
analgesic used in PO pain management. It has been a manageable level of pain. To facilitate this, the
found to have a significant opioid-sparing effect PACU nurse administers a bolus dose of opioid
when used in multimodal approaches to pain man- analgesia prior to commencing PCA. If possible,
agement. It can be given orally preoperatively and the nurse should discuss the use of PCA with
is rapidly absorbed via the gastrointestinal route. patients preoperatively to educate them in the
Intravenous administration is frequently used for operation of the device. Other patient-controlled
patients postoperatively (ANZCA & Faculty of Pain local anaesthetic devices such as patient-controlled
Management, 2013). epidural analgesia (PCEA) and continuous wound
catheters delivering local anaesthesia are also
SEROTONIN SYNDROME available in some healthcare facilities.
Certain medications used in acute pain relief
LOCAL ANAESTHETIC
such as pethidine, tramadol, tricyclic antidepres-
sants and monoamine oxidase inhibitors when A variety of local anaesthetic blocks and infiltration
given with selective serotonin re-uptake inhibitors may be given to assist in PO pain management.
(SSRIs) (e.g. fluoxetine [Prozac]) may result in the These range from simple infiltration of the local
release of excessive amounts of serotonin, causing anaesthetic into the surgical incision site, to arm
serotonin syndrome (Hatfield, 2014). This condi- blocks, femoral blocks and transversus abdominis
tion may present within minutes to hours and plane (TAP) blocks. These may form part of the
is characterised by neurological changes such as multimodal approach.
confusion, agitation, neuromuscular excitement
and autonomic stimulation (tachycardia, hyperten- NON-PHARMACOLOGICAL PAIN MANAGEMENT
sion and ventricular extrasystoles) (Hatfield, 2014). In addition to pharmacological measures, common
Treatment includes ceasing the causative agents, non-pharmacological pain relief measures may
350
include elevation of the affected body part where as in ear, nose and throat surgery (ENT), which is
applicable, appropriate temperature management, the most common surgical specialty for the paedi-
patient positioning so as not to put stress on the atric group. Very careful respiratory observations
surgical incision, breathing exercises and music and constant monitoring of pulse oximetry are
therapy (Gélinas, Arbour, Michaud, Robar & Côté, essential. Loss of a patent airway in a child is a
2013). medical emergency and the PACU nurse must
immediately press the emergency bell.
ACUTE PAIN SERVICE Cardiovascular status may be even more impor-
In Australia, 91% of training hospitals that are tant in children than in adults because they do not
accredited for anaesthetic training have an acute have the same physiological reserves (Howell,
pain service (APS) which is run from the Depart- 2013). Blood loss must be carefully observed and if
ment of Anaesthesia (ANZCA & Faculty of Pain active bleeding occurs this should be accurately
Management, 2010; Pasero, 2013). This service pro- measured. The PACU nurse must summon the
vides an excellent resource for the management of assistance of the treating anaesthetist and/or the
patients’ pain and for ongoing staff education. In surgical team and the blood pressure should be
some hospitals, anaesthetic or PACU nurses may be taken. Heart rates are very important in this popu-
included in the APS, which provides these nurses lation and a bradycardia in a child may be very
with a great opportunity for professional develop- serious as it reveals a decreased cardiac output, so
ment as well as increasing pain services for patients. medical help should be immediately summoned.
Paediatric patients require support from their
SPECIAL POPULATIONS parents and carers. Their presence may assist
nursing staff too, as parents can identify normal
MANAGEMENT OF PATIENTS WITH from abnormal behaviours and make children feel
DIABETES MELLITUS
safer. Research undertaken by Gélinas and col-
For patients with diabetes mellitus, the PACU nurse leagues (2013) has shown that family support is
regularly checks their blood sugar levels, fluids and effective as an adjunct to pharmacological pain
electrolytes, and urine for evidence of glycosuria. relief.
The stresses imposed by surgery and anaesthesia
cause imbalances that may require active manage- Having an environment conducive to children is
ment to return blood sugar levels to within the also desirable as it may be more familiar to them.
normal range. Patients may require insulin infu- This means having dedicated bays for their recov-
sions on a sliding scale during the perioperative ery, with protected side rails available on beds and
period depending on their blood sugar results, as cots and child-friendly pictures on the wall, as well
well as IV fluids to treat dehydration. Hyperglycae- as allowing younger children to have a toy or secu-
mia and coma may be difficult to ascertain in an rity blanket with them (Howell, 2013).
unconscious patient, making regular blood sugar
level monitoring a vital component of the overall CARE OF THE OLDER PATIENT
monitoring of the diabetic patient (Drain, 2013). Care of the elderly may be complicated in the PO
period as elderly patients often have comorbidities.
MANAGEMENT OF THE PAEDIATRIC PATIENT These may include, but are not limited to, cardiac
Caring for paediatric patients requires experience, conditions, hypertension, respiratory conditions,
expertise and an understanding of the uniqueness osteoarthritis, decreased vision, decreased hearing,
of this population. As this population covers such a fluid and electrolyte imbalance, dementia and dia-
wide range of ages, sizes and developmental stages, betes (Gendron, 2013). To treat many of these con-
meeting the needs of this diverse group can present ditions the patient commonly takes both prescribed
a huge challenge to perioperative nurses. and non-prescribed medications.
The smaller the child, the smaller the airway— Ageing alters pharmacokinetics affecting the
making very young children and babies vulnerable liberation, absorption, distribution, metabolism
to airway obstruction, laryngospasm and post- and excretion of medications (Gendron, 2013).
extubation croup. This can be even more problem- Recovery from anaesthesia may be prolonged
atic when the surgical site and airway are shared, in the elderly and an understanding of specific
351
medications and careful administration is required. patient is hypotensive (requiring lying flat), a dis-
Some medications may be titrated in smaller doses, cussion with the anaesthetist is required to assess
such as seen in narcotic administration. which problem is worse; however, the ‘banana’
The elderly should have their hearing aids, den- position (head up and feet up) may be employed. It
tures and eye glasses available for use during the is essential to provide support for positioning to
PO period to aid in situational awareness. PO cog- ensure that an upright sitting position is main-
nitive dysfunction has been reported to be as high tained. If the patient is edentulous, replace the
as 25.8% of patients aged over 65 years (Yu et al., teeth, as these will assist in upper airway support.
2015), so any alteration in cognition must to (See Chapters 7, 9 and 13 for further information
reported. about care of the bariatric patient.)
The PACU nurse should note the elderly patient’s

pressure injury risk assessment score and reassess DISCHARGE CRITERIA
skin integrity in the immediate PO period (ACORN, A discharge criteria system is used by nurses to
2016). Older patients are particularly vulnerable to determine when a patient is ‘ward ready’. Several
developing pressure injuries as their skin may be scoring systems are available to assess patients
paper-thin and they often have bony prominences (Hatfield, 2014), such as the Aldrete numerical
(see Chapter 9 for further information). Movement scoring system and the Postanaesthesia Discharge
may be impeded due to arthritis, so careful move- Scoring System (PADSS) (Drain, 2013). Some health-
ment is required when positioning or repositioning care providers prefer a patient-focused approach
the patient. The PACU nurse should take into whereby the patient must meet all discharge criteria
account the length of time the patient has been on prior to being transferred to the ward or stage 2
the operating table and the position required for recovery. Discharge criteria may differ between
the surgery. These factors may cause PO discomfort PACUs depending on the level of the expertise
for the patient. of the PACU nurse and the type of surgery per-
formed. Box 12-1 is an example of a patient-focused
CARE OF THE OBESE PATIENT approach.
Nursing care of obese patients includes compassion
(as they are often embarrassed by their body image), PATIENT HANDOVER FROM PACU
careful respiratory assessment, O2 therapy and
positioning. If the patient has a normal BP it is best
NURSE TO WARD NURSE
practice to nurse the patient sitting up to reduce When handing patients over to the ward staff, the
the weight of the chest wall from impeding ventila- ISBAR tool is again used (ACSQHC/the Commis-
tion. By sitting up, the weight of the chest wall is sion, 2012a). Figure 12-8 outlines the ISBAR hand
redistributed, allowing greater tidal volume. If the over requirements.
BOX 12-1 » A PATIENT-FOCUSED DISCHARGE CRITERIA SYSTEM

CONSCIOUS STATE
• The patient must be conscious and able to respond appropriately to verbal stimuli.
RESPIRATORY FUNCTION
• The patient must be able to protect his or her own airway.
• The patient has a cough reflex.
• The respiratory rate must be greater than 12 breaths per minute.
• Oxygen saturation may be assessed by trialling the patient on room air for at least 10 minutes prior
to discharge. If the SaO2 is less than 95% on room air in an otherwise healthy patient, the PACU
nurse should discuss with medical staff prior to discharge.
352
CARDIOVASCULAR FUNCTION
• Vital signs need to be within normal limits, referring to the patient’s baseline observations.
• Heart rate and BP should be within 20% of baseline values.
• If this is not met, but the patient is otherwise stable, the patient may be discharged only after
consultation with the anaesthetist and the variance written on the patient’s PO orders.
TEMPERATURE
• The patient’s core temperature should be between 36°C and 37°C.
PAIN
• Pain management continues until the patient is pain-free, has pain at a manageable level or the
vital signs indicate that it is inappropriate to continue, such as seen in a respiratory rate of less
than 12.
NAUSEA AND VOMITING

• Nausea always needs to be treated. Patients with persistent nausea may be returned to the ward on
oxygen after liaison with the anaesthetist and appropriate treatment ordered.
WOUND CARE
• There should be no excessive drainage from wound sites or drain tubes.
• Ooze through dressings must be marked and the time and date noted.
• Drain tube bottles are to be labelled with the amount, date and time.
• The fundal height in post-LSCS patients should be equal to or less than the level of the umbilicus.
INTRAVENOUS LINES
• IV bags need to have an IV label completed and attached.
• IV bungs that are left in situ need to be flushed with saline prior to discharge to the ward; this
should be noted on the patient’s record.
SPECIFIC OBSERVATIONS
• Specialised observations may be required, such as neurological observations or vascular
observations, and these must be within normal limits.
PATIENT COMFORT
• The patient needs to be in a position of comfort in a clean, dry bed.
DOCUMENTATION
• Nursing documentation must be completed contemporaneously and legibly in ink.
• Medical staff should have written up appropriate notes and orders; for example, orders for IV fluids,
pain relief, antiemetics and specific medications such as antibiotics and PO orders.
• If a score system is used to detect deterioration of patients in the ward areas, the last set of patient
observations should be transcribed onto the ward chart and a score calculated prior to discharge.
This provides a baseline for the ward nurses and alerts the PACU staff if the patient is still not
‘ward ready’. It is not appropriate to send a patient to the ward when their observations are at, or
very close to, triggering a medical emergency team call (Foran & Marshall, 2015).
353
• Patient’s name, checked and confirmed with patient wristband

(ACSQHC/the Commission, 2012a)
Identification
• Patient’s medical history, including allergies
• Includes type of anaesthesia and any other drugs administered

• Operative procedure
• Local anaesthetic injected at the end of the procedure
• Details of dressings, drains and catheters
• Specific patient care details that may be noted such as, physical
impairments, such as hearing, eyesight or movement difficulties
• Whereabouts of patient belongings such as teeth, hearing aids or
Situation glasses
• Whereabouts of relatives for paediatric or special needs patients
because most PACUs allow parents to visit and remain with their
child/special needs adult in the immediate postoperative (PO)
period
• Compromised pressure areas noted from the preoperative check
list and Bromage score
• Any other notable intra-operative events
• Observations—patient observations—preoperatively, operatively

and what is reasonable for the PO period
Background and history • Significant intraoperative events/actions (e.g. significant blood
loss)
• Intravenous (IV) access and fluid orders
• Postoperative orders for the administration of analgesia,

Assessment and action antiemetics and any other medications
to establish an agreed • Any specific, relevant PO issues, such as airway, intra-
management plan arterial devices, epidural catheters in situ or drug infusions
(ANZCA, 2006)
Recommendations • Ongoing management; for example who needs to be contacted

(responsibility and risk should help be required (e.g. end of the day, the treating
management) anaesthetist or the on-call anaesthetist)
FIGURE 12-8: ISBAR handover requirements
management of specific populations and discharge

CONCLUSION criteria. The knowledge presented enables the PACU
This chapter has outlined the purpose and role of the nurse to provide patients with a safe recovery from
PACU, the handover procedure from the OR to the both anaesthesia and surgery, to monitor the patient’s
PACU nurse, the ABCDE of recovery, the management conscious state, manage pain, anticipate complica-
of important complications, pain management, the tions and provide comfort and reassurance.

1. Accepting a patient into the PACU
You receive a patient into the PACU and as the anaesthetist is handing over to you, you realise that
you do not know what the surgery entailed or what the possible complications of that surgery might
be.
• Why would this situation be potentially unsafe for the patient?
• What would you do to rectify this situation? Provide rationales for your actions.
354
2. Deteriorating patient: respiratory

You are caring for a child following a tonsillectomy and adenoidectomy. When the child wakes up, he
develops an inspiratory stridor.
• What is the name of this condition and what might have caused it?
• How would you manage this patient? Provide rationales for your actions.
3. Deteriorating patient: cardiovascular
You are caring for a 68-year-old man who has had bilateral inguinal hernia repairs under a spinal
blockade with sedation. His preoperative BP was 120/80 mmHg and his BP on arrival into the PACU
was 105/85 mmHg. Your second blood pressure reading shows that his BP has fallen to 85/68 mmHg.
• How would you manage this patient? Provide rationales for your actions.
4. Discharge to the ward
You have been caring for a 78-year-old woman following a total hip replacement under an epidural
block and sedation. You judge that the patient is stable and ready to return to the ward. When the
ward nurse arrives, she believes that the patient’s BP is very close to triggering a MET call in the ward
and is not comfortable taking the patient at this time.
• How would you manage this situation? Provide rationales for your actions.
.org/AboutUs/History/tabid/3146/Default.aspx”http://www
RESOURCES .aspan.org/AboutUs/History/tabid/3146/Default
American Association of Nurse Anesthetists .aspx#BeginningAmerican>.
www.aana.com Anaesthesia UK. (2004). Bromage scale. Retrieved 28 July
American Society of PeriAnesthesia Nurses 2015 from <www.frca.co.uk/article.aspx?articleid=100316>.
www.aspan.org
Anderson, M., & Watson, G. (2013). Traumatic shock: The fifth
Association for Perioperative Practice shock. Journal of Trauma Nursing, 20(1), 37–43.
www.afpp.org.uk/home
Australian and New Zealand College of Anaesthetists (ANZCA).
Australian and New Zealand College of Anaesthetists (2006). Professional documents of the Australian and New
www.anzca.edu.au Zealand College of Anaesthetists. PS4. Recommendations for
Australian College of Operating Room Nurses the Post-Anaesthesia Recovery Room. Retrieved from <www
www.acorn.org.au .anzca.edu.au/resources/professional-documents/pdfs/
ps04-2006-recommendations-for-the-post-anaesthesia-
British Anaesthetic & Recovery Nurses Association recovery-room.pdf>.
www.barna.co.uk
International Association for the Study of Pain Australian and New Zealand College of Anaesthetists
www.iasp-pain.org (ANZCA) Faculty of Pain Medicine. (2010). Acute pain man-
agement: Scientific evidence [Booklet.] Retrieved from <www
International Federation of Nurse Anesthetists .anzca.edu.au/resources/college-publications/pdfs/
www.aana.com Acute%20Pain%20Management/books-and-publications/
Perioperative Nursing College of the New Zealand Nurses acutepain.pdf>.
Organisation Australian and New Zealand College of Anaesthetists
www.pnc.org.nz (ANZCA). (2013). Professional documents of the Australian and
The Australian Society of Post Anaesthesia and New Zealand College of Anaesthetists. PS53BP: Statement on
Anaesthesia Nurses handover by the anaesthetist. Retrieved from <www.anzca
www.aspaan.org.au .edu.au>.
REFERENCES (2016). Standards for Perioperative Nursing 2016–2017.
Aitkinhead, A., Moppett, I., & Thompson, J. (Eds.), (2013). Adelaide: Author.
Smith and Aitkenhead’s textbook of anaesthesia (6th ed.). Australian Commission on Safety and Quality in Health Care
Edinburgh: Churchill Livingstone. (ACSQHC/the Commission). (2012a). National Safety and
American Society of Peri-Anesthesia Nurses. (2012). ASPAN’s Quality Health Service Standards. Standard 3: Preventing and
history timeline. Retrieved 25 March 2012 from <www.aspan controlling healthcare associated infections. Sydney: Author.
355
Australian Commission on Safety and Quality in Health Care Hartog, C. S., Rothaug, J., Goettermann, A., Zimmer, A., &
(ACSQHC/the Commission). (2012b). National Safety and Meissner, W. (2010). Room for improvement: nurses’ and
Quality Health Service Standards. Standard 9: Care of the physicians’ views of a post-operative pain management
deteriorating patient. Sydney: Author. program. Acta Anaesthesiologica Scandinavica, 54, 277–283.
Bender, M., Self, B., Schroeder, E., & Brandon, G. (2015). Com- Harvey, A., Mukhtar, K., Sinclair, A., & Pearce, I. (2009).
paring new-technology passive warming versus traditional Transurethral resection of the Prostate Syndrome: Almost
passive warming methods for optimizing perioperative body gone but not forgotten. Journal of Endourology, 23(12),
core temperature. AORN Journal, 102(2), 183.e1–183.e8. 2010–2020.
Billeter, A., Hohmann, S., Druen, D., Cannon, R., & Polk, H. Hatfield, A. (2014). The complete recovery room book (5th ed.).
(2014). Unintentional perioperative hypothermia is associ- Oxford: Oxford University Press.
ated with severe complications and high mortality in elec- Haugan, B., Langerud, A., Kalvøy, H., Frøslie, K., Riise, E., &
tive operations. Surgery, 156(5), 1245–1252. Kapstad, H. (2013). Can we trust the new generation of
Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2014). infrared tympanic thermometers in clinical practice? Journal
Lewis’s medical-surgical nursing: Assessment and manage- of Clinical Nursing, 22(5/6), 698–709.
ment of clinical problems (4th ed.). Sydney: Elsevier. Howell, E. (2013). Care of the paediatric patient. In J. Odom-
Bryant, B., & Knights, K. (2014). Pharmacology for health Forren (Ed.), Drain’s perianaesthesia nursing: A critical care
professions (4th ed.). Sydney: Elsevier. approach (6th ed.). St Louis: Elsevier.
Burden, N. (2013). Care of the ambulatory surgery patient. Kiekkas, P., Gardeli, P., Bakalis, N., Stefanopoulos, N.,
In J. Odom-Forren (Ed.), Drain’s perianaesthesia nursing: A Adamopoulou, K., Avdulla, C., et al. (2015). Predictors of
critical care approach (6th ed.). St Louis: Elsevier. nurses’ knowledge and attitudes toward postoperative pain
in Greece. Pain Management Nursing, 16(1), 2–10.
Butterworth, J., Mackey, D., & Wasnick, J. (2013a). Airway
management. In J. Butterworth, D. Mackey, & J. Wasnick Larach, M., Gronert, G., Allen, G., Brandom, B., & Lehman, E.
(Eds.), Morgan and Mikhail’s clinical anesthesiology (5th ed.). (2010). Clinical manifestation, treatment and complications
New York: McGraw-Hill Medical. of malignant hyperthermia in North America from 1987 to
2006. Anesthesia and Analgesia, 110(2), 498–507.
Butterworth, J., Mackey, D., & Wasnick, J. (2013b). Spinal,
Moola, S., & Lockwood, C. (2011). Effectiveness of stategies
epidural & caudal blocks. In J. Butterworth, D. Mackey, &
for the management and/or prevention of hypothermia
J. Wasnick (Eds.), Morgan and Mikhail’s clinical anesthesiology
within the adult perioperative environment. International
(5th ed.). New York: McGraw-Hill Medical.
Journal of Evidenced-Based Healthcare, 9, 337–345.
Callaghan, A. (2011). Student nurses’ perception of learning
Moos, D. (2013). Regional anaesthsia. In J. Odom-Forren (Ed.),
in a perioperative placement. Journal of Advanced Nursing,
Drain’s perianaesthesia nursing: A critical care approach (6th
67(4), 854–864.
ed.). St Louis: Elsevier.
Clifford, T. (2013). Care of the obese patient undergoing Munk, L., Andersen, L. P. H., & Gögenur, I. (2013). Emergence
bariatric surgery. In J. Odom-Forren (Ed.), Drain’s perianaes- delirium. Journal of Perioperative Practice, 23(11), 251–254.
thesia nursing: A critical care approach (6th ed.). St Louis:
Elsevier. O’Brien, D. (2013). Postanesthesia care complications. In
J. Odom-Forren (Ed.), Drain’s perianaesthesia nursing: A criti-
Daley, K., & Huff, S. (2010). Incidence of arrhythmias in ASA cal care approach (6th ed.). St Louis: Elsevier.
1 patients in PACU. Journal of Peri-Anestheia Nursing, 25(5),
281–285. Odom-Forren, J. (Ed.), (2013). Drain’s perianaesthesia nursing:
A critical care approach (6th ed.). St Louis: Elsevier.
DeDea, L., & Bushardt, R. (2013). Codeine and acetami-
nophen recommendations for children. Journal of the Ameri- Parker, L., Webb, A., Albers, P., & Clarke, M. (2011). An audit
can Academy of Physician Assistants, 26(9), 11–12. to determine the incidence of postoperative hypoxaemia on
arrival in the recovery room after the institution of pulse oxi-
Drain, C. (2013). The respiratory system. In J. Odom-Forren metry and supplementary oxygen on transfer. Retrieved from
(Ed.), Drain’s perianaesthesia nursing: A critical care approach <www.anzca.edu.au/events/ANZCA%20annual%20scientific
(6th ed.). St Louis: Elsevier. %20meetings/csm-2011/pdf_abstacts/csm_2011_0057.pdf/
Foran, P., & Marshall, A. (2015). Post-anaesthesia recovery. view?searchterm=recoveryroom>.
In L. Aitken, A. Marshall, & W. Chaboyer (Eds.), ACCCN’s critical Pasero, C. (2013). Pain management. In J. Odom-Forren (Ed.),
care nursing (3rd ed., pp. 857–884). Sydney: Elsevier. Drain’s perianaesthesia nursing: A critical care approach (6th
Gélinas, C., Arbour, C., Michaud, C., Robar, L., & Côté, J. (2013). ed.). St Louis: Elsevier.
Patients and ICU nurses’perspectives of non-pharmacological Pereiraa, H., Xaráa, D., Santosa, A., & Abelhaa, F. (2014).
interventions for pain management. Nursing in Critical Care, Obese patients: Respiratory complications in the post-
18(6), 307–318. anesthesia care unit. Revista portuguesa de pneumologia,
Gendron, T. (2013). Care of the older patient. In J. Odom- 20(1), 12–19.
Forren (Ed.), Drain’s perianaesthesia nursing: A critical care Peterson, C. R. (2013). The hepatobiliary and gastrointestinal
approach (6th ed., pp. 711–720). St Louis: Elsevier. system. In J. Odom-Forren (Ed.), Drain’s perianaesthesia
356
nursing: A critical care approach (6th ed.). St Louis: Yu, X., Liu, S., Li, J., Fan, X., Chen, Y., Bi, X., et al. (2015).
Elsevier. MicroRNA-572 improves early post-operative cognitive dys-
Pinney, D., Pearce, M., & Feldman, S. (2010). Detecting function by down-regulating neural cell adhesion molecule
adverse events in dermatologic surgery. Dermatological 1. PLoS ONE, 10(2), 1–13.
Surgery, 36, 8–14.
Ruetzler, K., Blome, C. J., Nabecker, S., Makarova, N., Fischer, FURTHER READING
H., Rinoesl, H., et al. (2014). A randomised trial of oral versus Beckner, M., Aldridge, A., Pulice, C., Williams, C., Shafer, V., &
intravenous opioids for treatment of pain after cardiac Facemire, N. (2012). Electronic documentation in pre-
surgery. Journal of Anesthesia, 28(4), 580–586. admission, PACU and same day surgery. Journal of Perian-
Samaraee, A., Rhind, G., Saleh, U., & Bhattachacharya, V. esthesia Nursing, 27(3), e7.
(2010). Factors contributing to poor post-operative abdomi- Burke, J., Richart, S., Bird, T., & Latham, K. (2014). PACU
nal pain management in adult patient: A review. The Surgeon, liaison role: Keeping families updated. Journal of Perian-
Journal of the Royal College of Surgeons of Edinburgh and esthesia Nursing, 29(5), e6.
Ireland, 8, 151–158. Card, E., Nelson, D., Tomes, C., Lee, C., Woods, J., Hughes, C.,
Schick, L. (2013). Assessment and monitoring of the perian- et al. (2014). Incidence and risk factors for emergence and
esthesia patient. In J. Odom-Forren (Ed.), Drain’s perianaes- PACU delirium. Journal of Perianesthesia Nursing, 29(5),
thesia nursing: A critical care approach (6th ed.). St Louis: e35–e36.
Elsevier. Finnigan, M. A., Marshall, S. D., & Flanagan, B. T. (2010). ISBAR
Sear, J. (2013). Oxygen: Needed for life. But do we need sup- for clear communication: One hospital’s experience spread-
plemental oxygen during transfer from the OR to the ing the message. Australian Health Review, 34, 400–404.
PACU? Journal of Clinical Anaesthesia, 25, 609–611. <http://dx.doi.org/10.1071/AH09823>.
Segall, N., Bonifacio, A., Schroeder, R., Barbeito, A., Rogers, D., Gan, T. J., Diemunsch, P., Habib, A. S., Kovac, A., Kranke, P.,
Thornlow, D., et al. (2012). Can we make postoperative Meyer, T. A., et al. (2014). Consensus guidelines for the man-
patient handovers safer? A systematic review of the litera- agement of postoperative nausea and vomiting. Anesthesia
ture. Anesthesia and Analgesia, 115(1), 102–115. Analgesia, 118, 85–113.
Stephens, A. J., Woodman, R. J., & Owen, H. (2015). The effect Joanna Briggs Institute. (2011). Post-anesthetic discharge
of ondansetron on the efficacy of postoperative tramadol: scoring criteria. Best Practice, 15(17), 1–4.
A systematic review and meta-analysis of a drug interaction. Johnson, M., Jefferies, D., & Nicholls, D. (2012). Exploring the
Anaesthesia, 70, 209–218. structure and organization of information within nursing
Subbe, C. (2013). Failure to rescue: Using rapid response clinical handovers. International Journal of Nursing Practice,
systems to improve care of the deteriorating patient in 18, 462–470.
hospital. Clinical Risk, 19(1), 6–11. Margarson, M., Murray, H., & Kendall, A. (2013). Should obese
Wetsch, W. A., Spöhr, F. A., Hinkelbein, J., & Padosch, S. A. surgical patients be recovered in ICU or PACU? Should all
(2012). Emergency extracorporeal membrane oxygenation postoperative MO patients be monitored during their entire
to treat massive aspiration during anaesthesia induction. A hospitalization? In Y. Leykin, & J. B. Brodsky (Eds.), Contro-
case report. Acta Anaesthesiologica Scandinavica, 56(6), versies in the Anesthetic Management of the Obese Surgical
797–800. Patient (pp. 241–254). Milan: Springer.
357
Chapter 13
EVOLVING MODELS OF CARE IN
PERIOPERATIVE ENVIRONMENTS
LYNN RAPLEY AND LOIS HAMLIN
EDITOR: LOIS HAMLIN
LEARNING OUTCOMES
• Describe the ongoing evolution of day surgery and endoscopy settings and practices
• Explore the emergence of non-traditional environments and the range of procedures performed therein
• Outline the patient’s journey through day surgery/short-stay procedural settings
• Explain patient preparation for endoscopy and endovascular procedures
• Examine the complexity of equipment in endoscopy and other short-stay settings, and the associated
patient safety and risk management issues
KEY TERMS
ambulatory surgery
bowel cancer screening
carer
day surgery
endoscopy
endovascular procedures
infection control
interventional radiography
non-traditional environments
short-stay procedure
risk management
catheterisation laboratories and endovascular

INTRODUCTION suites) and freestanding facilities are now well-
The traditional operating suite has ceased to be established perioperative environments. Day sur-
the principal site for surgical interventions and gery units and endoscopy centres, whether they are
diagnostic procedures; instead, a range of hospital stand-alone facilities or an integral part of a hospi-
departments (e.g. radiology departments, cardiac tal, are not new. However, over the past decade
358
CHAPTER 13 | Evolving models of care in perioperative environments
there has been considerable expansion in the planning have gained prominence (Crouch, 2012)
number of day surgery settings, the types of proce- and patient selection continues to be refined.
dures performed in them and the volume of patients The ability to perform procedures previously
treated therein. considered to require overnight admission (or
This chapter provides an overview of the evolu- longer) has changed the profile of day surgery
tion of day surgery, endoscopy and interventional (Seker & Kulacoglu, 2012). Indeed, the concept of
radiography in Australia and New Zealand, the day surgery has itself evolved and now encompasses
processes involved in providing these services and extended day only (EDO), ambulatory procedures
the benefits for the patient, the facilities and and other variously titled, high-volume, short-stay
healthcare in general. Increasingly complex pro (HVSS) models of care (MOC) (NSW Health, 2011,
cedures are now performed on a day-stay basis, 2012). For example, EDO surgery generally refers to
including some revolutionary endoscopic pro surgical treatment that requires 23–28 hours of
cedures, which are a large and increasing compo- care; HVSS, a maximum of 72 hours. Key elements
nent of throughput in day surgery units, and there of these MOC include:
are unique patient care considerations associated • designated surgical beds, which are mostly
with them. Additionally, other interventional and within a dedicated surgical unit
image-guided procedures are now conducted in
hospital radiology and angiography suites where • appropriate selection of patients who must
once only diagnostic procedures were conducted. meet specific, predetermined criteria
The relentless growth in technology has facili- • a defined case mix of procedures and services
tated many of these changes, enabling doctors and • protocol-driven care
surgeons to diagnose and treat many more differ- • staggered admissions (NSW Health, 2011).
ent disease processes, while sparing patients from
traditional surgical interventions. This chapter It is anticipated that eventually 80% of all surgical
briefly summarises some of the more recently procedures could be treated as EDO cases (NSW
developed interventions undertaken in these non- Health, 2011).
traditional environments. It is important to note For the sake of brevity in this chapter, these
that only limited focus is given to nursing practice MOC are referred to as day surgery or ambulatory
here, as pre-, intra- and postoperative (PO) patient care, as appropriate. The development of these
care has been addressed in earlier chapters. newer models allows for more elaborate surgery,
advanced endoscopic procedures, interventional
GROWTH OF DAY SURGERY, radiography and complex endovascular interven-
tions to be performed, usually with excellent out-
ENDOSCOPY AND comes. However, they require careful patient
INTERVENTIONAL RADIOGRAPHY selection and screening and meticulous preopera-
The practice of day surgery (or ambulatory tive preparation and PO education.
surgery) has been evident in Australasia for several The drivers of change include the continued
decades and while it has grown continuously need to reduce hospital waiting lists and the rising
throughout this time, the pace of change has esca- costs of healthcare, which make the day surgery
lated over the past decade. Day surgery, endoscopy model very attractive (Ministry of Health New
units and endovascular suites—indeed, all short- Zealand, 2014a). Additionally, health funds stipu-
stay procedure environments—have faced many late timeframes for patient care in the private
challenges during this period, not just in the design sector and in due course this has had an impact on
and building (or adaptation) of facilities (Schaadt the public health system, further pushing the
& Landau, 2013; Williams, 2014) but also in the boundaries for day surgery. Indeed, a paradigm
nature and variety of surgical interventions/ shift is underway, reflected in an approach that asks
procedures, technological advances and risk man- not ‘Is this patient suitable for day surgery?’ but
agement tools. All have evolved significantly (Leary, rather ‘Is there any justification for admitting this
2013), along with better anaesthesia techniques case as an inpatient?’ (International Association for
and pain relief. Most importantly, patient-centred Ambulatory Surgery & European Agency for Con-
care models and consumer involvement in service sumers and Health [IAAS/EU], 2013).
359
BOX 13-1 » CLASSIFICATION OF FREESTANDING PRIVATE DAY SURGERY HOSPITALS

• General surgery
• Gastroenterology (originally specialist endoscopy)
• Ophthalmic
• Plastic/cosmetic
• Gynaecology
• Dental
• Oral/maxillofacial
• Oncology
• Dialysis
• Fertility treatment and family planning
Note: the last six classifications were added in 2010–2011.
SOURCE: ABS (2014).
The increasing use of ambulatory care settings the patient overnight, should the need arise. Most
is reflected statistically; for example, in New diagnostic and interventional angiographic pro
Zealand day surgery use increased from 53% to 58% cedures also fall into this category, as freestanding
between 2003 and 2013, in line with international day surgery hospitals are not suitable venues for
trends (Ministry of Health New Zealand, 2014a). In these procedures. Ambulatory care settings that
Australia, 1086,400 day surgery procedures were provide these more complex procedures can be
performed in 2012–2013, an increase of 16.3% organised by various models including:
compared with 2011–2012 and 2.3 times more than • within a hospital setting but completely
a decade earlier (Australian Bureau of Statistics independent, with all services incorporated
[ABS], 2014). Of these cases, 358,485 (12%) were within an ambulatory care area
undertaken in public hospitals and 801,039 (33.4%)
• within a hospital setting but all perioperative
were undertaken in private settings (Australian
services utilise the main theatre complex,
Institute of Health and Welfare [AIHW], 2013a).
whether day only, inpatient or day-of-surgery
(These data exclude endoscopy cases.) Likewise, in
admission (DOSA) patients
Australia the number of freestanding private day
surgery hospitals has continued to increase, rising • a satellite site where some services
from 140 in the mid-1990s to 256 a decade later (e.g. sterilising) are carried out by another
(ABS, 2007). The number currently stands at 319, department, perhaps away from the main
with more than half of these facilities located in hospital campus.
New South Wales and Victoria (ABS, 2014). By com- Feature box 13-1 overviews an approach to day
parison, the growth in public day surgery facilities surgery facilities that is currently being imple-
has been slower. Freestanding private day surgery mented in one Australian state.
facilities are currently classified into various cat New Zealand has developed a novel way of pro-
egorises; these are highlighted in Box 13-1. viding ambulatory and endoscopy care to rural
It should be noted that there is some overlap patients following the closure of many small local
in the type of surgery completed within either hospitals. Mobile Health Solutions (MHS) is a pri-
public or private hospitals that is not undertaken vately owned company that works in partnership
in freestanding facilities. In public hospitals, more with the Ministry of Health, District Health Boards
complex surgery such as single-level spinal surgery and other health providers to deliver the operating
or speciality orthopaedic procedures may be per- theatre to the doorstep of rural communities. MHS
formed, because there is the option to care for aims to provide effective, efficient surgical care
360
FEATURE BOX 13-1 » ‘TRANSFORMING HEALTH’: CHANGING CARE DELIVERY IN

SOUTH AUSTRALIA
In 2014, the South Australian government committed to a complete overhaul of its healthcare
system in order to provide patient-centred, high-quality, effective and adaptable healthcare. Titled
‘Transforming Health’, the four-year project (2015–2019) was developed after extensive commu-
nity and stakeholder consultation. There were many drivers for this change, among them (and of
relevance to day-only patient care):
• the high level of cancellation of elective surgery
• underutilisation of the operating rooms used for elective surgery
• the state’s day surgery rate, which at 52% is the lowest nationally (60–70% elsewhere in
Australia) and well below international benchmarks (SA Health, 2015); in order to increase
this rate, day surgery centres are to be re-established within current facilities and new
centres will be built (SA Health, 2015).
with a patient-centred focus, eliminating the need proceduralist. Instead, patients often see their GP
for patients to travel great distances for their pro- if they experience an adverse incident postopera-
cedures and keeping them close to their support tively. Protocols related to patient follow-up vary
networks. Since the inception of this service 13 across hospitals, an issue acknowledged in the
years ago, 18,500 elective day surgery/endoscopy relevant EQuIP National Guidelines (Australian
procedures have been completed (MHS, nd). This is Council on Healthcare Standards [ACHS], 2012a).
highlighted in Feature box 13-2. This directs organisations to follow up patients and
carers, and to check that the information related to
ADVANTAGES OF DAY SURGERY their condition and discharge was appropriate and
There are a range of advantages for both patients the written documentation effective.
and health services associated with undertaking Not all Australians have equal access to elective
investigations or procedures on a planned, non- surgery (or other interventions); similarly, Māori
resident basis (i.e. as day-only cases). This includes: and Pacific Islander peoples in New Zealand have
• day surgery is safe greater unmet healthcare needs. These issues are
• it is cost-effective, efficient and timely explored in Feature box 13-3.
• there is minimal need for costly inpatient More broadly, there remains a requirement to
hospital resources develop policies aimed at meeting the needs of
• there is less risk of cancellation various groups within the community and to iden-
tify ways to remove the barriers for accessing
• the risk of nosocomial infection and venous
healthcare, such as differing concepts of health and
thromboembolism (VTE) is reduced
illness. These may be culturally based and thus
• there is less social disruption for patients and affect understanding of causation, treatment and
their families (Langton, 2013). impact of compliance. Indigenous peoples, socio-
Despite these advantages, Shields (2014) com- economically disadvantaged Australians and people
ments that little evidence or research has been com- living in rural and remote areas are groups of special
pleted about the effect on the patient’s family; for interest because of their high incidence of health
example, concerning time off work for a parent, problems compared to the remainder of the popu-
anxiety at having to be the carer of a PO patient and lation. Many Indigenous Australians also have
the associated burden, or the quality of education other, unique issues related to accessing healthcare
provided on discharge. The incidence of PO infec- (Ride, 2014). Communication and language barri-
tion also remains unknown because it is not always ers, together with the remoteness of some com-
treated by or reported to the hospital or surgeon/ munities, additionally hinder access to allied health
361
FEATURE BOX 13-2 » ‘THE BUS’: NEW ZEALAND’S NOVEL APPROACH TO PROVIDING
SURGICAL SERVICES TO RURAL COMMUNITIES
The MHS Unit, colloquially referred to as ‘the Bus’, travels through the rural communities of both
islands making more than 23 stops during a 5-week cycle. On arrival at a designated stop, the Bus,
which has a well-equipped operating room, is located close to a medical centre or hospital so that
power can be sourced from the host facility (although back-up generators are on board the bus, if
required). Medical and nursing staff are sourced locally and organised in advance by MHS staff.
Patient access to this service is via general practitioner (GP) referral to a specialist surgeon/
proceduralist and subsequent inclusion on a waiting list. In due course, pre-booked procedures are
organised with the patient. More than 300 different procedures can be performed, including:
• general (hernia/haemorrhoidectomy)
• gynaecological (hysteroscopy/tubal ligation)
• orthopaedic (arthroscopy/carpal tunnel)
• dental (child fillings/extractions)
• ophthalmology (cataract extraction/ectropian/strabismus repair)
• ENT (myringotomy/septoplasty)
• plastics (skin lesion +/−flap repair)
• urology (cystoscopy/urethroscopy)
• endoscopy (gastroscopy/colonoscopy).
A key feature of this service is to provide educational opportunities for rural health professionals.
Initially focused on skills training for nurses to support them working in the operating theatre
and recovery area, this program has developed to provide a wide range of education sessions to
ensure that rural health professionals maintain their individual professional competencies. In the
past 10 years more than 35,000 hours of training and education have been provided throughout
New Zealand’s 35 rural locations.
SOURCE: MHS (nd).
FEATURE BOX 13-3 » INDIGENOUS, MĀORI AND PACIFIC ISLANDER PEOPLES: RATES OF
SURGICAL INTERVENTIONS
Indigenous Australians have a lower rate of access to procedures compared to non-Indigenous

Australians with the same condition (Australian Department of Health and Ageing [ADHA], 2013).
Additionally, they spend more time on the waiting list before accessing surgery compared to other
Australians. This is the case for most commonly performed procedures but is particularly marked
for cataract extraction and total knee replacement surgeries. For the latter, 23% of Indigenous
patients wait more than a year for surgery (AIHW, 2013b), which is twice the rate for non-
Indigenous Australians.
In New Zealand, Māori and Pacific Islanders report higher levels of unmet need for healthcare,
although increased access to elective surgery and concomitant reduction in waiting times has
been reported (Ministry of Health New Zealand, 2014a). However, limited participation has been
reported in a bowel cancer screening pilot study being conducted in the Waitemata District Health
Board region. As in Australia, this is deemed to be the result of low literacy rates and environmental
barriers (failure to receive testing kits) (ADHA, 2013; Ministry of Health New Zealand, 2014b, 2014c).
362
or pharmaceutical treatment regimens. The failure lines; meeting the latter is essential if hospitals and
to fully meet these health needs contravenes Stand- other organisations are to be accredited (ACHS,
ard 11 of the National Guidelines (ACHS, 2012b), 2012a, 2012b).
which addresses the requirement for equitable
access for all consumers. PATIENT SELECTION
Patient selection for any ambulatory care procedure
THE PATIENT JOURNEY IN remains paramount for positive patient outcomes.
AMBULATORY CARE SETTINGS This process goes beyond the narrowly defined cri-
teria used previously, such as patient age or well-
PATIENT ACCEPTANCE ness. Significantly, day surgery patients must agree
Patient acceptance of and satisfaction with day to be categorised in this way, thus putting them-
surgery remains high across all of the treatment selves at the centre of their care (IAAS/EU, 2013).
modalities, providing their expectations of the Importantly, one of the central concepts of the
experience are met—namely: National Standards is that of patient-centred care
• a smooth and trouble-free preoperative because this model of service delivery has demon-
admission process strably improved patient outcomes (ACSQHC/the
• a successful surgical intervention Commission, 2012). This can empower patients
through their perioperative care pathway. However,
• no or minimal PO side effects as part of careful patient selection and thoughtful
• able to go home on the same day with the perioperative assessment, it is also crucial that
confidence to cope and recover at home. patients’ social circumstances are satisfactory; that
Patients have even higher expectations related is, they must have access to an appropriate support
to the provision of their care compared to the recent network for their PO recovery once they are deemed
past, and that these expectations need to be met is ‘home ready’ (Langton, 2013). This highlights that
reflected in the National Safety and Quality Health the provision of information and patient education
Service (NSQHS) Standards (the National Stand- is important for the success of any ambulatory care
ards) (Australian Commission on Safety and Quality endeavour and is critical for patients to be able to
in Health Care [ACSQHC/the Commission], 2012). make informed decisions. These issues are addressed
The National Standards, discussed in Chapter 3, in Chapter 7.
note that safe, appropriate and effective delivery of As well as patient acceptance, patient suitability
care and services to patients depends on compre- needs to be determined by relevant health profes-
hensive systems of service delivery. In New Zealand, sionals. In most instances, the ‘ultimate decision as
the Health and Disability Commissioner Act 1994 to the suitability of a patient’ will remain that of
(and subsequent amendments) incorporates the the procedural anaesthetist and this decision will
Code of Health and Disability Services Consumers’ be based on the patient’s condition and various
Rights (Code of Rights), which enunciates similar aspects of the day surgery experience (Australian
expectations (Health & Disability Commissioner, and New Zealand College of Anaesthetists [ANZCA],
2014). 2010). The conditions that assist the anaesthetist
Whether or not these expectations are met is to determine the patient’s suitability or otherwise
determined by seeking critical feedback and com- are outlined in Box 13-2. However, it is important
ments from ambulatory care patients, obtained to reiterate that decision making is a collaborative
via regular hospital patient satisfaction surveys process that also includes input from the surgeon/
(Thurairatnam, Mathew, Montgomery & Stocker, proceduralist and the patient.
2014), PO phone calls and various healthcare satis-
faction benchmarking tools (e.g. Press Ganey). SPECIAL POPULATIONS AND
Surveys of this nature often highlight where envi- AMBULATORY SETTINGS
ronmental, dietary, organisational and/or hospital
services fall short of the mark and give ambulatory PAEDIATRIC PATIENTS
care providers an opportunity to address them Paediatric patients are well suited for day surgery
(Press Ganey Australia, nd). Such activities need to (IAAS/EU, 2013); in fact, it is the preferred approach
occur in order to fulfil requirements pertaining to for them (Langton, 2013; De Melo, 2013). However,
the National Standards and the National Guide- the parent(s) must be willing participants and be
363
BOX 13-2 » CONDITIONS THAT DETERMINE THE SUITABILITY OF PATIENTS FOR AMBULATORY
CARE PROCEDURES
Patient has low risk of bleeding
Patient has low risk of airway compromise
PO pain management
Patient’s ability to return to diet and fluids rapidly
Patient’s ability, in conjunction with a responsible adult, to manage their PO care
Type of surgery to be performed
SOURCE: ANZCA (2010) AND LANGTON (2013).
well educated in order to assume management and BARIATRIC PATIENTS

care of their child pre- and postoperatively (Jewell Managing the bariatric patient requires staff train-
& Clarke, 2012). Children have different fasting ing, risk reduction strategies and specialised equip-
needs and these should be clearly explained and ment and protocols (Al-Benna, 2011; Saber, nd).
provided in writing to the parent(s) so that the child Community prejudices are often an issue and these
remains well-hydrated (ANZCA, 2010). Children may be reflected by staff or other patients (Gagnon
should be fasted from clear fluids for only 2 hours & Karwacki Sheff, 2012; Rowen, Hunt & Johnson,
preoperatively; infants can have formula or breast 2012). Bariatric patients are frequently embar-
milk up to 4 hours preoperatively and clear fluids rassed by their appearance and may be anxious, for
2 hours pre-procedure (ANZCA, 2010). It is very example, that appropriately sized theatre attire
important that the child’s weight (and height, will be available. Ensuring their privacy and being
although this is less significant) are recorded to sensitive to their needs is of paramount importance
ensure that accurate drug dosage can be deter- (Gagnon & Karwacki Sheff, 2012).
mined for anaesthesia and pain management pur- As discussed in earlier chapters, the incidence of
poses (Australian Day Surgery Nurses Association obesity among the general population has resulted
[ADSNA], 2013; De Melo, 2013). in obese patients presenting across the spectrum of
Irrespective of their age, children requiring healthcare and not just in specialist, bariatric units
surgery can cause stress for their parents and (Reynolds, 2013). Appropriately sized trolleys, beds,
other family members. The stress burden is often chairs, toilets, mobilising aides and weighing scales
worsened by the realisation that the parent (or all need to be available for this cohort of patients
grandparent) will be responsible for the child’s and their safe weight loads known by all day surgery
care postoperatively. Thus, it is extremely impor- staff (Al-Benna, 2011). The availability of moving
tant that the child’s carers are well prepared and aids (e.g. HoverMatt) is essential and local policies
understand their role throughout the periopera- should indicate whether patient weight or BMI is
tive experience (ADSNA, 2013; IAAS/EU, 2013). the determinant of their use. It is essential that
Hospital protocols vary in relation to parents larger (oversized) BP cuffs are available within the
accompanying their child to the anaesthetic room; ambulatory care setting; otherwise, it is not possi-
however, this is desirable as it usually results in ble to obtain accurate BP recordings (ADSNA, 2013;
calm children (De Melo, 2013). Parents may also Rowen et al., 2012). Also required are a selection of
be allowed to remain with their child in the post larger-sized graduated compression stockings and
anaesthesia care unit. The child should have items calf compressors; these are important because bari-
of familiarity with them at all times and be offered atric patients have an increased risk of developing
tempting foods to encourage them to eat and venous thromboembolism (VTE) (Al-Benna, 2011).
drink postoperatively. It is advisable that there are These need to be correctly fitted otherwise they will
two adults available to take the child home, so cause unnecessary damage rather than assisting
there is one with the child while the second one with return blood flow. Perioperative nurses need
drives. specific training that addresses the physical, mental
364
and psychosocial needs of obese patients. This edu- the carer in identifying the top five ways in which
cation must include correct use of the equipment unknown nursing staff can care for a patient with
required for this cohort of patients (Rowen et al., dementia. This can be as simple as providing a
2012). Safe lifting policies, interdisciplinary team- favourite song or photo or managing the arrange-
work and effective communication are also required ment of the bed and/or immediate environment.
to prevent staff injuries (Al-Benna, 2011; Rowen This initiative shows promising outcomes, particu-
et al., 2012). larly in the areas of:
ELDERLY PATIENTS • staff confidence in caring for patients with

dementia
Elderly patients are more likely to be seen in the
ambulatory care setting now compared to the past, • acceptability to carers
and if they are well enough, this setting is more • reduced falls
beneficial, as they cope better at home and have
• reduced antipsychotic drug use
less risk of PO confusion (Langton, 2013). However,
careful preoperative assessment and patient selec- • impact on staffing levels and associated
tion are required as the elderly are more likely to potential cost savings (CEC, 2014).
have comorbidities and associated polypharmacy Of significance for the patient with dementia, as
(Bryant & Knights, 2015; Langton, 2013). The inci- well as the cognitively intact elderly, is PO delirium.
dence of perioperative complications is increased This is because risk factors include advanced age
in the elderly due to loss of functional reserve and and pre-existing cognitive impairment. Box 13-3
general organ decline, with the incidence of PO explores PO delirium further.
complications proportional to the number of
comorbidities (White, Khan & Smitham, 2011). The
most common complications are cardiac (White
ADVANCES IN PROCEDURES
et al., 2011) and pulmonary (ANZCA, 2014; White PERFORMED IN AMBULATORY
et al., 2011). CARE SETTINGS
Caring for the elderly patient requires consid- The range of ambulatory care settings means that
eration of the individual’s: many more procedures can be completed without
• overall health and the presence of any exposing patients to longer periods of hospitalisa-
comorbidities tion than is absolutely necessary. Additionally, the
past few years have seen the development of a
• medication regimen
plethora of interventional procedures and the nec-
• hearing and visual capabilities essary technologies to facilitate their implementa-
• cognitive status. tion. In such a small compass as this, it is possible
to explore only a small selection.
It is important that elderly patients are provided a
safe environment and one where they can easily ADVANCES IN FLEXIBLE ENDOSCOPY
reach their hearing aids, spectacles and personal
Flexible endoscopy has continued to develop at a
belongings. They also need a family member or
remarkable pace (see Figs 13-1 and 13-2). This has
other carer who should be available to assist them
resulted in procedures being performed today that
for 24 hours post-procedure (Langton, 2013).
as little as 5 or 10 years ago required an open surgi-
PATIENTS WITH DEMENTIA cal intervention. There are many conditions that
Caring for patients with dementia can prove chal- can be managed endoscopically, and a variety of
lenging for the day surgery team. A carer must be procedures and technologies that facilitate their
available and be included in care planning through- diagnosis or treatment.
out all stages of the perioperative pathway. TOP 5 The increased demand for these procedures
is a new program developed and piloted by Central has also created opportunities for appropriately
Coast Local Health District in New South Wales in experienced nurses to undertake further training to
conjunction with the Clinical Excellence Commis- become nurse endoscopists, and there has been a
sion (CEC) for the care of dementia patients in the concomitant rise in the number pursing this role
hospital setting (CEC, 2014). This program utilises (see Chapter 1 for further information). Flexible
365
BOX 13-3 » CAUSES AND MANAGEMENT OF PO DELIRIUM

There are several perioperative factors that may precipitate PO delirium:
• perioperative hypotension
• intraoperative blood loss
• electrolyte abnormalities
• PO infection
• malnutrition
• haematocrit <30%.
Management of PO delirium is aimed at preventing or lessening its impact. This is achieved by
frequent, careful assessment, addressing the risk factors and avoiding precipitating factors. Specific
measures to manage PO delirium, should it develop, include:
• providing adequate PO analgesia
• careful drug selection/dosage
• ensuring patients have their sensory aids (e.g. spectacles) and personal belongings
• communicating clearly
• providing consistent nursing care
• managing patients within a multidisciplinary framework.
SOURCE: BODENHAM & EYRE (2013); GRIFFITHS, BRIDGES, SHELDON & THOMPSON (2014); AND WHITE ET AL. (2011).
FIGURE 13-1: Flexible colonoscope

Source: OLYMPUS Australia.
FIGURE 13-2: Dissected flexible endoscope showing the complexity of the internal
structure and design
endoscopic techniques are commonplace in treat- Source: Ball (2015).
ing gastrointestinal (GI) conditions, but their
use goes beyond the GI tract to examine and
treat conditions in nearby organs such as the pan- to visualise the area of the GI tract where the endo-
creas, biliary system and lungs (Jackson, 2015). scope travels and perform screening, surveillance,
Box 13-4 overviews conditions commonly treated diagnostic and therapeutic procedures. Box 13-5
endoscopically. highlights some of these procedures, a few of which
Upper endoscopic examination (oesophagogas- are explored in more detail thereafter.
troduodenoscopy) and colonoscopy are interven-
tions that use flexible endoscopes to provide a DIAGNOSTIC PROCEDURES
portal into the upper and lower GI tract, respec- Endoscopic ultrasound (EUS) combines endoscopy
tively (Jackson, 2015). Consequently, it is possible with ultrasound using a linear or radial endoscope
366
BOX 13-4 » CONDITIONS THAT CAN BE TREATED USING FLEXIBLE ENDOSCOPES

• Gastro-oesophageal reflux disease (GORD)
• Barrett’s oesophagus
• Oesophageal varices
• GI bleeding
• Dysphasia
• Benign and malignant tumours in the GI tract
• Polyps and other pre-cancerous conditions
SOURCE: JACKSON (2015).
BOX 13-5 » ENDOSCOPIC PROCEDURES AND USES

• Take images of the GI tract (e.g. capsule endoscopy; see Fig. 13-3)
• Remove tissue for biopsy (e.g. from oesophageal epithelium or a suspicious lesion)
• Undertake fine-needle aspiration (e.g. of the liver or rectal canal)
• Perform an ultrasound examination (e.g. endoscopic ultrasound)
• Ligate varices (e.g. oesophageal variceal banding; see Fig. 13-4)
• Perform tumour ablation
• Excise lesions (e.g. polyps and superficial carcinomas)
• Undertaken surveillance (e.g. Barrett’s oesophagus and ulcerative colitis)
• Perform staging of GI malignancies
SOURCE: JACKSON (2015), CANCER COUNCIL AUSTRALIA (2014) AND MAYO CLINIC STAFF ( ND ).
depending on the extent of the investigation. This

25 mm Integrated procedure enables Doppler imaging for the evalua-
circuit transmitter tion of blood vessels close to the organs that are
Battery Antenna being examined. A transducer is placed at the distal
Complementary metal oxide
end of the endoscope and high-frequency sound
semiconductor imager waves are emitted to produce detailed images of the
Optical dome
organ being examined. EUS is mainly used for upper
GI work, including the surrounding organs (e.g.
lungs and biliary system), but can also be used else-
where in the GI tract (Jackson, 2015).
MAYO
Endobronchial ultrasound (EBUS) is a procedure
©2015 performed during a bronchoscopy and is similar
to, although newer than, EUS. It is undertaken
Lens for diagnostic purposes and includes an option
to acquire fluid or tissue samples via transbron-
Lens holder
chial needle aspiration (Gilbert, Yarmus & Feller-
Illuminating LEDs Kopman, 2014). This procedure is performed in
many of the larger teaching hospitals within Aus-
FIGURE 13-3: Capsule endoscopy camera tralia, where it is replacing traditional surgical pro-
Source: © Mayo Foundation for Medical Education and Research. All rights reserved. cedures such as thoracoscopy or thoracotomy.
367
Fine-needle aspiration via gastroscopy enables Endomicroscopy and endocytoscopy dramatically

fluid or tissue to be removed for diagnostic exami- expand the imaging capabilities of flexible endos-
nation; organs such as the liver, pancreas and copy because they enable the capture of ‘optical
adrenal glands together with abnormal lymph biopsies’ of nearly any accessible endoluminal
nodes are all accessible using this technique. It has surface. They are used for the detection of dysplasia
90–95% sensitivity for the detection of pancreatic and neoplasia in conditions such as Barrett’s
cancer and, when combined with CT scanning, oesophagus and ulcerative colitis.
identifies regional metastases. This procedure can
be used in conjunction with endoscopic retrograde THERAPEUTIC INTERVENTIONS
cholangiopancreatography (ERCP) to locate gall- There are many therapeutic uses that can be accom-
stones in the common bile duct, as well as to iden- plished using flexible endoscopes, such that they
tify thickening of the lining of the oesophagus or have dramatically expanded the concept of mini-
stomach. Fine-needle aspiration can also be under- mally invasive surgery, as discussed in Chapter 10.
taken during EUS examination of the lower rectum They include:
and anal canal region to identify the pathology
• endoscopic mucosal resection (EMR)
associated with faecal incontinence (Mayo Clinic
Staff, nd; Society of Gastroenterology Nurses and • endoscopic submucosal dissection (EMD)
Associates [SGNA], 2013). • stricture dilation
Confocal laser endomicroscopy and endocystos- • foreign body retrieval
copy are emerging technologies that can be utilised
• palliative stenting of tumours
during an endoscopic procedure; they permit
high-magnification assessment by taking cross- • radiofrequency ablation (RFA)
sectional images of gastrointestinal epithelium. • argon plasma coagulation
This enables a tissue diagnosis without biopsy or • photodynamic therapy
histopathology. That is, this technology provides
high-resolution histology at a cellular and sub- • LASER treatment (Jackson, 2015).
cellular level, and in real time (Meining, 2015). • oesophageal variceal banding (see Fig. 13-4).
Scope
Rubber Band
Ligation System®
Banded
varices
C
A B
FIGURE 13-4: Oesophageal variceal banding. A, Endoscope with band ligators on tip; B, banded oesophageal varices; C, corresponding endoscopic image
Source: C, I.-Tsung Lin et al. (2008). Copyright © 2008 American Society for Gastrointestinal Endoscopy.
368
Feature box 13-4 explores one of these interven- DIAGNOSTIC AND INTERVENTIONAL
tions. Other treatment modalities and interven- ENDOVASCULAR PROCEDURES
tions continue to be researched and one such Advances in imaging techniques and interventional
approach, natural-orifice transluminal endoscopic procedures are aggressively embraced by cardiolo-
surgery (NOTES), is reviewed in Research box 13-1. gists, and vascular and cardiothoracic surgeons
A recent advance in flexible endoscopic technology, (Schaadt & Landau, 2013). Many of these thera
the Medigus ultrasonic surgical stapler (MUSETM), peutic interventions are now seen routinely in
is presented in Research box 13-2. angiography and radiology departments. In some
FEATURE BOX 13-4 » ENDOSCOPIC MUCOSAL RESECTION
Endoscopic mucosal resection was originally pioneered by the Japanese to treat gastric cancer,
but it is now used to diagnose and treat a range of GI lesions (Greenwald, nd). These include the
treatment of various upper GI tract carcinomas (both diagnostic and curative uses) and Barrett’s
oesophagus, as well benign lesions or early-stage adenocarcinoma in the colon. Use of EMR in
the colon is an alternative technique for those patients who refuse surgical resection or have
significant comorbidities (Haidry et al., 2014). However, when the procedure is performed in the
colon there is a substantial rate of complications and this necessitates having emergency equip-
ment on hand should bleeding occur (e.g. thermostatic clips, endoscopic injection needles and
adrenaline solution). Other complications include non-controlled bleeding, perforation, the devel-
opment of strictures (reported in approx. 6% of patients) and transient bacteraemia in the colon.
The patient may require further intervention for these complications, necessitating an overnight
stay in hospital. As with many procedures, careful patient selection and extensive preoperative
work-up are absolutely crucial.
Only highly proficient gastroenterologists/surgeons should perform EMR because it requires addi-
tional training. This can be provided only in centres that perform large numbers of such interven-
tions. This is confirmed by a small survey conducted by the Gastroenterological Nurses College of
Australia (GENCA), which identified that EMR is performed in fewer than 40% of responding depart-
ments (Bull, 2010).
For a video file of this procedure, see Brickhov (2014).
RESEARCH BOX 13-1: Natural-Orifice Transluminal Endoscopic Surgery
The development of natural-orifice transluminal endoscopic surgery is one of the most significant innova-
tions in surgery since the appearance of laparoscopic surgery and its use has increased significantly in
the past decade. The procedure involves removal of internal organs via the mouth, urethra, vagina or
rectum. The areas with the most promising clinical application include direct-target NOTES, such as
transanal total mesorectal excision and perioral endoscopic myotomy. The clinical experiences with
distant-target NOTES, such as for appendectomy and cholecystectomy, show feasibility; however, these
are associated with NOTES-specific morbidity and this represents an important limitation. The procedure
is performed with the use of a flexible endoscope, specially designed knives/balloon and, more recently,
robotics (Atallah, Martin-Perez, Keller, Burke & Hunter. 2015). As technical limitations are overcome, the
clinical application of NOTES is predicted to increase. For a video clip of a natural-orifice transluminal
endoscopic cholecystectomy procedure, see Carlson (2013).
369
RESEARCH BOX 13-2: Medigus Ultrasonic Surgical Endostapler
The Medigus ultrasonic surgical endostapler is a new instrument that allows a gastroenterologist working
alone to perform a transoral anterior fundoplication to treat GORD, avoiding an abdominal incision. It
comprises:
~ a flexible surgical endostapler
~ standard titanium surgical staples
~ video capabilities
~ ultrasonic sight (see Fig. 13-5)
~ digital console (Medigus, nd).
The stapler is guided by ultrasound to determine when a proper stapling gap has been achieved. The
procedure is an option for patients looking to reduce or discontinue GORD medication therapy and avoid
the problematic side effects associated with incisional approaches. However, long-term follow-up is
required to establish its safety and efficacy (Zacherl et al., 2015).
To watch a video of this procedure, see www.medigus.com/healthcare-professional/muse-system-videos.
For a more detailed presentation, see Bowman (2013).
(Schaadt & Landau, 2013). (See Chapter 5 for more

Distal tip
information on hybrid ORs.) Box 13-6 highlights
Insufflation some diagnostic and interventional endovascular
procedures and several are explored in more detail
Suction thereafter.
Illumination
TRANSOESOPHAGEAL ECHOCARDIOGRAM
Miniature Alignment Transoesophageal echocardiogram (TOE) is a pro-
camera pin cedure similar to that of EUS (see Fig. 13-6). It
comprises passing a flexible probe (similar to
a bronchoscope) down the oesophagus, which,
because it incorporates an ultrasound at the tip,
provides Doppler readings that give clear views of
the heart muscle, valves and pericardium. The
patient is fasted as for gastroscopy and sedation is
used during the procedure for the patient’s comfort.
This test is useful for the detection of blood clots,
Ultrasound masses/tumours, infection, tears or congenital
heart diseases (Abdulla, nd). For more information
about TOE, see British Heart Foundation (2014).
Irrigation Stapling anvil
RADIOFREQUENCY ABLATION TO TREAT
Anvil screw ATRIAL FIBRILLATION
FIGURE 13-5: Medigus ultrasound surgical endostapler Cardiac catheter ablation is used for the treatment
Source: © Medigus.
of symptomatic atrial fibrillation (AF) when phar-
macological interventions have been unsuccessful.
new facilities and hospitals that have redeveloped It is also a valid treatment for heart failure and/or
their operating suites these procedures take place reduced ejection fraction. Patient selection requires
in a hybrid (or interventional) operating room that extensive and careful assessment taking into con-
incorporates the necessary radiological equipment sideration age, left atrial size, the presence of
370
BOX 13-6 » DIAGNOSTIC AND INTERVENTIONAL ENDOVASCULAR PROCEDURES

• Ablations (e.g. atrial fibrillation)
• Angiography (e.g. coronary artery)
• Coiling (e.g. aneurysms)
• Diagnostic (e.g. transoesophageal echocardiogram)
• Dialysis (e.g. grafts, repairs of AV fistulae)
• Embolisations (e.g. pulmonary [and other] vessels)
• Thrombectomy and thrombolysis (e.g. dialysis grafts)
• Stents (angioplasty) (e.g. renal, pelvic arteries).
SOURCE: JACKSON (2015), KALMAN ET AL. (2013) AND KAUFMAN (2014a, 2014b).
Oesophagus
Sound
waves
TOE
transducer
Heart
FIGURE 13-6: Transoesophageal echocardiogram (TOE)

Source: Kaplan, Reich & Savino (2011).
structural heart disease and the duration of AF et al., 2013). Cryoablation is an alternative energy
(Kalman et al., 2013). Patients are fasted and source; however, the results using this modality
sedated as for TOE. The pulmonary veins are known have been inconsistent. The main complication of
to be a dominant source of AF initiation and are this procedure is thrombus formation; other com-
targeted during the ablation. To be successful, the plications include:
procedure requires full-thickness ablation of the • haematoma
atrial myocardium and uses radiofrequency energy
to achieve this outcome. It is necessary to repeat • thromboembolic events
the procedure in one-third of patients (Kalman • tamponade
371
• valvular injury
• pulmonary vein stenosis
TABLE 13-1: Stent features
• phrenic/gastric nerve injury Metal Stainless steel, nitinol, Elgiloy,

tantalum, platinum
• atrio-oesophageal fistula (Kalman et al., 2013).
A TOE examination is considered mandatory Construction Laser-cut, welded, woven, wire spring,
sutured
prior to or concurrent with the procedure. Anti
coagulation therapy is recommended for 1–3 Deployment Balloon expanded, elastic recoil,
months post-procedure in conjunction with thermal memory
antiarrhythmic drugs. Follow up at 5 years reveals
Precision of Stent design, deployment technique
a 63–82% success rate. deployment
Many organs within the body can be subjected
Hoop strength Stent design, type of metal
to ablation therapy as a means to treat malignancy
and may be offered to patients who are non- Flexibility Stent design, construction, type of
responsive to systemic chemotherapy or local radi- metal
ation (Beland & Mayo-Smith, 2014). These ablations Radio-opacity Type of metal, coatings, markers
may be chemical, or use radiofrequency energy or
cryoablation. Newer modalities include microwave Size Diameter and length before and after
ablation, interstitial laser photocoagulation and deployment
high-intensity focused ultrasound (the latter on the Drug eluting E.g. paclitaxel heparin, dexamethasone
brain). For more information about this procedure,
see JAMA Network (2014). Delivery French size, flexibility, guidewire
system requirements
STENTS (ANGIOPLASTY) Regulatory Government approval for vascular and
Stents are used primarily to widen the lumen into status non-vascular use
which they are being placed and they have wide SOURCE: KAUFMAN (2014b).
application in the body (Kaufman, 2014b). There
are many different types of stents and their fea-
tures vary (note: non-vascular use was reviewed For an overview of various endovascular approaches
earlier). Table 13-1 identifies the many and varied to the management of blocked arteries see Doctor
features of deployable stents, including the manner Klioze (2012).
in which they are manufactured and deployed into
the body and the materials from which they are PREOPERATIVE PATIENT
made. Some stents are impregnated with specific PREPARATION
drugs for treatment purposes and they are all regu-
lated by the Therapeutic Goods Administration The delivery of high-quality care, tailored to meet
(TGA) in Australia. the individual patient’s needs is challenging for
perioperative nurses. This is due to the number of
The indications for using stents in the aorta or
patients admitted on any given day, as well as the
iliac arteries include:
processes associated with their management. Expe-
• failed angioplasty rienced day surgery nurses work hard to ensure that
• common iliac artery origin lesion they prioritise patient care and make time for
meaningful interactions with their patients despite
• recurrent stenosis the time pressures that may be present in ambula-
• anastomotic stenosis tory care settings.
• occlusive dissection of flap Patient preparation and the pre-admission
• recanalisation following total occlusion process are of extreme importance and are dis-
cussed in Chapter 7. However, these topics are
• ulcerated plaque re-examined here in the context of specific preop-
• planned distal revascularisation procedure erative preparation associated with endoscopy and
(Kaufman, 2014a). other image-guided interventions. Understanding
372
the criteria, and the preoperative preparation and instead of all the preparation being taken the
care of different patient groups in the ambulatory evening beforehand, patients may ingest half the
care setting, is important if positive patient out- dose the evening prior to admission and the other
comes are to be achieved. half very early on the day of their procedure. This
split dosing is better tolerated by patients (Riegert
PREPARATION FOR FLEXIBLE & Nandwani, 2014) and produces significant
ENDOSCOPIC PROCEDURES improvement in bowel cleansing.
Some procedures have unique and specific preop- The importance of good bowel preparation
erative preparation requirements. Patients attend- cannot be over-stressed: when it is achieved pro
ing ambulatory care for flexible endoscopic cedure time is shortened and the benchmark of
procedures are required to fast for a longer period being able to reach the caecum is attained more
than is otherwise normally the case and to com- often. In addition, abnormal pathology is more
plete bowel preparation. This preparation may need easily found and patients do not need to undergo a
to commence several days prior to the procedure. repeat colonoscopy. In the absence of satisfactory
Some patients find the long fasting from food a bowel preparation, good visualisation of the bowel
major challenge. Copious amounts of clear fluids is not possible, the procedure time is lengthened
are also required for those patients having a colon- and the risk of misdiagnosis or overlooking patho-
oscopy or a flexible sigmoidoscopy; even patients logical abnormalities increases (Riegert & Nand-
having a virtual colonoscopy will be required to wani, 2014).
follow this preparation regimen as well. There are Enemas are most often given to patients having
several types of bowel preparation available and a flexible sigmoidoscopy (Jackson, 2015). However,
proceduralist preference determines which is used. these can be very embarrassing for patients and the
Isosmotic solutions containing polyethylene glycol provision of a private area is essential. Appropriate
(PEG) and electrolytes (e.g. sodium bicarbonate, education prior to performing this procedure is also
sodium chloride) are marketed for use before GI necessary.
procedures (Bryant & Knights, 2015). Commonly
used powders of this type include Glycoprep and Endoscopy patients are frequently advised not
Moviprep. A similar preparation but containing to cease taking anticoagulants because the prac-
sodium picosulfate, magnesium and citric acid tice of removing lesions, such as polyps, without
(Picoprep) is an alternative. Enemas may also be using cautery (‘cold snaring’) is becoming much
used (Jackson, 2015). more commonplace (Hewett, 2013). However, it is
important for the admitting nurse to ascertain
Glycoprep is usually taken in large amounts of from patients if they have been taking natural
fluids, 3–4 L, which patients may find difficult to remedies such as fish/krill oil, as these need to be
manage. However, it is safe to use for the elderly discontinued prior to the procedure (they have
and does not result in electrolyte imbalance (Bryant natural anticoagulation properties). If they have
& Knights, 2015). A combined preparation of not been discontinued, the nurse must ensure that
2 glasses (500 mL) of Glycoprep plus Picoprep has this information is relayed to staff within the pro-
been found to be more manageable. One packet of cedure room.
Picoprep is usually consumed in one glass of fluid
(250 L); however, many patients find the taste of PREPARATION FOR ENDOVASCULAR
this more unpleasant than that of the Glycoprep. PROCEDURES
Picoprep works more rapidly and has a cathartic Preoperative preparation for patients undergoing
effect as it works by osmosis on the gut wall, causing endovascular procedures largely follows the process
a shift in electrolytes. This shift is often identified outlined in Chapter 7. However, there are several
when patients complain of a headache or light- specific pre-procedure requirements for these
headedness (Bryant & Knights, 2015). Anecdotally, patients and they include:
patients who are provided with a litre of intra
venous (IV) fluids during/post-procedure feel better • ECG
than they did when they were admitted. • a chest X-ray, which is frequently ordered for
A more recent development related to bowel patients undergoing cardiac angiography
preparation is that of split dosing. This means that • full blood count and coagulation studies
373
BOX 13-7 » POST-PROCEDURE CARE FOLLOWING CARDIAC CATHETERISATION VIA

FEMORAL ARTERY
• Ensure the patient remains flat initially, as per unit protocol.
• Frequently assess the circulation to the limb used for the catheter insertion.
• Check distal pulse, colour, sensation and temperature of limb used for catheter insertion as per unit
protocol; for example 1 4-hourly (1 hour), 1 2-hourly (2 hours) and 6-hourly until discharge.
• Observe the puncture site for haematoma and bleeding; for example, 1 4-hourly (1 hour), 1 2-hourly
(1 hour) and 1-hourly (2 hours).
• Monitor vital signs and ECG as per unit protocol.
• Assess for hypotension or hypertension, arrhythmias and signs of pulmonary emboli.
• Encourage the patient to drink large amounts of fluid to counteract the dehydration caused by the
use of contrast medium, which has a diuretic effect.
• If bleeding occurs, place a compression device over the arterial site to achieve haemostasis and
seek medical assistance. Maintain the pressure for 15 minutes and instruct the patient to keep the
limb still.
Note: The amount of sedation and analgesia given, vital signs, pain level and the status of the puncture
site will determine the recovery period and monitoring requirements.
SOURCE: KAUFMAN (2014b) AND SCHAADT (2015).
• shaving the right and left groin regions 2014b). Box 13-7 outlines the post-procedure care
• baseline recording of peripheral pulses of a patient following cardiac catheterisation via
femoral artery.
• unless specified by the anaesthetist, the IV
cannula is sited in the left arm (if possible) Other procedure-specific observations must
(Kaufman, 2014c; Schaadt, 2015). also be instigated. Once the patient has regained
consciousness, is haemodynamically stable and, if
appropriate, has a surgical site that is stable, she or
POSTOPERATIVE NURSING CARE he can be transferred to stage 2 (step-down) recov-
FOLLOWING ENDOSCOPIC AND ery. In stage 2 recovery the patient is awake, has
ENDOVASCULAR PROCEDURES minimal pain or nausea and is breathing effectively
on room air. Additionally, vital signs are stable
Postoperative patient care depends on the nature and reflect pre-intervention recordings (+/− 20%)
of the procedure and whether this was performed (ANZCA, 2010), and if appropriate, there is no evi-
under general, regional or local anaesthesia, or pro-
dence of bleeding or other procedural-specific
cedural sedation. Patients who have received a
sequelae (Odom-Forren, 2015; Rice, Muckler, Miller
general anaesthetic need to be cared for in stage 1
& Vacchianp, 2015).
recovery (Langton, 2013), as described in Chapter 12.
In addition to routine observations, patients who Modern anaesthesia techniques that include the
have undergone endoscopic procedures need to be use of drugs such as midazolam or propofol, with
observed for haemorrhage, distension or a rigid or without analgesia (e.g. fentanyl, non-steroidal
abdomen, breathing difficulty and excessive pain, anti-inflammatory drugs given pre- or intraopera-
as these could indicate an adverse event such as tively) result in rapid recovery with minimal PO
bowel perforation (Jackson, 2015; SGNA, 2013). sequelae (ANZCA, 2014; Langton, 2013). More than
Patients who have undergone an endovascular 15 years ago this led to the development of fast
procedure need the puncture site monitored for tracking, whereby patients bypass stage 1 recovery
signs of swelling or haemorrhage, and the distal and proceed directly from the OR to stage 2 recov-
pulses should be palpated frequently (Kaufman, ery (Odom-Forren, 2015; Rice et al., 2015). (See
374
BOX 13-8 » DISCHARGE CRITERIA FOR AMBULATORY CARE PATIENTS

• Stable vital signs for at least 1 hour
• Oriented in time, place and person
• Adequate pain control
• Minimal nausea, vomiting or dizziness
• Adequate oral hydration
• Minimal bleeding or wound drainage
• Able to pass urine
• Responsible carer
• Discharge authorised by an appropriate member of staff
• Suitable analgesia provided
• Written and verbal instructions given (to patient and carer)
• Any required teaching completed (for patient and carer)
• The patient’s readiness for discharge is confirmed
SOURCE: LANGTON (2013) AND ODOM - FORREN (2015).
Chapter 8 for more information on anaesthesia

drugs and techniques.)
PATIENT SAFETY AND RISK
In stage 3 recovery, the patient is ambulant,
MANAGEMENT
functioning at or near the preoperative level and An important risk management strategy, and as
ready for discharge home. Box 13-8 displays typical part of the accreditation process, it is essential that
discharge criteria for day surgery patients. Indi- day surgery, endoscopy and angiography facilities
vidual ambulatory care settings may develop dis- regularly evaluate performance, clinical outcomes
charge criteria that are specific for their caseload. and staff/patient satisfaction, and use the findings
Figure 13-7 is an example of the discharge informa- to improve patient safety and care delivery. The
tion given to patients who have had an angiogram. Australian Council on Healthcare Standards identi-
In some ambulatory settings, policies and protocols fies the clinical indicators that must be monitored
have been developed that underpin and direct in all ambulatory care settings, namely:
nurse-initiated discharge. • cancellation of booked procedures
• unplanned return to the operating room
POST-DISCHARGE
• unplanned transfer (or overnight admission)
Within 24 hours of discharge home, all ambulatory
care patients should receive a telephone call from • delayed discharge
the unit nurse to check that they are progressing • the incidence of aspiration
as anticipated and coping satisfactorily (ANZCA,
• the incidence of perforation (ACHS, 2012c).
2010). They should also be afforded the opportunity
to ask and have any questions answered (Langton, These are endorsed by the Australian Day Surgery
2013). Follow-up calls should be documented and Council (ADSC) (Adams, 2014), along with other
evaluated as part of the unit/facility quality ACHS indicator sets, which specifically relate to
improvement and risk management program anaesthesia, endoscopy, ophthalmology and oral
(ACHS, 2012a, 2012b; ACSQHC/the Commission, health. Note: the work of the ACHS complements
2012). the National Standards (ACHS, 2013).
375
GENERAL DISCHARGE INFORMATION POST-ANGIOGRAM
1. Remove adhesive dressing, applied post-procedure immediately during showering

the next day.
2. Do not sit in a bathtub or pool for 5 days or until wound has healed.
3. Gently clean site using soap and water. Dry thoroughly.
4. You may apply antibacterial ointment such as Betadine, otherwise cleaning with
soap and water is sufficient. DO NOT apply powders or lotions.
5. Resume normal activity in 2 days, including driving.
6. DO NOT lift over 5 kilograms for a week or until wound is healed.
7. Soreness or tenderness may last a week.
8. Bruising could last 2 weeks.
9. There may be formation of a small lump, which could last up to 6 weeks.
10. Please call your doctor if any of the following symptoms occur:
a. Any ooze or bleeding from wound site.
b. Increased swelling around groin area or leg.
c. Unusual pain at groin or down the leg.
d. Any signs of infection:
i. Redness
ii. Warmth to touch
iii. Poorly healing wound
iv. Fever and chills
Nursing/DaySurgery/VMOs/General Discharge Post-Angiogram
FIGURE 13-7: Day patient discharge sheet post-angiogram

Source: Mater Hospital, Sydney.
A robust system of investigating and analysing supervision of the cleaning and care of flexible
incidents and complaints, along with prompt endoscopes. Due to the high risk of cross-
implementation of corrective measures, is essential contamination during the reprocessing of these
in order to improve patient outcomes and safety. instruments, staff engaged to perform this task
These activities are also mandatory (ACSQHC/the must be educated and trained and have demonstra-
Commission, 2012) (see Chapter 3 for further infor- ble competency (American Society for Gastrointes-
mation about the National Standards). A culture of tinal Endoscopy [ASGE], 2011; Association of
reporting incidents and mishaps in a blame-free periOperative Registered Nurses [AORN], 2015;
environment is crucial, and staff education to rein- Gastroenterological Society of Australia [GESA],
force this approach may be needed. Gastroenterological Nurses College of Australia
[GENCA], Australian Gastrointestinal Endoscopy
Association [AGEA], 2010). Most breaches of infec-
CARE OF ENDOSCOPY EQUIPMENT tion control occur as a result of inadequate clean-
One aspect of nursing practice particularly preva- ing of flexible endoscopes and accessories (GESA/
lent in endoscopy and angiography settings is GENCA/AGEA, 2010; Spry, 2015).
376
Technological advances over the past 5 years 2015; GESA/GENCA/AGEA, 2010) and microbiologi-
have resulted in the development of fully auto- cal testing for biofilm growth remains the gold
mated reprocessing systems, which have released standard in Australia (GESA/GENCA/AGEA, 2010).
staff from having to undertake some aspects of Following sterilisation (e.g. with peracetic acid)
endoscope cleaning prior to sterilisation or high- or high-level disinfection and the use of blown
level disinfection. This is because many of these
washer/disinfecting machines are capable of repli-
cating all of the manual steps once performed by
central sterilising department (CSD) or nursing
staff (see Fig. 13-8). While this has been a positive
development overall, the need to oversee the
process cannot be relinquished. Nursing staff are
still required to undertake some activities, such
as passing a brush down the channel to check
for patency or to ascertain the subtle nuances asso-
ciated with minor damage/kinking of the endo-
scope, post-cleaning. Failure to complete this
activity has been identified by GENCA as a matter
of significant concern, with reports of haemostatic
clips being retained within the endoscope channel.
Feature box 13-5 details two incidents highlighted
by the TGA.
GENCA has addressed the issue of educational
requirements for staff who are engaged to clean
and reprocess flexible endoscopes. A yearly require-
ment to complete an online learning package is
recommended and can be sourced through its
website. Validation of adequate cleaning methods FIGURE 13-8: Automated endoscope reprocessor
should be performed on a scheduled basis (AORN, Source: © 2016 MEDIVATORS Inc. All rights reserved.
FEATURE BOX 13-5 » TGA MEDICAL DEVICE SAFETY ALERT
Two incidents reported to the TGA in 2014 highlight issues with items being left behind in endo-
scopes despite multiple instances of cleaning and sterilisation. In one incident a small metal clip
was flushed out of a colonoscope during cleaning. However, the same type of clip had been used
with the colonoscope 5 days earlier. It is thought that the clip had been sucked into the device’s
internal biopsy channel during surgery and become lodged inside. The manufacturer could not
rule out that the facility performed insufficient reprocessing or did not perform a biopsy channel
inspection before or after use.
In the second incident, a 3-cm pancreatic stent was removed from a patient using a duodenoscope,
but was noted not to have exited the device. Despite undergoing normal cleaning, brushing and
leak testing, the stent remained inside. Over the next 5 days, four patients underwent procedures
using this duodenoscope after it was cleaned and sterilised in the usual manner. The stent came
out of the scope during the fourth procedure.
To help avoid incidents such as these, health facilities are advised to ensure that appropriate
education is in place for staff cleaning and sterilising endoscopes. These incidents also highlight
the importance of following manufacturers’ instructions carefully (ASGE, 2011; AORN, 2015; GESA/
GENCA/AGEA, 2010).
377
hospital grade air and 70% alcohol to dry flexible 2010). Further information on endoscope reproc-
endoscopes, it is necessary to store them appropri- essing is available via a link provided in the ‘Video
ately, to reduce the risk of recontamination (ASGE, resources’ section at the end of the chapter.
2011; GESA/GENCA/AGEA, 2010). When not in use,
they should be stored in purpose-built, well-
ventilated cabinets that allow for good airflow
CONCLUSION
around the endoscopes. They should never be This chapter has explored a range of surgical and
stored within a box or suitcase while still wet. procedural care delivery environments that have
Endoscopes can be stored horizontally; however, evolved from the traditional operating suite to
there must be continuous airflow throughout the encompass other hospital departments, such as
channels while in storage (GESA/GENCA/AGEA, radiology and angiography suites, and dedicated,
2010). The length of time endoscopes can be stored short-stay/ambulatory surgical units. The number
without the need to reprocess before subsequent of independent, freestanding day surgery and
use is controversial, with recommendations ranging endoscopy centres has grown rapidly; these changes,
from 5 days (AORN, 2015) to 10 days (ASGE, 2011). which have been driven by increasing demand and
However, endoscopes that are used in high-risk the need for cost containment, have also been facili-
cases (e.g. bronchoscopy, EUS, TOE, cystoscopy tated by the explosive growth in technological capa-
and ERCP) need to be processed prior to use and bility. It has not been possible in such a small
subsequently used within 12 hours. (See Chapter 6 compass to do other than provide a mere glimpse of
for further information on infection control meas- some of the thousands of procedures that can now
ures.) Documentation continues to be a crucial be undertaken in these newer settings and elude to
aspect of endoscope care (GESA/GENCA/AGEA, what these mean for patients and their care.

1. Day surgery admission criteria
You are precepting a third-year undergraduate student nurse and together you admit a 75-year-old
man, Mr Suggerarman, to your ambulatory care unit for a pelvic angiogram. The student nurse
expresses surprise that a patient of this age is deemed suitable for a day-only procedure.
• Explain why it may be appropriate for Mr Suggerarman to be admitted as a day patient. Provide
rationales for your answers.
2. Caring for a bariatric patient
Ms Rawinia Wharekawa, a patient for bariatric surgery, exhibits anxiety as you complete her admis-
sion. She is afraid that she might develop a blood clot and is concerned about the resources your unit
may or may not have to avoid this complication. She is also anxious about ‘the looks’ she claims she
has been getting from other patients in the waiting room, as well as from one member of staff.
• What measures can you take regarding Ms Wharekawa’s fear of VTE? Provide rationales for
your answers.
• How will you manage her anxiety about the reactions she claims she is getting from those
around her? Provide rationales for your approach.
3. Care of endoscopic equipment
During a routine colonoscopy examination, a large polyp was found and successfully removed; however,
several haemo clips were required intraoperatively to control haemorrhage.
• What actions are required of staff during the cleaning of the endoscope if a fully automated
process is implemented in your endoscopy unit? Provide rationales for each of the suggested
staff actions.
378
4. Post-procedure discharge criteria and education following endovascular intervention

You are preparing Mr Youssef Abidi, a 59-year-old patient who has undergone a right-sided cardiac
catheterisation procedure, for discharge home from stage 3 recovery in your facility.
• What criteria must be met before he can leave the unit? Provide rationales for your answer.
• What information and education will Mr Abidi and his carer (his wife) need to manage his
recovery post-discharge? Provide rationales for your suggested teaching plan.
Abdulla, A. M. (nd). TEE or transesophageal echo. Retrieved
Ambulatory Surgery Journal of the International from <www.heartsite.com/html/tee.html>.
Association for Ambulatory Surgery
www.iaas-med.com/index.php/home Adams, W. (2014). Australian Day Surgery Council Inc. (ADCS)
chair’s report, 2013. Retrieved from <www.adsc.org.au/
Australian and New Zealand College of Anaesthetists 2013-report>.
www.anzca.edu.au
Al-Benna, S. (2011). Perioperative management of morbid
Australian Day Surgery Nurses Association obesity. Journal of Perioperative Practice, 21(7), 225–233.
www.adsna.info
American Society for Gastrointestinal Endoscopy (ASGE).
Australian national cancer screening programs (2011). Multisociety guideline on reprocessing flexible gas-
www.cancerscreening.gov.au trointestinal endoscopes. Gastrointestinal Endoscopy, 73(6),
British Association of Day Surgery 1075–1084. doi:10.1016/j.gie.2011.03.1183.
www.bads.co.uk Association of periOperative Registered Nurses (AORN).
Endonurse (2015). Guidelines for perioperative practice: Guideline for
www.endonurse.com cleaning and processing flexible endoscopes and endoscope
accessories. Denver, CO: Author.
Gastroenterological Nurses College of Australia
www.genca.org Atallah, S., Martin-Perez, B., Keller, D., Burke, J., & Hunter, L.
(2015). Natural-orifice transluminal endoscpic surgery.
Gastroenterological Society of Australia British Journal of Surgery, 102, e73–e92. doi:10.1002/
www.gesa.org.au bjs.9710.
Joanna Briggs Institute Australian and New Zealand College of Anaesthetists
www.joannabriggs.edu.au (ANZCA). (2010). PS15: Recommendations for the perioperative
Perioperative Nurses College of the New Zealand Nurses care of patients selected for day care surgery. Retrieved from
Association <www.anzca.edu.au/resources/professional-documents>.
www.nzno.org.nz/groups/colleges/ Australian and New Zealand College of Anaesthetists
perioperativenursescollege (ANZCA). (2014). PS09: Guidelines on sedation and/or analge-
Royal Australasian College of Surgeons sia for diagnostic and interventional medical, dental or surgical
www.surgeon.org procedures. Retrieved from <www.anzca.edu.au/resources/
Society for Ambulatory Anesthesia professional-documents>.
www.sambahq.org Australian Bureau of Statistics (ABS). (2007). Private hospi-
Society for Vascular Nursing tals, Australia 2005–2006. Cat. no. 4390.0. Canberra: Author.
www.svnnet.org Australian Bureau of Statistics (ABS). (2014). Private hospi-
Society of Gastroenterology Nurses and Associates tals, Australia 2012–2013. Cat. no. 4390.0. Retrieved from
www.sgna.org <www.abs.gov.au/AUSSTATS/[email protected]/Latestproducts/
DDCBC0700038DAEACA257D0400128B96?opendocument>.
Australian Commission on Safety and Quality in Health
VIDEO RESOURCES Care (ACSQHC/the Commission). (2012). National Safety and
Queensland Health Centre for Healthcare-related Quality Health Service Standards. Sydney: Author. Retrieved
Infection Surveillance and Prevention (CRISP). (2014, 5 from <www.safetyandquality.gov.au>.
June). Endoscopy reprocessing Australian Council on Healthcare Standards (ACHS). (2012a).
www.health.qld.gov.au/EndoscopeReprocessing/default.asp EQuIP National Guidelines: Standard 12: Provision of care.
or www.genca.org Sydney: Author.
Radiopaedia. (nd). About radiopaedia [an online radiology Australian Council on Healthcare Standards (ACHS). (2012b).
reference and teaching site] EQuIP National Guidelines: Standard 11: Service delivery.
http://radiopaedia.org/about Sydney: Author.
379
Australian Council on Healthcare Standards (ACHS). (2012c). Crouch, A. (2012). Implementing Standard 2: Partnering with
EQuIP 5 day procedure centres standards and guidelines. consumers from a single speciality day surgery perspective.
Retrieved from <www.achs.org.au/publications-resources/ Day Surgery Australia, 11(3), 18–19.
equip5-day-procedure-centres>. De Melo, E. (2013). Paediatric anaesthesia. In A. R. Aitken-
Australian Council on Healthcare Standards (ACHS). (2013). head, I. K. Moppett, & J. P. Thompson (Eds.), Smith and Aitken-
Programs & services. Retrieved from <www.achs.org.au/ head’s textbook of anaesthesia (6th ed., pp. 731–750).
programs-services>. Edinburgh: Churchill Livingstone.
Australian Day Surgery Nurses Association (ADSNA). (2013). Doctor Klioze. (2012, 9 October). Repairing a blocked artery
Best practice guidelines for ambulatory surgery and proce- [Video.] Retrieved from <https://www.youtube.com/watch?v
dures. Osborne Park, WA: Cambridge Publishing. =Bg6UQTMqQGc>.
Australian Department of Health and Ageing (ADHA). (2013). Gagnon, E. L., & Karwacki Sheff, E. J. (2012). Outcomes and
National Aboriginal and Torres Strait Islander health plan, complications after bariatric surgery. American Journal of
2013–2023. Canberra: Author. Nursing, 112(9), 26–36.
Australian Institute of Health and Welfare (AIHW). (2013a). Gastroenterological Society of Australia (GESA), Gastroen-
Australian hospital statistics 2011–12. Retrieved from terological Nurses College of Australia (GENCA), Australian
<www.aihw.gov.au/publication-detail/?id=60129543133>. Gastrointestinal Endoscopy Association (AGEA) [GESA/
GENCA/AGEA]. (2010). Infection control in endoscopy (3rd ed.).
Australian Institute of Health and Welfare (AIHW). (2013b).
Melbourne: GESA.
Australian hospital statistics, 2012–13. Elective surgery
waiting times. Retrieved from <www.aihw.gov.au/ Gilbert, C. R., Yarmus, L., & Feller-Kopman, D. (2014). Educat-
publication-detail/?id=60129544692>. ing the next generation of pulmonary fellows in transbron-
chial needle aspiration. Leading the blind to see. Annals of
Beland, M. D., & Mayo-Smith, W. W. (2014). Image-guided
the American Thoracic Society, 11(5), 828–832. doi:10.1513/
tumor ablation: Basic principles. In J. A. Kaufman & M. J. Lee
AnnalsATS.201403-112OI.
(Eds.), Vascular and interventional radiology (2nd ed., pp.
547–553). Philadelphia: Elsevier Saunders. Greenwald, B. D. (nd). Endoscopic mucosal resection. Retrieved
from <http://emedicine.medscape.com/article/1891659
Bodenham, A., & Eyre, L. (2013). The intensive care unit. In
-overview>.
A. R. Aitkenhead, I. K. Moppett, & J. P. Thompson (Eds.), Smith
and Aitkenhead’s textbook of anaesthesia (6th ed., pp. 902– Griffiths, P., Bridges, J., Sheldon, H., & Thompson, R. (2014).
931). Edinburgh: Churchill Livingstone. The role of the dementia specialist nurse in acute care:
a scoping review. Journal of Clinical Nursing, 23(3–4),
Bowman, T. A. (2013, 13 September). Transoral incisionless
doi:10.1111/jocn.12717.
fundoplication [Video.] Retrieved from <https://www
.youtube.com/watch?v=1QWKvDNsn40>. Haidry, R. J., Butt, M. A., Dunn, J. M., Gupta, A., Lipman, G.,
Smart, H. L., et al. (2014). Improvement over time in out-
Brickhov, I. (2014, 6 March). Endoscopic mucosal resection
comes for patients undergoing endoscopic therapy for
[Video.] Retrieved from <https://www.youtube.com/watch?v
Barrett’s oesophagus-related neoplasia: 6-year experience
=vUoS8Qf_5x0>.
from the first 500 patients treated in the UK patient registry.
British Heart Foundation. (2014, 14 August). Your guide to Gut Journal Online, doi:10.1136/gutjnl-2014-308501.
TOE (transoesophageal echocardiogram): heart disease test
Health & Disability Commissioner (Te Toihau Hauora Haua-
[Video.] Retrieved from <https://www.youtube.com/watch
tanga). (2014). The code of health and disability services
?v=X_E9HqXHFSA>.
consumers’ rights. Wellington: Author. Retrieved from <www
Bryant, B., & Knights, K. (2015). Pharmacology for health .hdc.org.nz>.
professionals (4th ed.). Sydney: Mosby Elsevier.
Hewett, D. G. (2013). Colonoscopic polypectomy current
Bull, J. (2010). Who are your neighbours and what are they techniques and controversies. Gastroenterological Clinics of
doing? Outcomes of a nationwide survey of facilities offer- North America, 42(3), 443–458.
ing gastrointestinal services. Journal of the Gastroenterologi-
International Association for Ambulatory Surgery & Euro-
cal Nurses College of Australia, 20(2), 13–17.
pean Agency for Consumers and Health (IAAS/EU). (2013).
Cancer Council Australia. (2014). Clinical practice guidelines Policy brief: Day surgery as the new paradigm of surgery
for the diagnosis and management of Barrett’s oesophagus and best practices and recommendations. Retrieved from <www
early oesophageal adenocarcinoma. Retrieved from <http:// .daysafe.eu>.
wiki.cancer.org.au/australia/Guidelines:Barrett%27s>. Jackson, D. (2015). Gastrointestinal surgery. In J. Rothrock &
Carlson, M. (2013, 18 July). Natural-orifice transluminal endo- D. McEwen (Eds.), Alexander’s care of the patient in surgery
scopic cholecystectomy (NOTES) [Video.] Retrieved from (15th ed., pp. 295–349). St Louis: Elsevier Mosby.
<https://www.youtube.com/watch?v=cQP6MFg6h-o>. JAMA Network. (2014, 13 May). Pulmonary vein radiofre-
Clinical Excellence Commission (CEC). (2014). TOP 5: Improv- quency catheter ablation therapy for atrial fibrillation [Video.]
ing the care of patients with dementia, 2012–2013. Sydney: Retrieved from <https://www.youtube.com/watch?v=M3BB
Author. Retrieved from <www.cec.health.nsw.gov.au>. zmhL4Fc>.
380
Jewell, N., & Clarke, L. (2012). Can Jaffa come too? A visual from <www.health.govt.nz–final-followup-bsp-provider
representation of a child’s day surgery experience. Day -survey-150414>.
Surgery Australia, 11(2), 6–8. Mobile Health Solutions (MHS). (nd). Mobile surgical services.
Kalman, J. M., Sanders, P., Brieger, D., Aggarwal, A., Zwar, N., Retrieved from <www.mobilesurgical.co.nz>.
Tatoulis, J., et al. (2013). National Heart Foundation of Aus- NSW Health. (2011). Extended day only admission policy,
tralia consensus statement on catheter ablation as a therapy PD2011_045. Retrieved from <www0.health.nsw.gov.au/
for atrial fibrillation. Medical Journal of Australia, 198(1), policies/pd/2011/PD2011_045.html>.
27–28.
NSW Health. (2012). High volume short stay surgical model
Kaplan, J. A., Reich, D. L., & Savino, J. S. (2011). Kaplan’s cardiac toolkit. Retrieved from <www.health.nsw.gov.au/
anesthesia: The echo era (6th ed.). Philadelphia: Elsevier Performance/Publications/hi-vol-short-stay-surgery.pdf>.
Saunders.
Odom-Forren, J. (2015). Postoperative patient care and pain
Kaufman, J. (2014a). Abdominal aorta and pelvic arteries. In management. In J. Rothrock & D. McEwen (Eds.), Alexander’s
J. A. Kaufman & M. J. Lee (Eds.), Vascular and interventional care of the patient in surgery (15th ed., pp. 270–294). St
radiology (2nd ed., pp. 199–228). Philadelphia: Elsevier Louis: Elsevier Mosby.
Saunders.
Press Ganey Australia. (nd). Improving health care. Retrieved
Kaufman, J. (2014b). Vascular interventions. In J. A. Kaufman from <www.pressganey.com.au/improvinghealthcare.html>.
& M. J. Lee (Eds.), Vascular and interventional radiology (2nd
ed., pp. 68–98). Philadelphia: Elsevier Saunders. Reynolds, N. (2013). Bariatric patients. In A. R. Aitkenhead, I.
K. Moppett, & J. P. Thompson (Eds.), Smith and Aitkenhead’s
Kaufman, J. (2014c). Fundamentals of angiography. In J. A. textbook of anaesthesia (6th ed., pp. 550–559). Edinburgh:
Kaufman & M. J. Lee (Eds.), Vascular and interventional radiol- Churchill Livingstone.
ogy (2nd ed., pp. 25–55). Philadelphia: Elsevier Saunders.
Rice, A. N., Muckler, V. C., Miller, W. R., & Vacchianp, C. A.
Langton, J. A. (2013). Day case anaesthesia. In A. R. Aitken- (2015). Fast-tracking ambulatory surgery patients following
head, I. K. Moppett, & J. P. Thompson (Eds.), Smith and Aitken- anesthesia. Journal of Perianesthesia Nursing, 30(2), 124–133.
head’s textbook of anaesthesia (6th ed., pp. 560–567). doi: 10.1016/j.jopan.2014.01.006.
Edinburgh: Churchill Livingstone.
Ride, K. (2014). Within reach. Nursing Review, 1, 17–19.
Leary, C. (2013). Streamlining day surgery using information
technology [online]. Day Surgery Australia, 12(2), 16–18. Riegert, M., & Nandwani, M. (2014). Enhancing the quality
<http://search.informit.com.au.acs.hcn.com.au/document of colonoscopy through split-dose bowel preparation. Gas-
Summary;dn=534694299240183;res=IELHEA> ISSN: 1446- troenterology Nursing, 37(2), 148–154.
8999. Rowen, L., Hunt, D., & Johnson, K. L. (2012). Managing obese
Lin, I. T., Chang, W. H., Wang, T. E., Chu, C. H., Lin, S. C., Shih, patients in the OR. OR Nurse, 26–35. doi: 10.1097/01.ORN.
S. C., et al. (2008). Successful endoscopic band ligation for 0000412324.97287.aa.
bleeding venous bleb. Gastrointestinal Endoscopy, 67(6), SA Health. (2015, March). Delivering Transforming Health:
971–972. our next steps. Adelaide: Author. Retrieved from <http://
Mayo Clinic Staff. (nd). Endoscopic ultrasound. Retrieved transforminghealth.sa.gov.au/about/journey>.
from <www.mayoclinic.org/tests-procedures/endoscopic Saber, A. A. (nd). Bariatric surgery. Retrieved from <http://
-ultrasound/basics/definition/prc-20012819>. emedicine.medscape.com/ar ticle/197081-overview
Medigus. (nd). MUSETM leading the GERD revolution. Retrieved #a0112>.
from <www.medigus.com/healthcare-professional/muse Schaadt, J. (2015). Interventional and image-guided proce-
-system-gerd-relief-in-sight>. dures. In J. Rothrock & D. McEwen (Eds.), Alexander’s care of
Meining, A. (2015). Confocal laser endomicroscopy and endo- the patient in surgery (15th ed., pp. 1132–1160). St Louis:
cytoscopy. Retrieved from <www.uptodate.com/contents/ Elsevier Mosby.
confocal-laser-endomicroscopy-and-endocytoscopy Schaadt, J., & Landau, B. (2013). Hybrid OR 101 a primer for
?Source=search_result&search=Confocal+laser+endomicro the OR nurse. AORN Journal, 97(1), 81–100.
scopy+and+endocytoscopy.&selectedTitle=1~12>.
Seker, G., & Kulacoglu, H. (2012). The acceptance rate of
Ministry of Health New Zealand. (2014a). Annual report for local anaesthesia for elective inguinal hernia repair among
the year ended 30 June 2014. Retrieved from <www.health the surgeons working in a teaching hospital. Journal of the
.govt.nz/publication/annual-report-year-ended-30-june College of Physicians and Surgeons–Pakistan, 22(2), 126–127.
-2014>. doi:02.2012/JCPSP.126127.
Ministry of Health New Zealand. (2014b). Revised draft evalu- Shields, L. (2014). The core business of caring: A nursing
ation of the bowel screening pilot 2013 immersion visit. oxymoron? Collegian (Royal College of Nursing, Australia),
Retrieved from <www.health.govt.nz-bps-immersion-visit 21(3), 193–199.
-report150414>.
Society of Gastroenterology Nurses and Associates (SGNA).
Ministry of Health New Zealand. (2014c). Evaluation of the (2013). Gastroenterology nursing: A core curriculum (5th ed.).
bowel screening pilot follow-up provider survey. Retrieved Chicago, IL: Author.
381
Spry, C. (2015). Infection prevention and control. In FURTHER READING

J. Rothrock & D. McEwen (Eds.), Alexander’s care of the
Burden, N. (2013). Care of the ambulatory surgery patient.
patient in surgery (15th ed., pp. 69–123). St Louis: Elsevier
In J. Odom-Forren (Ed.), Drain’s perianaesthesia nursing: A
Mosby.
critical care approach (6th ed.). St Louis: Elsevier.
Therapeutic Goods Administration (TGA). (2014). Endo-
Eccleshall, S., & Waliszewski, M. (2015). The NICE recom-
scopes reprocessing procedures. Medical Devices Safety
mendation for drug-coated balloons and its global impact.
Update, 2(5), Retrieved from <https://www.tga.gov.au/
Therapeutic Advances in Cardiovascular Disease, 2, ii.
publication-issue/medical-devices-safety-update
-volume-2-number-5-september-2014#endoscopes>. Hatfield, A. (2014). The complete recovery room book (5th ed.).
Oxford: OUP.
Thurairatnam, R. R., Mathew, G. S., Montgomery, J., & Stocker,
M. (2014). The role of patient satisfaction surveys to improve Kuipers, E. J., Rösch, T., & Bretthauer, M. (2013). Colorectal
patient care in day surgery. Day Surgery Australia, 13(3), cancer screening: Optimizing current strategies and new
6–8. directions. Nature Reviews Clinical Oncology, 10, 130–142.
White, J. J., Khan, W. S., & Smitham, P. J. (2011). Perioperative Levine, G. N., Bates, E. R., Blankenship, J., Bailey, S., Bittl, J.,
implications of surgery in elderly patients with hip frac- Cercek, B., et al. (2012). 2011 ACCF/AHA/SCAI guideline for
tures: An evidence-based review. Journal of Perioperative percutaneous coronary intervention: Executive summary. A
Practice, 21(6), 192–197. report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guide-
Williams, J. (2014). Shaping Australian healthcare facilities for
lines and the Society for Cardiovascular Angiography and
the future case studies: The new St John of God Midland public
Interventions. Journal of the Society for Cardiac Angiography
and private hospitals. Retrieved from <www.austhealthweek
and Interventions, 79(3), 453–495. doi:10.1002/ccd.23438.
.com.au/hfdd/Default.aspx>.
Nguyen, T., Nguyen, J., Chen, S. L., Phan, H., & Nanjunddappa,
Zacherl, J., Roy-Shapira, A., Bonavina, L., Bapaye, A., Kiesslich,
A. (2014). Closure device complications. In R. S. Dieter Jr.,
R., Schoppmann, S. F., et al. (2015). Endoscopic anterior
R. A. Dieter Jr., & R. A. Dieter III (Eds.), Endovascular interven-
fundoplication with the Medigus untrasonic surgical
tions; A case-based approach (pp. 529–533). New York:
endostapler (MUSETM) for gastroesophageal reflux disease:
Springer Verlag.
6-month results from a multicentre prospective trial. Surgi-
cal Endoscopy, 29(1), 220–229.
382
Glossary
Ablation: Amputation, excision of any part of the body or Aseptic field: Refers to the area around the surgical site
removal of a growth or harmful substance. that has been prepared by cleansing with an antimicrobial
Accountability: Nurses and midwives must be prepared to agent and draping, thus separating it from the rest of the
answer to others, such as healthcare consumers, the rele- patient’s body. The aseptic field also includes all furniture
vant national nursing and midwifery regulatory authority, covered with drapes, such as the instrument table, and the
their employer and the public for their decisions, actions surgical team who are gowned and gloved.
and behaviours, and the responsibilities that are inherent Aseptic non-touch technique (ANTT): see surgical ANTT and
in their roles. Accountability cannot be delegated. Regis- standard ANTT.
tered nurses or midwives who delegate an activity to
another person are accountable not only for the delegation Aseptic technique: Any healthcare procedure in which
decision, but also for monitoring the standard of perform- added precautions are taken to prevent contamination of a
ance of the activity by the other person and for evaluating patient, an object or an area by microorganisms.
the outcomes of the delegation. Atraumatic: Pertaining to therapies or therapeutic instru-
Accreditation: Public recognition by a healthcare accredita- ments and devices (e.g. needles) that are unlikely to cause
tion body of the achievement of accreditation standards by tissue damage.
a healthcare organisation, demonstrated through an inde- Autonomy: The ethical principle of self-determination and
pendent external peer assessment of that organisation’s independence.
level of performance in relation to the standards.
Basic life support (BLS): Emergency treatment of a victim
Advance health directive (AHD): Also known as a living will.
of cardiac or respiratory arrest through cardiopulmonary
A document that expresses a patient’s preferences regard-
resuscitation and emergency cardiac care.
ing end-of-life issues. An AHD becomes effective only when
an individual loses the capacity to make those choices Bougie: A long, thin flexible rod that can be passed through
themselves. an endotracheal tube (ETT) to enable the tube to be
Adverse event: An incident in which unintended harm moulded to a shape that can be guided through the laryn-
results to a person receiving healthcare. geal opening.
Advocacy: Speaking or intervening on behalf of another. Bradycardia: A pulse rate less than 50 beats per minute.
Nurses act as patient advocate when the latter are unable Bronchospasm: An excessive and prolonged contraction of
to do so due to their physical or mental condition. the smooth muscle of the bronchi and bronchioles, result-
Ambulatory procedures/care: Also known as day surgery. ing in acute narrowing and obstruction of the respiratory
Usually refers to the care of patients on a day-only basis. airway. Contractions may be localised or general and may
However, it also encompasses extended day only (EDO) and be caused by irritation (e.g. secretions, airway equipment or
other variously titled, high-volume, short-stay (HVSS) pulmonary aspiration) or injury to the respiratory mucosa,
models of care (MOC). infections, allergies, drug hypersensitivity or the rapid intro-
duction of volatile anaesthetic agents. Bronchospasm is the
Anaerobic: Absence of oxygen. chief characteristic of asthma and bronchitis and is managed
Analgesia: Absence of pain in response to a stimulus that by increasing the level of inhalational anaesthesia, bron-
would normally produce pain. chodilators (e.g. salbutamol) and other drugs (e.g. steroids,
Angiography: Injection of contrast medium into an artery ketamine or adrenaline) or repositioning the endotracheal
and subsequent radiological examination; used to deter- tube in anaesthetised patients.
mine the patency of an artery and collateral circulation. Capnography: Graphical representation of expired carbon
Angioplasty: Reconstitution or recanalisation of a blood dioxide (CO2), often termed end-tidal CO2. An adaptor placed
vessel; may involve balloon dilation, mechanical stripping in the breathing circuit during general anaesthesia collects
of intima, forceful injection of fibrinolytics or placement of CO2, which is then analysed and displayed as a waveform
a stent. on a monitor. Measurement assists in early detection
of technical catastrophes (e.g. oesophageal intubation) or
Apnoea: Complete absence of breathing. changes in the patient’s respiratory, circulatory or metabolic
Arrhythmia: Any deviation other than the normal pattern condition.
of the heartbeat. Cardiac arrest: The cessation of cardiac mechanical activity
Asepsis: Absence of pathogenic microorganisms on living with the absence of a detectable pulse, unresponsiveness
tissue. and apnoea (or agonal respirations).
383
GLOSSARY
Cardiac catheterisation: Insertion of a catheter into a large Compartment syndrome: A pathological condition caused
vein or artery (in the arm or leg), which, in the case of by the progressive development of arterial compression and
venous cannulation, is then directed into the superior vena consequent reduction of blood supply to the extremities.
cava and the right atrium, or following arterial cannulation, Clinical manifestations include swelling, restriction of
is threaded into the proximal aorta and left ventricle. As the movement, brown urine, myoglobinuria, vascular compro-
catheter tip passes through the chambers and vessels of mise and severe pain or lack of sensation. Treatment
the heart the blood pressure is monitored and blood includes elevation, removal of restrictive dressings or casts
samples may be taken. Injection of contrast medium aids in and, potentially, surgical decompression (often in the form
examination of cardiac structures and heart motion. The of a fasciotomy, to relieve the pressure).
procedure accurately identifies congenital heart disease, Competence: Combination of skills, knowledge, attitudes,
tricuspid stenosis and valvular incompetence. values and abilities that underpin effective and/or superior
Cardioversion: The attempt to restore the heart’s normal performance in a profession/occupational area.
sinus rhythm via an electric shock delivered by a defibrilla-
Complementary therapies: Treatments not considered part
tor either internally or externally. Application of the shock
of mainstream Western medicine and that are generally
is synchronised to the QRS complex.
used as an adjunct to standard medical treatments. These
Central nerve block: Administration of local anaesthetic include massage, relaxation techniques, osteopathy, acu-
drugs into the subarachnoid or epidural space, thus blocking puncture, chiropractic, aromatherapy, meditation and
nerves as they exit the spinal cord and causing large naturopathy. Complementary and mainstream medicine
areas of the lower body to lose sensation (hence, the term combined is known as integrative medicine.
block).
Compliant: Refers to the ease with which lungs can be
Clinical decision making: The cognitive processes and inflated; compliant lungs are more readily inflated than
strategies that nurses use when utilising data to make clini- incompliant lungs.
cal decisions regarding patient assessment and care.
Computed tomography (CT): An imaging procedure that
Clinical governance: This is the main vehicle by which makes use of computer-processed combinations of many
healthcare organisations are held accountable for ensuring X-ray images taken from different angles to produce cross-
high standards of healthcare (including dealing with poor sectional (tomographic) images (virtual ‘slices’) of specific
professional performance), for continuously improving the areas of a scanned object, enabling the user to see inside
quality of their services, and for creating and maintaining the object without cutting it.
an environment in which clinical excellence can flourish.
Confidentiality: The non-disclosure of information about a
Clinical pathway: A document outlining a standardised, person unless consented to by that person, or an authorised
evidence-based, multidisciplinary and cost-effective man- person, or under statutory authority or in the public interest
agement plan that identifies an appropriate sequence of under strict conditions. Preserving confidentiality of patient
clinical interventions, associated time lines and milestones, information is a primary duty of healthcare professionals
and expected outcomes for a homogeneous patient group. and is included in codes of ethics and health legislation.
Closed wound suction: Any of several techniques for drain- Conscious sedation: A drug-induced depression of con-
ing potentially harmful fluids (e.g. blood, pus, serosanguine- sciousness during which patients are able to respond pur-
ous fluid or tissue secretions) from surgical wounds. posefully to verbal commands or light tactile stimulation.
Postoperative drainage aids the healing process by remov- Conscious sedation can be achieved by a wide variety of
ing dead space and helping to draw healing tissues together. drugs including propofol and may accompany local anaes-
Closed wound suction devices usually consist of disposable thesia. All conscious sedation techniques should provide a
transparent containers attached to suction tubes and port- margin of safety that is wide enough to render loss of con-
able suction pumps. sciousness unlikely.
Coagulopathy: A pathological condition that affects the Core temperature: The temperature of the deep structures
ability of the blood to coagulate. of the body, such as the liver.
Code of conduct: A collection of standards and rules of Cricoid pressure: see Sellick’s manoeuvre.
behaviour.
Cultural safety: The provision of effective healthcare to
Code of Rights: In New Zealand, the Health and Disability persons of dissimilar cultures, respecting difference and
Commissioner Act 1994 and subsequent amendment incor- ensuring that care is not diminishing, demeaning or disem-
porate the code of health and disability services consumers’ powering. Culture encompasses not only ethnicity or origin
rights (Code of Rights), which is wide and extends to any but also age, gender, disability, sexual identity, socioeco-
person or organisation providing a health service to the nomic status, spiritual beliefs and migrant experience.
public. The code of rights also covers all health profession-
als and one of its obligations is to take reasonable action Culture: A set of learned values, beliefs, customs and behav-
in the circumstances to give effect to the rights and comply iour that is shared by a group of interacting individuals.
with the duties. Dead space: Air or empty space between layers of tissue or
Cognitive impairment: Deficiency in the ability to think, beneath wound edges that have been approximated.
perceive, reason or remember that may result in the loss of Debride: To remove dirt, foreign objects, damaged tissue
ability to attend to one’s activities of daily living. and cellular debris from a wound or burn to prevent
384
GLOSSARY
infection and promote healing. In treating a wound, debri- permitting positive pressure ventilation and decreasing the
dement is the first step in cleansing; it allows thorough risk of aspiration.
examination of the extent of the injury.
Epidural anaesthesia/analgesia: A type of central nerve
Defibrillation: The application of a controlled electrical block in which a local anaesthetic drug is injected via a fine
shock to the victim’s chest in order to terminate a life- catheter into the epidural space surrounding the dural
threatening cardiac rhythm. membrane, which contains cerebrospinal fluid and spinal
nerves. The catheter lies between the dura mater and
Deontological: A philosophical view reflecting duty or a
the ligamentum flavum at the L3–4 or L5–6 level. An epi-
moral obligation to behave or act in a particular way,
dural injection can be used to facilitate surgery of the lower
regardless of the consequences.
half of the body and/or provide prolonged postoperative
Electronic health record (EHR) (or electronic medical record, analgesia.
EMR): An individual patient’s medical record in digital
Error: A generic term encompassing all of those occasions
format. EHR systems coordinate the storage and retrieval
in which a planned sequence of mental or physical activi-
of individual records with the aid of computers. EHRs/EMRs
ties failed to achieve its intended outcome and when the
are usually accessed on a computer, often over a network
failure cannot be attributed to the intervention of some
that comprises records from many locations and/or sources.
chance agency.
A variety of types of healthcare-related information may be
stored and accessed in this way. EHRs/EMRs may also be Eschar: Black necrotic tissue or scab that results from
personally controlled. Integrated EHRs are increasingly trauma, such as thermal or chemical burns, infection or
seen as the way to achieve quality and continuity in treat- ulcerating skin disease.
ment, fill the gaps in public health research and contain
Ethical: Right or morally acceptable.
costs; however, such systems have created many concerns
about privacy. Ethics: The study of morals and values (including ideals of
autonomy, beneficence and justice).
Electrosurgical unit (ESU) (diathermy machine): A system
that generates a high-frequency electrical current, which Evaluation and Quality Improvement Program (EQuIP): The
creates heat in body tissue, resulting in coagulation or des- Australian Council on Healthcare Standards’ framework to
iccation of tissue. This provides haemostasis and a blood- improve the quality and safety of healthcare. It comprises
less field during a surgical procedure. There are two main a four-year continuous, quality assessment and improve-
types: monopolar and bipolar. Use of the former requires ment accreditation program for healthcare organisations
placement of a patient return electrode (diathermy plate/ that supports excellence in consumer/patient care and
pad) on/under the patient’s body, away from the operative services.
site.
Evidence-based nursing: The conscientious, explicit and
Emotional intelligence: The ability to understand and judicious use of theory-derived, research-based information
manage one’s own emotions and those of others. This in making decisions about care delivery to individuals or
quality gives individuals a variety of skills, such as the groups of patients.
ability to manage relationships, navigate social networks,
Exogenous: Originating outside of the body or an organ of
and influence and even inspire others.
the body, or produced from external causes.
Endogenous: Originating from within the body or produced
5 moments of hand hygiene: Part of the World Health
from internal causes.
Organization’s global program, ‘Save Lives: Clean Your
Endoscope: An illuminated optic instrument for visualising Hands’, launched in 2009. The program identifies each occa-
the interior of a body cavity or organ. It may be rigid or sion when hand hygiene should be performed, that is:
flexible and is introduced through a natural orifice or (1) before touching a patient; (2) before commencing a
inserted via an incision. Fibreoptic endoscopes have great procedure; (3) after a procedure or body fluid risk exposure;
flexibility and can reach previously inaccessible areas. (4) after touching a patient; and (5) after touching a patient’s
surroundings.
Endoscopy: Visualisation of the interior of organs and cavi-
ties of the body with an endoscope. The gastrointestinal General anaesthesia: A reversible, unconscious state char-
tract, hepatobiliary system, pancreatic ducts, renal system, acterised by amnesia, loss of sensation, analgesia and sup-
upper and lower airways and female reproductive system pression of reflexes.
can all be examined, and cytological and histological
Haemodynamic monitoring: Measurement of pressure, flow
samples collected. Some conditions can also be treated via
and oxygenation within the cardiovascular system.
an endoscopic procedure.
Haemostasis: Termination of bleeding by mechanical or
Endotracheal tube (ETT): A large-bore, disposable catheter
chemical means or by the coagulation processes of the
made of silicone or PVC tubing that is inserted through the
body, which comprise vasoconstriction, platelet aggrega-
mouth or nose and into the trachea to the point above the
tion, and thrombin and fibrin synthesis.
bifurcation of the trachea. It is used to deliver anaesthetic
gases and oxygen directly into the trachea through the Health policy: A statement of a decision regarding a goal
vocal cords. ETTs may have a single or double lumen (for in healthcare and a plan to achieve that goal (e.g. to prevent
lung surgery). Adult-sized ETTs have a cuff at their distal an epidemic, a program for inoculating a population is
end, which when inflated with air seals off the trachea, developed and implemented).
385
GLOSSARY
Healthcare-associated infection (HAI): Also known as noso- Justice: That which concerns fairness or equity, often
comial infection or hospital-acquired infection. Infection divided into three parts: (1) procedural justice, concerned
acquired during the course of receiving healthcare. Common with fair methods of making decisions and settling dis-
causative agents include Candida albicans, Escherichia coli, putes; (2) distributive justice, concerned with fair distribu-
pseudomonas, Staphylococcus aureus and Staphylococcus tion of the benefits and burdens of society; and (3) corrective
epidermidis, and hepatitis viruses. justice, concerned with correcting wrongs and harms
through compensation or retribution.
Human Factors: The interrelationships of people to their
environment and to each other that need to be considered Laparoscopy: Examination of the abdominal cavity and
to optimise performance and assure safety. In healthcare viscera using a laparoscope (viewing tube) inserted through
settings these range from the design of tools such as one or more small incisions in the abdominal wall, usually
medical devices, services and systems, to the working envi- around the umbilicus. Laparoscopic surgery can be diagnos-
ronment and working practices such as tasks, roles and tic or therapeutic (e.g. laparoscopic cholecystectomy—
team behaviours. removal of the gallbladder via the laparoscopic incisions).
Inadvertent perioperative hypothermia (IPH): A common It is a form of minimally invasive surgery (MIS).
but preventable complication of perioperative procedures Laryngeal mask airway (LMA): Also called the Brain airway,
that is associated with poor outcomes for patients. IPH after its inventor. A device for maintaining a patent airway
should be distinguished from the deliberate induction of during general anaesthesia without tracheal intubation,
hypothermia for medical reasons. During the first 30–40 consisting of a tube connected to an oval inflatable cuff
minutes of anaesthesia, a patient’s temperature can drop that seals the larynx.
below 35.0°C. Reasons for this include loss of the behav-
ioural response to cold, impairment of thermoregulatory Laryngospasm: Spasmodic closure of the larynx. It may
heat-preserving mechanisms under general or regional be caused by local irritation, such as the presence of secre-
anaesthesia, anaesthesia-induced peripheral vasodilation tions, airway equipment or pulmonary aspiration in the back
(with associated heat loss) and the patient getting cold of the pharynx, resulting in partial or complete spasm of
while waiting for surgery. Current practice is to initiate the vocal cords and an inability to breathe effectively.
active warming measures if the patient’s temperature drops Partial laryngospasm may be characterised by a ‘crowing’
below 36.0°C. sound made on inspiration. However, in total laryngospasm
no sound is made as no air moves into or out of the
Incident: An event or a circumstance that could have led, lungs; ineffective respiratory effort will be noted in chest
or did lead, to unintended and/or unnecessary harm to a movement.
person and/or to a complaint, loss or damage.
Laser: An acronym for light amplification by stimulated
Indigenous: Refers here to Aboriginal and Torres Strait emission of radiation. The energy generated by laser equip-
Islander peoples. ment can be used to destroy or refashion tissue and fix it
Infection: Invasion of the body by pathogenic microorgan- in place. Laser beams can be harmful to the eyes of person-
isms that reproduce and multiply, causing disease by local nel activating and assisting with procedures, so protective
cellular injury, secretion of a toxin or antigen-antibody reac- goggles must be worn.
tion to the host.
Latex allergy: Anaphylactic hypersensitivity to the soluble
Infection prevention: The policies and procedures of a hos- proteins in latex, most often seen in patients sensitised by
pital or other health facility to minimise the risk of spread- repeated exposure to latex. Reactions range from irritant
ing healthcare-associated or community-acquired infections dermatitis and eczema to anaphylactic collapse.
to patients or members of staff.
Local anaesthesia: Direct administration of an agent
Inflammation: The normal response of connective tissue (e.g. lignocaine) to tissues to induce the absence of pain
and blood vessels to sublethal irritation or injury. Inflam- sensation in that part of the body. Local anaesthetics do not
mation may be acute or chronic, the time scale relating to depress consciousness.
the nature of the injurious stimulus. The cardinal signs of
inflammation are redness, heat, swelling and pain, often Magnetic resonance imaging (MRI): A scanning technique
accompanied by loss of function. that exposes the body to a strong magnetic field and uses
the electromagnetic signals emitted by the body to form an
Informed consent: Authorisation obtained from a patient to image of soft tissue and cells.
perform a specific test or procedure. The concept of informed
consent is a composite of: (1) the person’s consent to a Malignant hyperthermia: A rare, life-threatening, genetic
procedure (or participation in a research study); and (2) the hypermetabolic condition characterised by severe hyper-
nature and extent of information that must be provided in thermia and rigidity of the skeletal muscles triggered by
order for the person’s decision to be adequately informed. inhalational anaesthetics and the muscle relaxant succinyl-
A broad indication of the nature and risks of the procedure choline. Treatment involves the use of dantrolene sodium
is sufficient to defeat an action in trespass, assuming that injection, administration of 100% oxygen, removal of trig-
the other requirements of a valid consent are met, including gering agents, immediate cooling, cessation of surgery and
voluntariness and competence of the patient. correction of acidosis and hyperkalaemia.
Intraoperative: Pertaining to the period during a surgical Māori: The Indigenous people of New Zealand; they com-
procedure. prise about 10% of the country’s population.
386
GLOSSARY
Microorganism: Any living organism that can be seen only aprons, used to protect healthcare staff from infectious
under a microscope. Microorganisms may be pathogenic organisms.
and include bacteria, algae, protozoa, fungi (cellular), viruses
Policy: A principle or guideline that governs an activity and
and prions (acellular).
that employees or members of an institution or organisa-
Minimally invasive surgery (MIS): Also known as minimal tion are expected to follow.
access surgery (MAS). Surgery undertaken with only a small
incision or no incision at all, as through a cannula with a Postoperative: Pertaining to the period of time after
laparoscope or an endoscope. surgery. It begins with the patient’s emergence from anaes-
thesia and continues throughout the time required for the
National Standards: The National Safety and Quality Health acute effects of the anaesthetic and the surgery or proce-
Service (NSQHS) Standards were developed by the Aus dure to abate.
tralian Commission on Safety and Quality in Health Care
(ACSQHC) to drive the implementation of safety and quality Practice guidelines: Statements about appropriate health-
systems and improve the quality of healthcare in Australia. care for specific clinical circumstances that assist practi-
The 10 NSQHS Standards provide a nationally consistent tioners in their day-to-day practice. Practice guidelines
statement about the level of care consumers can expect provide a basis for the evaluation of care and the allocation
from health service organisations. of resources.
Near miss: An unplanned event that did not result in injury, Preoperative: Pertaining to the period before a surgical
illness or damage but that had the potential to do so. procedure. Commonly the preoperative period begins with
the first preparation of the patient for surgery or other
Negligence: A legal term defined as ‘causing damage unin- procedure and ends with the induction of anaesthesia in
tentionally but carelessly’. A court will determine negli- the operating suite.
gence based on reasonable foreseeability that the damage
might have been possible, the existence of a duty of care Pressure injury/ulcer: An injury caused by unrelieved pres-
to the person damaged, a breach in that duty could be sure, friction and/or shearing that damages the skin and
demonstrated and that damages were indeed experienced underlying tissue, usually over a bony prominence.
by the victim. Privacy: Control over the extent, timing and circumstances
Neuraxial block: A collective term for spinal and epidural of sharing oneself (physically, behaviourally or intellectu-
anaesthesia. ally) with others. Implies a zone of exclusivity, where
Never events: Also termed sentinel events in Australasia. A individuals and collectives are free from the scrutiny of
term coined in the early 2000s and used in the UK and the others.
USA to signify adverse events that are unambiguous (clearly Procedural sedation and/or analgesia: Implies that the
identifiable and measurable), serious (resulting in death or patient is in a state of drug-induced tolerance of uncomfort-
significant disability) and usually preventable. able or painful diagnostic or interventional medical, dental
Pacific Islander peoples: Migrants to Australasia from the or surgical procedures. Lack of memory of distressing events
island groups of Micronesia, Melanesia and Polynesia. and/or analgesia may be the desired outcome, but lack of
Despite often being grouped together, populations from response to painful stimulation is not assured.
these regions are heterogeneous with diverse cultures, lan- Professional misconduct: Conduct by a health practitioner
guages and religions. that is substantially below the standard reasonably expected
Patient-controlled analgesia (PCA): A drug delivery system of a registered health practitioner of an equivalent level of
that dispenses an intravascular dose of a narcotic analgesic training or experience.
when the patient pushes a switch on an electric cord. The Professional practice standard: The standard of health pro-
device consists of a computerised pump with a chamber fessional care as determined by groups within the particu-
holding a syringe of drug. The patient administers a dose of lar profession.
narcotic when the need for pain relief arises. A lockout inter-
val automatically inactivates the system if the patient tries Pulse oximeter: A device that measures the amount of
to increase the amount of narcotic within a pre-set period. saturated haemoglobin in the tissue capillaries. A beam of
light is transmitted through the tissue to a receiver. This
Patient journey: Begins as early as the pre-hospital patient non-invasive method of measuring the saturated haemo-
assessment and includes the period of hospitalisation and globin is a useful screening tool for determining basic res-
surgical intervention, through to discharge home for recov- piratory function. A clip-like probe is usually placed on the
ery and rehabilitation in the community. patient’s finger, toe or earlobe. As the amount of saturated
Personal information: Information by which individuals or haemoglobin alters the wavelengths of the transmitted
collectives can be identified. This is defined in the Privacy light, analysis of the received light is translated into a per-
Act 1988 (Cth) as information or an opinion (including infor- centage of oxygen saturation (SpO2) of the blood, which is
mation or an opinion forming part of a database), whether displayed on a monitoring device. A reading of 95% or
true or not, and whether recorded in a material form or not, above is considered a satisfactory value.
about an individual whose identity is apparent, or can rea- Quality improvement: Evaluation of services provided, with
sonably be ascertained, from the information or opinion. the results achieved compared to accepted standards. Any
Personal protective equipment (PPE): A range of equip- deficiencies noted or identified serve to prompt recommen-
ment, such as gloves, eye protection, masks and plastic dations for improvement.
387
GLOSSARY
Rapid sequence induction (or intubation): A method of pro- Sepsis: Infection or contamination.
tecting the airway during induction of anaesthesia in
Sepsis-induced hypotension: A systolic blood pressure
patients at risk of aspiration of gastric contents. This is
<90 mmHg or a reduction of >40 mmHg from baseline in
achieved by minimising the time between loss of conscious-
the absence of other causes of hypotension.
ness and intubation, and by applying cricoid pressure.
Septic shock: A form of shock that occurs in septicaemia
Regional anaesthesia: Anaesthesia provided by injection
when endotoxins or exotoxins are released from certain
of a local anaesthetic drug to block a group of sensory
bacteria into the bloodstream. The toxins cause profound
nerve fibres. Types of regional anaesthesia include axillary,
hypotension.
brachial plexus, caudal, epidural, pudental, intercostal, para
cervical and spinal anaesthesia. Severity assessment code (SAC): A numerical score applied
to an incident based on the type of incident, its likelihood
Respect for persons: Has two fundamental aspects:
of recurrence and its consequence. A matrix is used to strat-
(1) respect for the autonomy of those individuals who are
ify the actual and/or potential risk associated with an inci-
capable of making informed choices and respect for their
dent. There are four SAC ratings, ranging from SAC1 (extreme
capacity for self-determination; and (2) the protection of
risk) to SAC4 (low risk).
persons with impaired or diminished autonomy (i.e. those
individuals who are incompetent or whose voluntary capac- Situation awareness: An ability to identify and process
ity is compromised). many pieces of information from within the environment
and act accordingly. Situation awareness requires the ability
Risk: The function of the magnitude of a harm and the
to watch, listen and understand cues, and anticipate what
probability of its occurrence (i.e. the effect of uncertainty
may happen next. Team members (e.g. those who comprise
on objects). It is measured in terms of consequences and
the surgical team) need to be aware of the big picture,
likelihood.
rather than focusing only on a particular task. To achieve
Risk management: A function of administration of a hospi- this, individuals take in data from their senses, interpret the
tal or other health facility directed towards identification, data and make predictions about what will happen in the
evaluation and correction of potential risks leading to injury future. Situation awareness relies on good teamwork and
of patients, staff members or visitors and resulting in prop- communication.
erty loss or damage.
Skill mix: The relative mix of skilled and experienced staff
Robotic surgery: Remote, computer-assisted telemanipula- in a team. For example, in the operating suite there may be
tors developed for use in surgery to overcome some of the experienced, qualified registered nurses (RNs) and enrolled
limitations associated with laparoscopic equipment. The nurses (ENs), less-experienced RNs and ENs, newly gradu-
advanced technology incorporates sophisticated mechani- ated/qualified RNs/ENs and various technical, ancillary and
cal equipment, which is used to hold and manoeuvre endo- other non-nursing personnel. A poor skill mix has a higher
scopic instrumentation during minimally invasive surgery proportion of staff with lower order qualifications and less
(MIS). The surgeon can control robotic devices remotely. experience; conversely, a good skill mix has a higher pro-
portion of experienced and qualified staff.
Root cause analysis: A systematic approach whereby factors
that contributed to an incident are identified and recom- Smoke plume: Smoke generated during tissue ablation or
mendations to prevent recurrence are generated. In the disruption while using energy-based devices such as elec-
healthcare setting, a team of unbiased experts may be trosurgical equipment, radiofrequency devices, ultrasonic
called on to investigate how and why an error occurred by shears or lasers. This smoke has been shown to contain
looking more at the system problems that emerged than at toxins, carcinogens and viruses. The use of smoke extraction
individual negligence. units and high-filtration masks is recommended to protect
the surgical team from inhaling the smoke plume.
Scope of practice (SOP): The full spectrum of roles, func-
tions, responsibilities, activities and decision-making capac- Social media: The online and mobile tools that individuals
ity that individuals within a profession are educated, and groups use to share opinions, information, experiences,
competent and authorised to perform. images and video or audio clips; includes websites and
apps used for social networking.
Sellick’s manoeuvre: A technique used to reduce the risk of
aspiration of gastric contents during induction of general Standard ANTT: A general aseptic field is required for pro-
anaesthesia. The cricoid cartilage is pushed against the cedures that are simple, of short duration and involve only
body of the sixth cervical vertebra, occluding the upper end a few key parts or sites (e.g. insertion of an IV cannula or
of the oesophagus and preventing passive regurgitation. injection into an IV line/port). Unsterile gloves may be used
The technique cannot stop active vomiting. Cricoid pressure provided the key parts and key sites remain protected and
is applied immediately after injection of anaesthesia and are not touched. Hubs of syringes are protected by the
before tracheal intubation, and as part of a rapid sequence sterile packaging and form a critical micro aseptic field. This
intubation. Regurgitated gastric contents entering the lungs equipment is then placed within a main general aseptic
can result in a condition known as Mendelson’s syndrome. field.
Sentinel events: Also called never events in the UK and the Standard precautions: A range of strategies designed to
USA. Rare, adverse events leading to serious patient harm reduce the transmission of microorganisms from both rec-
or death that are specifically caused by healthcare rather ognised and unrecognised sources—for example, use of
than the patient’s underlying condition or illness. safe work practices and protective barriers (e.g. personal
388
GLOSSARY
protective equipment [PPE]). Standard precautions apply to Tidal volume: The volume of air that is moved into or out
blood, all body secretions (except sweat), non-intact skin of the lungs with each breath.
and mucous membranes (including the eyes). Transmission-based precautions: Safeguards designed for
Stent: A scaffolding device inserted into a vessel or pas- patients who are known or suspected to be infected with
sageway to keep it open and prevent closure. Stents can be highly transmissible or epidemiologically important patho-
bare metals or coated with drug-eluting substances. gens for which additional precautions beyond standard
precautions are needed to interrupt transmission in hospi-
Sterile: Absence of all forms of microbial life. tals. There are three types of transmission-based precau-
Sterilisation: The processes used to eliminate or destroy all tions: airborne precautions, droplet precautions and contact
forms of microbial life from equipment and surgical instru- precautions. They may be combined for diseases that have
ments, to prepare them for use during a surgical procedure. multiple routes of transmission and, either singly or in com-
Methods to achieve sterilisation include the use of steam, bination, are used in addition to standard precautions.
ethylene oxide, dry heat, gamma radiation, peracetic acid Transoesophageal echocardiography (TOE): An examina-
and gas plasma. Note: Sterilised items remain sterile only tion that uses a probe with an ultrasound transducer at the
for as long as they remain inside unopened, uncompromised tip. As the probe passes through the oesophagus, it sends
sterile packaging. In the operating room, sterile items are back clear images of the size of the heart as well as move-
removed from their sterile packaging and are aseptically ment of the walls, valvular abnormalities, endocarditis veg-
introduced into the surgical field where they remain for the etation and possible sources of thrombi.
duration of the procedure. During that time, these items are
exposed to the constant presence of airborne pathogens Ultrasound imaging: The use of high-frequency sound,
from the operating room environment and can no longer usually greater than 1 MHz, to image internal structures.
be considered sterile, even if not used. Therefore, they are Unlike radiological examination, ultrasound does not use
considered aseptic, meaning free from additional patho- ionising radiation.
genic microorganisms. Unethical: Wrong or morally unacceptable.
Surgical ANTT: In the operating room, a critical aseptic Utilitarian: Ethical theory that presupposes an action is
field is created, which can be one large, complex key site right if it achieves the greatest good for the greatest
(the incision) and multiple key parts (instruments). Person- number of people.
nel working within the critical aseptic field must wear Venous thromboembolism (VTE): A condition that involves
sterile gloves and gown; and sterile drapes must be used the development of venous thrombosis and subsequent
to maintain the aseptic field. pulmonary embolus (PE). VTE is a mostly preventable surgi-
Surgical conscience: An individual’s professional honesty cal complication, yet remains a significant cause of postop-
and inner morality system, which allows no compromise in erative morbidity and mortality in the form of chronic
practice, particularly when breaches occur in accepted venous insufficiency, recurrent thromboembolism and post-
behaviours or aseptic technique. These breaches must be thrombotic syndrome.
corrected immediately, regardless of personal consequences Voluntary: Free of coercion, duress or undue inducement.
or embarrassment.
World Health Organization Surgical Safety Checklist (WHO
Surgical site infection (SSI): An infection caused by the SCC): A tool developed by WHO to reduce the occurrence of
introduction of pathogenic microorganisms into a wound unnecessary surgical deaths and avoidable complications.
during or following a surgical procedure. Most commonly Its aim is to reinforce accepted safety practices (such as Time
caused by staphylococcal, streptococcal, enterococcal or Out prior to commencement of surgery) and improve com-
pneumococcal bacteria, with Staphylococcus aureus being munication and teamwork among members of the surgical
the most frequently identified organism in SSIs. team, activities known to improve patient safety.
389
Index
Page numbers followed by ‘f ’ indicate figures, ‘b’ indicate boxes, and ‘t’ indicate tables.
A adverse events 49–52, 51f, 134

advocacy 75–76
procedures performed in
365–372
abdominal incisions 306 nurses’ experiences of 19 special populations and
abdominal muscles and 307f patient advocate 3–4 363–365
common types of 308t–309t AHD see advance health directive stents and 372, 372t
abdominal minimally invasive air-assisted lateral transfer device therapeutic interventions in
surgery 292 235f 368–369
abdominal muscles 307f airborne precautions 140 TOE 370, 371f
absorbable collagen sponge 318 air conditioning 101, 108b. ambulatory surgery see day surgery
absorbable gelatin 317–318 See also ventilation system anaesthesia
ACHS see Australian Council on airway airway establishment of 208
Healthcare Standards airway fires 116b bariatric patient and 226–229,
accountability 11b, 75–76 assessment 194–195, 336–337, 228t
evidence-based practice, 337b airway and ventilation
engagement with 17 of bariatric patient in 227–228
in regulatory environment 10– anaesthesia 227–228 central neural blockade and
11, 11b complications of 341–344 214–217
accountable items 260–261 emergencies of 211–214 CICO during 211b
checklists for management of establishment of 208 elderly patient and 226, 227t
62–63 head-chin-lift manoeuvre 343f emergencies 223–224
count of 261 management 194–195 epidural 215–217, 216t, 217b
emergency situations and 263 artificial 202–203 haemodynamic monitoring
incorrect count and 262–263 in bariatric patients 338b during 218–221
management of 260–263 equipment and techniques for induction of 208
ACN see Australian College of 202–207 local 214–218, 218b, 350
Nursing LMA and 203–204, 205f, 212f machine and monitoring devices
ACORN see Australian College of upper anatomy of 204f for 203f
Operating Room Nurses allergic reaction types 117 maintenance of 208–210
ACORN Standards see professional allergies and sensitivities 117, 184. paediatric patients and 224–
practice standards, See also latex allergies 226, 225b
professional standards ambulatory care setting patient care during 193–231
active immunity 134 diagnostic and interventional regional 218
acute pain service 351 endovascular procedures spinal 214, 216–217, 216t
adequate preoperative preparation in 369–370, 371b stages of 197t
160–161 diagnostic procedures in TIVA 197
adrenaline 318 366–368 types of 196–201, 214–218.
advance health directive (AHD) patient journey in 363 See also general anaesthesia
80–81, 81b patient acceptance 363 anaesthetic nurse 5
advanced practice patient selection 363, 364b airway establishment and 208
influence for change in nursing patient safety and risk anaesthesia induction and 208
practice 12 management in 375–378 anaesthesia maintenance and
formal development for 13 post-discharge and 375, 375b 208–210
advanced practice nurse (APN) 8, preoperative patient preparation assessment by 195–196
21–23 in 372–374 clinical handover and 211
390
Index
general anaesthesia emergence Australian Council on Healthcare cardiovascular system, patient

and 210–211 Standards (ACHS) 60–61, positioning and 238–242
laryngoscopy and intubation and 361, 363, 375 ceiling-mounted endoscopic
208 Australian Nursing & Midwifery equipment 295f
role responsibilities of 5b Federation (ANMF) 15–16 ceilings, doors, floors and walls, of
anaesthetic rooms 102 aviation lessons, for non-technical operating suite 106
analgesics 198, 214, 348–350 skills 33–35, 34b central neural blockade 214–217,
anaphylaxis 223 216f, 339–340
ancillary worker roles 20–21
ANMF see Australian Nursing &
B central venous pressure (CVP) 220
checklists. See also Surgical Safety
Midwifery Federation bacteria 129–130 Checklist
anterior surgical incisions 307f barbed sutures 287–288, 288b, reducing adverse events 62–63
anticoagulant prophylaxis, for VTE 288f use in clinical handover 56–57
254 bariatric patient chemical safety 119–120
antiemetics 201 airway management of 338b chest drains 325, 326f
antimicrobial stewardship clinical ambulatory care setting and chest X-ray 172
care standard 56b 364–365 chronic wounds 305
ANTT see aseptic non-touch anaesthesia and 226–229, 228t CICO see can’t intubate, can’t
technique airway and ventilation of oxygenate
ANZCA see Australian and New 227–228 circulating nurse 5–6, 6b
Zealand College of intraoperative care of 228–229 circulation monitoring
Anaesthetists in PACU 352 blood pressure 219, 220b
APN see advanced practice nurse POA of 226–227 CVP 220
appeals, for regulatory action 89 transferring and positioning of electrocardiograph and 219
artery clamps 277 234b CJD see Creutzfeldt-Jakob disease
artificial airways 202–203 biochemical mediator release clamps 276–277
asepsis 141–150 311–312 artery 277
asepsis practices, techniques 132, biological wound products 328 crushing 277
141–150, 143f–144f, 144b, blood pressure 219, 220b, 339 non-crushing 277
146f–148f blood transfusions 223 clinical audit 65–67, 66b–68b, 67f
aseptic field, pouring liquids onto consent to treatment and 82 in clinical governance 48f
143, 145f Jehovah’s Witness and 82, 83b clinical governance 48–49, 48f–49f
aseptic non-touch technique blunt dissection 273 clinical handover 57, 211
(ANTT) 145–146 body defences see normal body ISBAR, ISOBAR 57
ASIORNA see Asian Perioperative defences PACU and 334–335, 336f, 352
Nurses Association body part or hair return 185, 186f clip applicator 316f
Asian Perioperative Nurses bolster/tie-over dressings 323 closed gloving 147–148
Association (ASIORNA) 17 bone wax 317 closed wound drainage system
Aspergillus fumigatus 130 Bookwalter retractor 277f 325, 325f
aspiration pneumonitis 345 bowel cancer screening 362b C-MAC video laryngoscope 212f
aspiration 213–214 bronchospasm 213, 344 codeine, in paediatric patient 350
assertiveness, graded 41–43, 42b colonoscope, flexible 366f
assisted gloving 148
Association of periOperative
C colonoscopy 373–375
bowel preparation for 373
Registered Nurses (AORN) C. difficile 130 common law 76
16–17 camera use within hospitals 92, health policies and professional
evidence-appraisal tool 21 294f practice standards 76–77
atrial fibrillation, RFA for cannula 293f statutes and 76–85, 76t
370–372 can’t intubate, can’t oxygenate communication 35–37
Australian and New Zealand (CICO), during anaesthesia competency 10
College of Anaesthetists 211b in regulatory environment 8–9
(ANZCA) 194 capillary permeability, increase in professional practice standards
Australian College of Nursing 312 17
(ACN) 13 capnography 221 complaints
Australian College of Operating cardiac catheterisation, post- assessment of 86–87
Room Nurses (ACORN) 9f, procedure care following notifications and 85
15–16, 15b, 135b 374b sexual harassment 36b
391
Index
confidentiality 89–91
confocal laser endomicroscopy 368
dementia patients, ambulatory care
setting and 365
E
consciousness level, in PACU 339 depolarising neuromuscular EBP see evidence-based practice
consent to treatment 79–82, 184 blockers 198 EBUS see endobronchial ultrasound
contact precautions 140 deteriorating patient 341 ECG see electrocardiography
continuing professional diabetes patients 176–177, 178f, ECT see electroconvulsive therapy
development (CPD) 12–13 351–352 EDO see extended day only
professional portfolios, keeping diagnostic procedures, in EHR see electronic health record
records 14b ambulatory care setting elderly patients
continuous running/locking blanket 366–368 ambulatory care setting and
stitch 320 diathermy see electrosurgery 365
coroners’ courts 83–84 bipolar, monopolar 109–110, anaesthesia and 226, 227t
cough etiquette, respiratory hygiene 110f in PACU 351–352
and 139 diclofenac 350 perioperative implications of
count see surgical count difficult airway 211–212 257b
CPD see continuing professional discharge criteria, for PACU 352, surgical complications of 256
development 352b–353b, 354f electrical safety. See also workplace
Creutzfeldt-Jakob disease (CJD) dissecting forceps 274–275 health and safety
155–156 dissecting instrument see cutting extension cords, macroshock,
cricoid pressure 207f and dissecting instruments microshock 108–109
crushing clamps 277 distributed expertise 35 electrocardiography (ECG) 172–
cultural competence, cultural safety doctor-led pre-admission 173, 219, 339
and 4b service 170b electroconvulsive therapy (ECT)
cultural safety 3, 4b documentation 84–85 81–82
cultural sensitivity 174 double gloving 147 electrolyte balance 221–223,
culture, religion, surgery and drain sutures 321 222t
82–83 drains 324–325 electronic health record (EHR) 85
curved needles 291f active 325 electrosurgery 318
cutting and dissecting instruments chest 325, 326f hazards of 110–111
273 closed wound drainage system related equipment for 111–112
cutting-edge needles 289 325, 325f safe use of 112b
CVP see central venous pressure gastric decompression 325 electrosurgical equipment 109
passive 325 electrosurgical unit (ESU) 109–
D specialised 325
for uncomplicated laparoscopic
110. See also patient return
electrode
day surgery cholecystectomy 324b EMD see endoscopic submucosal
advantages of 361–363 urinary 325 dissection
general discharge information draping patient 150 emergency situations, accountable
post angiogram 376f dressings items influenced by 263
growth of 359–363 application of 324 emotional intelligence 39, 39f
in New Zealand 360 types of 323–324 EMR see endoscopic mucosal
debridement 315 bolster/tie-over 323 resection
decision making dry sterile 323 endobronchial ultrasound (EBUS)
ancillary worker roles 21 hydrocolloid 323–324 367
in regulatory environment 8–12, one-layer 323 endocystoscopy 368
11b–12b pressure 323 endoscope reprocesser 377f
dedicated operating room 104 silver 324 endoscope
deep vein thrombosis (DVT) 179, skin closure 323 flexible 365–372, 366f, 367b
254b stent 323 rigid 294f
delegation three-layer 323 endoscopic mucosal resection
accountability 11b vacuum-assisted 324 (EMR) 369b
ancillary worker roles 21 wet-to-dry 323 endoscopic retrograde
APN role 22 for wound care 321–324 cholangiopancreatography
CPD activity 14b droplet precautions 140 (ERCP) 368
in regulatory environment 9f, dry heat sterilisation method 154 endoscopic submucosal dissection
10–12 dry sterile dressings 323 (EMD) 368
delirium, causes and management dual corridor see racetrack style endoscopic ultrasound (EUS)
of 366b DVT see deep vein thrombosis 366–367
392
Index
endoscopy 368f ESBL see extended spectrum beta freestanding private day surgery
capsule camera 367f lactamase hospitals, classification of
ceiling-mounted equipment for Esmarch bandage 317f 360b
295f ESU see electrosurgical unit friction, integumentary system and
equipment care for 376–378 ethylene oxide gas (ETO) 237
growth of 359–363 sterilisation method fungi 130
instrumentation used in 295f 154–155
postoperative nursing care
following 374–375
ETT see endotracheal tube
European Pressure Ulcer Advisory
G
preoperation patient preparation Panel (EPUAP) 237, 238b gamma radiation sterilisation
for 373 EUS see endoscopic ultrasound method 155
procedures and uses of 367b Evaluation and Quality gas plasma sterilisation method
endotracheal tube (ETT) 245 Improvement Program 155
correct position of 208–210 (EQuIP) 60–61 gastric decompression 325
general anaesthesia evidence-based practice (EBP) Gastroenterological Nurses
and 204–206 17–19 College of Australia
uncuffed 226f AORN evidence-appraisal tool (GENCA) 369
endovascular procedures 21 Gastroenterological Society of
diagnostic and interventional explosion prevention 115–117 Australia (GESA) 376
369–370, 371b extended day only (EDO) 359 GelPoint access platform, for MIS
postoperative nursing care extended spectrum beta lactamase 298b
following 374–375 (ESBL) 132 GENCA see Gastroenterological
preoperative patient preparation external barriers 133–134 Nurses College of
for 373–374 eye protection 139 Australia
enrolled nurse 179 general anaesthesia 196–201
environmental cleaning 140
contact precautions and 140
F adjuncts to 198, 200t
analgesics 198
environmental controls face mask 138–139 antiemetics 201
healthcare personnel attire for general anaesthesia 203 awareness under 202b
135–137, 136f one hand hold of 204f clinical handover and 211
for infection prevention paediatric 226f emergence from 210–211
135–137 Facebook, unprofessional conduct muscle relaxants 198–201
environmental factors 39–41 and 92b nursing considerations during
ergonomics and 40 fasting, for anaesthesia 225b 208–211
graded assertiveness 41–43, 42b fentanyl 349 pharmacological agents used in
noise and distraction and 40– fibrin glue 318, 322b 197–198
41, 120 fibroblasts 312–313 procedure for preparation 201–
sterile cockpit and 41 fine-needle aspiration 368 211, 205f–206f, 212f
task management and 39–40 fire prevention 113, 115–117 sequence of 208, 209t
environmentally controlled airway fires 116b GESA see Gastroenterological
unit 98 flipping, of sterile supplies 144b, Society of Australia
epidural anaesthesia 215 144f glidescope 212f
administration of 216–217 fluid and electrolyte balance gloves, non-sterile 138
error with 217b 221–223 gloving 147–149, 148f
spinal anaesthesia compared to fluid labelling 64–65 assisted 148
216t food and drink in clinical areas closed 147–148
epithelialisation 313 139 double 147
EPUAP see European Pressure Ulcer forceps gowning 147, 147f–148f
Advisory Panel dissecting 274–275 graded assertiveness see
EQuIP see Evaluation and Quality needle holders 275–276, 276f assertiveness, graded
Improvement Program sponge-holding 276 graduated compression stockings
equipment see surgical instrument tissue 274–275, 275f 254b
ERCP see endoscopic retrograde towel clips 275 Gram-positive cocci 129–130
cholangiopancreatography formal development 13–15, 14b enterococci 129–130
ergonomics 40 Fowler’s position, for surgery staphylococci 129
errors 49–50, 52f, 57f 247–251 streptococci 129
with medication 50, 52f, 56, fracture table position, for Gram-positive rods 130
63–65 surgery 251, 251f granulation 313
393
Index
grasping and holding instruments hydraulic lift-assisted stirrups 249f infection, as adverse event 134
273–276 hydrocolloid dressings 323–324 infectious agent, as link in chain of
dissecting forceps 274–275 hypertension 346 infection 132
tissue forceps 274–275, 275f hyperthermia 345 inflammatory phase, of wound
growth factors, wound management hypotension 346 healing 311–312
and 328 hypoventilation 344 biochemical mediator release
hypoxaemia 341 311–312
H capillary permeability, increase
haemodynamic monitoring
I in 312
haemostasis 311, 312f
during anaesthesia 218–221 ibuprofen 350 phagocytosis 312
blood transfusion 223 ICN see International Council of plasma protein systems 312
of circulation 219–220, 220b Nurses vasodilation 312
fluid and electrolyte balance ICSP see International Council on inflammatory response 134
221–223, 222t Surgical Plume inhalational agents 197–198, 199t
monitor for 219f IFPN see International Federation injectable medicine labelling
respiration 220–221 of Perioperative Nurses 64–65
temperature 221 immediate action, disciplinary 87, instrument nurse 6, 7b
haemostasis 311, 312f 88b, 88t instrumentation 272
chemical methods 318, 322b immune response 134 care of 281
mechanical methods 315–317, impaired registrants panel (IRP) 87 in endoscopy 295f
316f–317f implantable tissue repair, for wound instruments see surgical
surgical methods 315–319 management 326–327, 327f instruments
hair removal inadvertent perioperative integumentary system
preoperative 177 hypothermia (IPH) 208– friction and 237
SSIs and 141t 210, 253f, 345 moisture and 237
for surgical patients 177b adverse effects of 255 patient positioning and
hand hygiene 137, 138t, 146f patients at risk of 255 236–238
HCCC v Burggraaff (2012) 91b prevention and management of pressure and 236–237, 237f
health policies 76–77 255–256 pressure injury prevention and
Health Practitioner Competence incident management 237–238
Assurance Act 8–9, 9f in clinical governance 48f, 55 shear and 237
Health Practitioner Regulation reporting, Severity Assessment interdisciplinary team 30–31
National Law 8–9, 9f Code (SAC) tools, root cause International Council of Nurses
health workforce innovations, analysis (RCA) processes, (ICN) 15
medical colleges and 23b significant incident review International Council on Surgical
healthcare personnel attire 135– process (SIRP) 51–52 Plume (ICSP) 115b
137, 136f systems 59 International Federation of
high spinal/epidural block 345 Indigenous, Māori and Pacific Perioperative Nurses (IFPN)
holding area, admission to 179 Islander peoples, surgical 17
holding instruments see grasping intervention rates of 362b International Perioperative
and holding instruments infection control and prevention Associations 16–17
hospitals, camera use within 92 128–159, 137b, 376 interventional radiography, growth
Hovermatt adjustable positioning control practices 134–141 of 359–363
device 228f environmental controls and intraoperative patient care
human factors 32–43 135–137 232–268
communication 35–37 microorganisms classification and bariatric patient and 228–229
components of 33f types 129–132 patient positioning and
leadership and multigenerational microorganisms risk management 233–251
workforce 38–39 132–133 intravenous (IV)
non-technical skills 33–39, 34b normal body defences for general anaesthesia agents 197,
shared mental models 37, 37f 133–134 199t
situation awareness 37–38, 38b patient considerations in line label 196f
teamwork 35 140–141 intubation
humidity, of operating suite 106 standard precautions for 137– complications of 207
hybrid operating room 104–105, 140, 149–150 equipment for 206–207, 206f
105f sterilisation for 153–157 laryngoscopy and 208
394
Index
investigation 87–89 ligating clips 316–317 susceptible host 133

IPH see inadvertent perioperative ligature/ties 316 transmission 132
hypothermia lighting, in operating suite viruses 130–131
IRP see impaired registrants panel 107–108 minimally invasive surgery (MIS)
IV see intravenous lithotomy position, for surgery 105, 291–300
247, 248f–250f, 250t advances in 297–300
J LMA see laryngeal mask airway
loading needles 291
blunt tip laparoscopic sealer 296f
camera and video set-up for 294f
Jehovah’s Witness, blood local anaesthesia 214–218, 350 ceiling-mounted endoscopic
transfusions and 82, 83b infiltration of 218 equipment for 295f
jewellery and piercings, operating toxicity of 218, 218b clip applicator 296f
suite care with 185 endo GIA stapler 296f
M endo shear 297f
K malignant hyperthermia (MH) 59b,
endocatch bag 296f
endograsp instrument 296f
ketamine 350 223–224 equipment for 295–297
Mallampati assessment 195, 195f exposure and 292–294
L mandatory notifications 85–86
manual handling, of patients 114,
GelPoint access platform 298b
laparoscopic stapler 297f
labelling 114b paediatric considerations for
of injectable medicines, fluids manual retractors 277f 297
and lines 64–65 maturation phase, of wound performance of 295
of intravenous line 196f healing 313 ports for 293f
pre-printed container examples Mayo table 280f robotic instruments 300f
of 65f MDR-TB see multidrug-resistant OR set-up for 297, 299f
laminar airflow (LAF) ventilation tuberculosis single-entry access platform 298f
system 107b mechanical prophylaxis, for VTE surgery sequence for abdominal
Langer’s lines 306 254 292
Langley & Another Glandore Pty Ltd medical colleges, health workforce trocar and cannula for 293f
(in Liq) & Another (1997) innovations and 23b Versaport 294f
78–79, 78b medication errors 50, 56, 63, 65, visualisation for 294–295
laparoscopic cholecystectomy, 77, 88b minors, consent to treatment and
drains for 324b medication management 63–65 81
laryngeal mask airway (LMA) 203– injectable medicines, fluids and MIS see minimally invasive surgery
204, 212f lines labelling 64–65, 64f, miscommunication 36
insertion of 205f 65f Mobile Health Solutions (MHS)
in situ 205f special populations and 66b 360–361, 362b
laryngoscope Medigus ultrasonic surgical MOC see models of care
C-MAC video 212f endostapler 370b, 370f models of care (MOC) 359
for paediatric patient 225f mental illness, consent to treatment in perioperative environments
use of 210f and 81–82 358–382
laryngoscopy 208, 210f MH see malignant hyperthermia in South Australia 361b
laryngospasm 212–213, 343 MHS see Mobile Health Solutions moisture, integumentary system
management 212–213 microorganisms and 237
management flowchart for 213f antimicrobial drug resistance monofilament sutures 285, 286f
in PACU 343 for 132 monopolar diathermy 109, 110f
laser 112–113, 113f. See also bacteria 129–130 morphine 348–349
International Council on classification and types of multidrug-resistant tuberculosis
Surgical Plume 129–132 (MDR-TB) 132
laser safety officer (LSO) 113 common types of 131t multifilament sutures 285, 286f
lateral position, for surgery 245– fungi 130 multigenerational workforce,
247, 247f, 248t prions 131 leadership and 38–39
latex allergies 117 risk management of multiple-layer closure 320
patient precaution for 118b infectious agent 132 muscle relaxants 198–201
prevention of 117 portal of entry 132–133 depolarising neuromuscular
leadership, multigenerational portal of exit 132 blocker 198
workforce and 38–39 reservoir 132 inadequate reversal of 344
395
Index
muscle relaxants (Continued) nervous system, patient positioning nursing, definition of 75b
non-depolarising neuromuscular and 238 nursing practice
blocker 201 neuraxial anaesthesia 339–340 change influences in 12, 12b
musculoskeletal system, patient New Zealand decision guide for 12b
positioning and 238 accountability perspective 11b scope of 11–12
day surgery in 360 perioperative nursing roles
N MHS in 360–361, 362b
OR admission checklist 183f
5–9
scope of practice 9f, 10–12,
National Pressure Ulcer Advisory retained surgical items reported 11b–12b
Panel (NPUAP) 237, 238b in 53f nursing specialisation, opportunities
National Safety and Quality Health New Zealand Nurses Organisation created for 19–20
Service (NSQHS) Standards (NZNO) 5, 16, 49, 77 NZNO see New Zealand Nurses
53–59, 54f, 56b, 60b regulatory and professional Organisation
acute health-care clinical entities of relevance 9f
deterioration 58
blood and blood products 57–58
NMBA see Nursing and Midwifery
Board of Australia
O
clinical handover 57 noise and distraction 40–41, 120, obese patients
consumer partnering and 55 121b manual handling and 114b
falls prevention and 58–59 non-crushing clamps 277 surgery assessment and
healthcare-association infection non-depolarising neuromuscular preparation for 176
prevention and control blockers 201 wound healing and 315b.
55–56 non-sterile gloves 138 See also bariatric patient
medication safety 56 non-steroidal anti-inflammatory occupational exposure 117–120
patient identification and drugs 349–350 chemical safety and 119–120
procedure matching 56–57, non-technical skills 33–39, 34b radiation safety and 117–119
57b non-traditional environments 359 oesphageal variceal banding 368f
pressure injury prevention and normal body defences 133–134 one-layer dressings 323
management 58 external barriers 133–134 open disclosure 77–78
Version 2 59, 60b immune response 134 in clinical governance 48
National Standards see NSQHS inflammatory response 134 definition 54–55
Standards normothermia, management operating rooms (ORs) 98
natural-orifice transluminal strategies for 255–256 dedicated 104
endoscopic surgery (NOTES) NOTES See natural-orifice hybrid 104–105, 105f
105, 369b transluminal endoscopic MIS set-up in 297, 299f
NCNZ see Nursing Council of New surgery moving around 145
Zealand notifications preparation of 120–121
needle holders 275–276, 276f, assessment of 86–87 room cleaning 120
291f complaints and 85 terminal cleaning 120–121
needles 281–291 mandatory 85–86 standard 104, 104f
anatomy of 288–289 NP see nurse practitioner operating suite
body of 290 NPUAP see National Pressure Ulcer Australian admission checklist
curved 291f Advisory Panel for 180f–182f
cutting-edge 289 NSQHS see National Safety and New Zealand admission checklist
loading 291 Quality Health Service for 183f
ordinary 290 Standards preoperative care in 179–187
point types of 289–290, 290f nurse endoscopist 22, 365–366 allergies and sensitivities 184
swaged 290 nurse practitioner (NP) 5, 8b body part or hair return 185,
taper point 289–290 nurse sedationist 23 186f
types and uses of 289t nurse-led clinics 163 consent 184
negligence 77–79 Nursing and Midwifery Board of implants 185
nerves Australia (NMBA) 75 jewellery and piercing 185
of inner thigh 241f regulatory and professional patient identification 184
of right leg 242f entities of relevance 9f patient warming 185–187
sciatic 242f Nursing Council of New Zealand premedication and
of thigh and upper leg 242f (NCNZ) 3 medications 184–185
of upper forearm 243f regulatory and professional preoperative fasting 184
of upper limb 242f entities of relevance 9f zones 101–102
396
Index
operating suite design 98–101, fasting and 225b peripheral nerve injury and 241t
105–108 temperature of 225 surgical positions 242–251
Australasian health facility codeine and 350 patient pre-assessment health
guidelines 98 face mask for 226f questionnaire 164f–165f
ceilings, doors, floors and walls laryngoscope for 225f patient return electrode
106, 108b MIS and 297 application of 111b
humidity 106 in PACU 351 reusable capacitive pad 110f
lighting 107–108 surgery assessment and single-use split pad 110f
operating suite zones, preparation of 171, 224 patient safety 233
unrestricted, semi-restricted, underbody body blanket for adverse and sentinel events
restricted 101–102 226f and 49–52
racetrack style corridor 99f pain assessment 347–351, 348f in ambulatory care setting
single corridor 99f pain management, in PACU 375–378
small cluster 100f 347–351 clinical governance and 49f
technological advances in acute pain service 351 professional practice standards
105 non-pharmacological 350–351 and 61–62
temperature 106 pain assessment and 347–351 quality and 52–62
traffic flow through 101f Pan Pacific Pressure Injury Alliance retained surgical items and 53f,
ventilation system 106–107, (PPPIA) 237, 238b 260–263
108b panel and committee hearings, for risk management and 49–52
windows 105 regulatory action 86t, 89 wrong site surgeries 52f,
operating suite layout 102–105, paracetamol 350 256–259
279f PACU see postanaesthesia care unit patient selection, in ambulatory
anaesthetic rooms 102 passive drains 325 care setting 363, 364b
Australasian health facility patient acceptance, in ambulatory patient transfer 233–236
guidelines 98 care setting 363 of bariatric patients 234b
changing rooms 102 patient advocate 3–4 complications of 235–236
operating suite zones, patient care methods and rationales of 235
unrestricted, semi-restricted, during anaesthesia 193–231 patient warming 185–187
restricted 101–102 social media and 92–93. See also patties 317
PACU 102–103 intraoperative patient care PE see pulmonary embolus
preoperative holding bay 102 patient education and information PEEP see positive end-expiratory
reception 102 163–171 pressure
scrub bays 104 patient identification 184 peracetic acid 155
staff rooms 102 patient journey performance, complaint of 86
sterile stock room 102 contribution of perioperative Performance Review Panel (PRP)
sterilising department 103 roles to the 6–9 86
storage areas 102 nursing students following the perioperative environment
opioid analgesics 348–349 19 97–127
ordinary needles 290 perioperative 2–3, 3f culture and context of 32
orientation programs patient journey, in ambulatory care hand hygiene in 138t
sample content 20b settings 363 MOC 358–382
students and clinical placements patient acceptance 363 noise and 120
20 patient selection 363, 364b sights, sounds and smells in
ORs see operating rooms patient positioning 233–251 121b
oxidised cellulose 318 anatomical and physiological perioperative equipment, fires in
oxytocin 318 considerations for 236–242 116b
cardiovascular system perioperative nurse practitioner 8,
P 238–242
integumentary system
23b–24b
Perioperative Nurses College of
packing 317 236–238 the New Zealand Nurses
paediatric patient musculoskeletal system 238 Organisation (PNC NZNO)
ambulatory care setting and nervous system 238 9f, 16
363–364 respiratory system 242 perioperative nursing 1–29
anaesthesia and 224–226 Hovermatt adjustable positioning future of 19–23
drugs and IV fluids 225–226 device for 228f philosophy of 2
equipment for 224 patient transfer and 233–236 roles 4–8
397
Index
perioperative nursing care record complications and 341–347 postanaesthesia care unit (PACU)
239f–240f airway and breathing nurse 5, 7
perioperative nursing standards see complications 341–344 role, responsibilities of 8b, 332
professional practice aspiration pneumonitis 345 post-discharge 375, 375b, 376f
standards, professional bronchospasm 344 post-intubation croup 343–344
standards deteriorating patient 341 postoperative delirium 346–347,
perioperative patient safety high spinal/epidural block 345 366b
47–73 hypertension 346 postoperative nausea and vomiting
clinical governance and 48–49, hyperthermia 345 (PONV) 344–345
48f hypotension 346 postoperative nursing care,
perioperative registered nurse, hypoventilation 344 following endoscopic and
changing, evolving and hypoxaemia 341 endovascular procedures
advancing roles for 21–23 IPH 345 374–375
perioperative team 30–46 laryngospasm 343 pouring liquids, on aseptic
peripheral nerve injury, patient muscle relaxant inadequate field 143, 145f
positioning and 241t reversal 344 PPE see personal protective
personal protective equipment PONV 344–345 equipment
(PPE) 103, 138–139 post-intubation croup/ PPPIA see Pan Pacific Pressure
appropriate care of 119f subglottal oedema 343–344 Injury Alliance
eye protection 139 postoperative delirium practice standards see professional
face mask 138–139, 203, 204f, 346–347 practice standards,
226f respiratory 342t professional standards
food and drink in clinical areas secretions/blood obstructions preadmission nurse 5
139 341–342 pre-admission stage 161–163,
inappropriate care of 119f shock 346 163b
non-sterile gloves 138 tongue obstruction 341 pre-anaesthetic assessment
respiratory hygiene and cough urinary retention 346 194–196
etiquette 139 design features of 332–334, 333f airway 194–195
sharps safety and 139 diabetes patients in 351–352 Mallampati assessment 195
pethidine 349 discharge criteria system and preoperative assessment (POA)
phagocytosis 312 352, 352b–353b 161–163, 161f
pharmacological agents, in general elderly patient in 351–352 of bariatric patient 226–227
anaesthesia 197–198 equipment requirements goals of 162f
plasma protein systems 312 333–334 preoperative bathing 177
pledgets 317 function of 332 preoperative care 179–187
PNC NZNO see Perioperative Nurses ISOBAR in 335f, 354f allergies and sensitivities 184
College of the New Zealand nurse role in 332 body part or hair return 185,
Nurses Organisation paediatric patient in 351 186f
pneumatic tourniquet 317f pain management in 347–351 consent 184
POA see preoperative assessment acute pain service 351 implants 185
PONV see postoperative nausea and pain assessment 347–351 jewellery and piercing 185
vomiting pharmacological patient identification 184
portal of entry, as link in chain of interventions 348–350 patient warming 185–187
infection 132–133 patient management in premedication and medications
portal of exit, as link in chain of 335–341 184–185
infection 132 blood pressure 339 preoperative fasting 184
portfolios, professional 13, 14b cardiovascular assessment 339 preoperative fasting 184
ports, types of 293f consciousness level 339 preoperative holding bay 102
positive end-expiratory pressure ECG 339 preoperative patient preparation
(PEEP) 212–213 general comfort measures in ambulatory care setting
postanaesthesia care unit (PACU) 340–341 372–374
102–103, 331–357 heart rate 339 for endovascular procedures
airway assessment 336–337, initial 335 373–374
337b temperature control 340 for flexible endoscopic procedures
bariatric patients in 352 patient observation and 373
clinical handover and 334–335, monitoring 337–339 pre-procedure screening tool
336f, 352 recovery stages and 334f 166f–169f
398
Index
pressure dressings 323 reconstructive phase, of wound retractors 277–278

pressure injuries, prevention of healing 312–313 Bookwalter 277f
237–238 epithelialisation 313 manual 277f
pressure fibroblasts 312–313 reusable medical devices (RMDs)
injury prevention 237–238 granulation 313 150–151
integumentary system and wound contraction 313 decontamination and cleaning
236–237 regional anaesthesia 218 of 151–152
tissues affected by 237f registered nurse first surgical inspection, assembly and
primary intention wound healing assistant (RNFSA) 6–7 packaging of 152–153
313–314 regulatory action and disciplinary reprocessing and storage of 151t
prions 131 hearings storage of 157
privacy see confidentiality Australian Nursing Board Panel reusable patient return electrode
professional associations, role of Decisions 86t capacitive pad 110f
15–17. See also ACN; ACORN; immediate action 89 reverse Trendelenburg position,
ANMF; AORN; ASIORNA; investigation 87–89 for surgery 244–245, 245f,
ICN; IFPN; NZNO; PNC mandatory notifications 85–86 246t
NZNO monitoring and compliance for RFA see radiofrequency ablation
professional conduct 88b 89 Ring-Adair-Elwyn (RAE) tubes
professional development notifications and complaints 85 205–206
ACORN’s essential values for panel and committee hearings ring-handled instrument 272, 272f
15b for 86t, 89 rinsing hands 146f
formal 13–15, 14b tribunal hearings 89 risk management
informal and continuing 12–13 regulatory environment 8–12 in ambulatory care setting
professional hierarchy, perioperative accountability, delegation and 375–378
team and 31–32 supervision relationships patient safety and 49–52
professional misconduct 87b–88b within 10–11, 11b RMDs see reusable medical devices
professional nursing associations competency and 10 RNFSA see registered nurse first
15–16 inconsistencies in 10b surgical assistant
professional practice standards 9f, regulatory and professional robotic instruments 300f
17, 61–62, 76–77 entities of relevance 9f Rogers v Whitaker (1992) 79, 80b
and patient safety 61–62 religion 82–83, 83b room cleaning 120
professional standards 87 replacement material, for wound RSI see retention of surgical item
prone position, for surgery 245, management 326–327, 327f
246f, 247t
propofol 197
research
evidence-based practice and
S
PRP see Performance Review Panel 17–19 scaffolds 328
pulmonary embolus (PE) 251 on perioperative bathing 18b scalpel 273
pulse oximetry 220–221 perioperative practice areas for science, religion vs 83b
18b scissors 273, 274f
Q reservoir, as link in chain of
infection 132
scope of practice 9f, 10–12,
11b–12b
quality, patient safety and 52–62 residual current devices (RCD) 108 perioperative nursing roles 5–9
in clinical governance 48–49, respiration monitoring 220–221, scrubbing 128
48f 336–337 secondary intention wound healing
capnography 221 314
R pulse oximetry 220–221
respiratory hygiene, cough etiquette
secretions/blood obstructions
341–342
racetrack style (dual corridor) 99f and 139 sedation/analgesia 214
radiation safety 117–119, respiratory system, patient semi-Fowler’s position, for surgery
118f–119f positioning and 242 247–251
radiofrequency ablation (RFA), for restricted operating suite zones semi-restricted operating suite
atrial fibrillation 370–372 102 zones 102
RAE see Ring-Adair-Elwyn tubes retained surgical items, reported in sensitivities and allergies 117, 184
rapid sequence induction New Zealand 53f sentinel events 52f, 53f
207–208 retention of surgical item (RSI) patient safety and 49–52
RCD see residual current devices 260–261 reporting on, in Australasia
reception 102 retention sutures 320–321 50–52
399
Index
serotonin syndrome 350 standard precautions, for infection day 359–363

sexual harassment complaints 36b prevention 137–140 elderly complications from
shared mental models 37, 37f draping of patient 150 256
sharp dissection 273 environmental cleaning 140 selection factors for 171–174
scalpel 273 hand hygiene 137 surgery assessment
scissors 273, 274f PPE 138–139 physical status classification
sharps safety 139, 291 skin preparation 149–150 system 173t
shear, integumentary system and standards see professional practice surgery assessment and preparation
237 standards, professional 160–192
shock 346 standards cultural sensitivity and 174
short-stay procedure 359 staples, for wound closure 321, immediate preoperative period
silver dressings 324 321f 177–179
simple continuous sutures 320 statutes 76–85, 76t DVT prevention 179
simple interrupted sutures 320 steam sterilisation method preoperative bathing 177
single corridor 99f 153–154 preoperative hair removal
single-layer closure 320 steep Trendelenburg position see 177
single-use patient return electrode lithotomy position, for surgical site marking 177
split pad 110f surgery patient education and
situation awareness 37–38, 38b stent dressings 323 information 163–171
skin adhesives 287 stents 372, 372t patient pre-assessment health
skin anatomy, wound healing and sterile 141 questionnaire 164f–165f
305, 305f sterile cockpit 41 patient selection and assessment
skin closure 287b, 323 sterile stock room 102, 103b for 161–163, 163b
skin integrity 237–238 sterile supplies nurse-led clinics 163
skin preparation 149–150, 149f flipping of 144b, 144f patient selection 161
alcohol-based solutions for 149 opening of 142, 143f POA 161–163, 161f–162f
procedure for 149–150 presentation of 143f pre-admission stage 161–163
small cluster 100f storage of 103b preoperative investigations for
smoke evacuation see surgical sterilisation 153–157, 154t 172–174
plume disinfection 156–157 pre-procedure screening tool
smoking 174–176 dry heat 154 166f–169f
cessation for surgery 175b ETO 154–155 selection factors 171–174
effects of 175b gamma radiation 155 blood investigations 173
smoke evacuation see surgical gas plasma 155 chest X-rays 172
plume monitoring processes of 156 electrocardiography 172–173
social media 91–93 peracetic acid 155 other considerations for
misuse of 91–92 steam 153–154 173–174
patient care and 92–93 tracking and traceability of 156 paediatric patients and 171,
South Australia, MOC in 361b sterilising department 103 224
specialised drains 325 storage areas 102 preoperative visiting 174
specimens, identification, collection strikethrough 150 special populations,
and handling of 263, subarachnoid anaesthesia see spinal considerations for 174–177
263t–264t anaesthesia ambulatory settings 363–365
spinal anaesthesia 214 subcutaneous sutures 320 diabetes 176–177, 178f
administration of 216–217 subglottal oedema 343–344 obesity 176
epidural anaesthesia compared substitute consent 80 smoking 174–176, 175b
to 216t supervision surgery sequence 271–272, 272f,
spinal cord 215f ancillary worker roles 21 292f
splash bowl 280f changing, evolving and advanced for abdominal MIS 292
sponge-holding forceps 276 roles 22–23 concepts for 271f
SSC see Surgical Safety Checklist in regulatory environment stages of 271–272
SSIs see surgical site infections 10–11 surgery site, ensuring correct
staff rooms 102 supine position, for surgery 244, 256–259
standards see professional practice 245t surgical assistant nurse
standards, professional surgery role, responsibilities of 6–7, 7b
standards common indications for 270t surgical conscience 145
standard operating room 104, 104f culture, religion and 82–83 surgical count 260–261, 262b
400
Index
surgical incisions 306 Surgical Safety Checklist (SSC) 5, TCI devices see target-controlled
abdominal incisions 306, 307f, 34–35, 34b, 49, 62, 218, 256, infusion devices
308t–309t 258f teamwork 35
anterior 307f methodologies 63b temperature monitoring 221, 225,
landmarks for 306f surgical scrub 146–147, 146f 340
Langer’s lines 306 surgical site infections (SSIs) terminal cleaning 120–121
surgical instruments 272–281 129 tertiary intention wound healing
assembly of 152 ‘bundle’ approach to 141t 314
categories for 272–278 hair removal and 141t Therapeutic Goods Administration
clamp 276–277 surgical site marking 177 (TGA) 372, 377
cutting and dissecting 273 surgical wounds 305, 310b therapeutic interventions, in
grasping and holding 273–276 clean wound 310 ambulatory care
miscellaneous/ancillary/ clean-contaminated wound setting 368–369
accessory 278 310 three-layer dressings 323
retractors 277–278 contaminated 310 thrombin (Thrombostat) 318
cleaning, decontamination and dirty (infected) 310 Time Out 40, 57, 149, 257
sterilisation of 150–153 surgical-historical perspective tissue forceps 274–275, 275f
decontamination and cleaning 270–271 tissue specimen, identification,
of 151–152 operative techniques 271f collection and handling
handling of 278–281 susceptible host 133 of 263, 263t–264t
inspection, assembly and sutures 281–291 TIVA see total intravenous
packaging of 152–153 absorbable/non-absorbable anaesthesia
Mayo table and splash bowl for materials for 281–285 TOE see transoesophageal
280f availability of 282t–284t echocardiogram
for mechanical haemostasis 316 barbed 287–288, 288b, 288f tongue obstruction 341
for MIS 293f–294f, 295–297 handling characteristics of total intravenous anaesthesia
packaging of 152–153 285–287 (TIVA) 197
passing 278–281, 278t–279t, capillarity 286 tourniquets 259–260, 317
279f elasticity or memory 286 inflation pressures for 260t
ring-handled 272, 272f pliability and coefficient pneumatic 317f
robotic 300f friction 286 use of 259–260
symbols for 153f tensile and knot strength towel clips 275
table layout for 280f. See also 286–287 tracking 156
needles; reusable medical material gauge 285, 285f traffic patterns, through operating
devices; sutures material properties of suite 101
surgical intervention 269–303 281–285 tramadol 349
instruments for 272–281 monofilament and multifilament transmission of micoorganisms
MIS 291–300 285, 286f 132
sharps safety and 291 natural/synthetic materials for transmission-based precautions
surgery sequence and 271–272, 285 140
271f–272f, 292f packet example 285f transoesophageal echocardiogram
surgical-historical perspective relative sizes of 286f (TOE) 370, 371f
270–271 ties and 285 traumatic wounds 305
sutures and needles for 281–291 tissue reaction, characteristics treatment consent 79–82
surgical landmarks 306f of 287 Trendelenburg position, for
surgical plume 110–111, 114–115, suxamethonium 198 surgery 244–245, 245f,
115f, 135b swaged needles 290 246t
surgical positions 242–251 tribunal hearings 89
Fowler’s/semi-Fowler’s 247–251
fracture table position 251, 251f
T trocar and cannula 293f
lateral 245–247, 247f, 248t

lithotomy 247, 248f–250f, 250t
taper point needle 289–290
tapes, for wound closure 321,
U
prone 245, 246f, 247t 322f unprofessional conduct, Facebook
supine position 244, 245t target-controlled infusion (TCI) and 92b
Trendelenburg and reverse devices 197 unregulated worker roles 20–21
Trendelenburg position Targin 349, 349b unrestricted operating suite zone
244–245, 244f, 246t task management 39–40 101
401
Index
upper airway anatomy 204f workplace health and safety 113– wound healing 304–330
upper limb innervation 120. See also electrical safety, continuum of 311f
243f–244f occupational exposure, debridement and 315
urinary drainage 325 personal protective factors affecting 314–315
urinary retention 346 equipment, X-ray protective mechanisms of 313f
equipment obesity and 315b
V trip hazards 108, 121
World Health Organization (WHO)
phases of 309–313
skin anatomy and 305, 305f
vacuum-assisted dressings 324 SCC (Australia and New surgical incisions and 306
vasodilation 312 Zealand) 17, 34–35, 49, 55, types of 313–314
venous thromboembolism (VTE) 141t, 258f, 263 wound management
179, 251 wound care 321–325 biological wound products and
patients at risk of 252b drains 324–325 328
prevention and management of dressings for 321–324 grown factors and 328
251–254 wound closure 319–321 HBOT 328
prevention methods for continuous running/locking implantable tissue repair
252–254 blanket stitch 320 326–327
prophylaxis guide for 253f drain sutures 321 replacement material 326–327
signs and symptoms of 252, methods of 319–321 scaffolds and 328
252t multiple-layer closure 320 skin substitutes for 327–328
ventilation system 106–107 retention sutures 320–321 technological advances in
Versaport 294f simple continuous sutures 325–328
vicarious liability 77 320 wound
viruses 130–131 simple interrupted sutures classification of 309
VTE see venous thromboembolism 320 types of 305. See also surgical
single-layer closure 320 wounds
W staples for 321, 321f
subcutaneous sutures 320
wrong site surgeries 52f
waste management 121–122

wet-to-dry dressings 323
suturing techniques for 320f
tapes for 321, 322f
X
windows, of operating suite 105 tissue adhesives 321 X-ray protective equipment
workplace bullying 35 wound contraction 313 118f–119f
402

Perioperative Nursing

Uploaded by

Copyright:

Available Formats

Perioperative Nursing

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Perioperative Nursing

Uploaded by

Copyright:

Available Formats

You’ve just

Copyright 2016 Elsevier Australia. 1st edition © 2009 Elsevier Australia

All rights reserved. No part of this publication may be reproduced or transmitted

Hamlin, Lois, author.

Senior Content Strategist: Libby Houston

Cover images from:

Chapter 1 Perioperative nursing 1

Chapter 2 The perioperative team and interdisciplinary collaboration 30

Chapter 3 Perioperative patient safety 47

Chapter 4 Medico-legal aspects of perioperative nursing practice 74

Chapter 5 The perioperative environment 97

Chapter 6 Infection prevention and control 128

Chapter 7 Assessment and preparation for surgery 160

Chapter 8 Patient care during anaesthesia 193

Chapter 9 Intraoperative patient care 232

Chapter 10 Surgical intervention 269

Chapter 11 Wound healing 304

Surgical incisions 306

Chapter 12 Postanaesthesia nursing care 331

Chapter 13 Evolving models of care in perioperative environments 358

KIM BRYANT | RN, BN, MEd, GradCert (Adult Ed), MACN

JANNELLE CARLILE | RN, PGCert (OR Nsg), Cert IV TAE, MACORN

MARGARET EVANS | RN, RM, BHlthSc, MPH, CICP

PAULA FORAN | RN, PhD, FACORN, MACN

BRIGID M GILLESPIE | RN, PhD, FACORN

ZOE KUMAR | RN, MN, MACORN

TRACEY LEE | RN, MN (Hons)

BEN LOCKWOOD | RN, BN (Hons), MACORN

MICHELLE LOVE | RN, BN, GradCert (Periop Nsg), MACN

CATIE McCULLAGH | RN, AdvDip (Nsg Stud)

SONYA OSBORNE | RN, PhD, Centaur Fellow, MACN, MACORN

ANN PARKMAN | RN, GradCert (Periop Nsg), GradCert HE, MPET

VICKY WARWICK | RN, MN, GradCert (PNSA), FACORN

SANDRA DE ROME | RN, CNOR, BN, GradCert Mgt, CGHE

ANGELA McKAY | RN, BN (Hons), GradDip (Periop Nsg)

PATRICIA NICHOLSON | RN, RM, PhD, FACORN

JOSEPHINE M PERRY | RN, MSN (Nurse Educator), MACORN

Dr Jed Duff | RN, PhD, FACORN

Dr Sonya Osbourne | RN, PhD, Centaur Fellow, MACN, MACORN

SALLY SUTHERLAND-FRASER, SONYA OSBORNE AND KIM BRYANT

optimal patient outcomes and research-based

FIGURE 1-1: The perioperative patient journey

Perioperative nurses have a duty of care throughout

BOX 1-1 » CULTURAL SAFETY AND CULTURAL COMPETENCE

BOX 1-2 » ROLE RESPONSIBILITIES OF THE ANAESTHETIC NURSE

BOX 1-3 » ROLE RESPONSIBILITIES OF THE CIRCULATING NURSE

BOX 1-4 » ROLE RESPONSIBILITIES OF THE INSTRUMENT NURSE

BOX 1-5 » ROLE RESPONSIBILITIES OF SURGICAL ASSISTANT NURSES

BOX 1-6 » ROLE RESPONSIBILITIES OF THE PACU NURSE

BOX 1-7 » ROLE RESPONSIBILITIES OF THE NP

PERIOPERATIVE NP authority. Box 1-7 details some of the role respon-

Health Practitioner Regulation National Law

Health Practitioner Competence Assurance Act

FEATURE BOX 1-1 » INCONSISTENCIES IN THE REGULATORY SYSTEM

COMPETENCY The NCNZ’s extended definition of accountability

BOX 1-8 » UNDERSTANDING ACCOUNTABILITY: THE NEW ZEALAND PERSPECTIVE

BOX 1-9 » EXAMPLES OF THE PERIOPERATIVE RN’S ACCOUNTABILITY FOR DELEGATED

BOX 1-10 » GUIDE FOR NURSING PRACTICE DECISIONS: STATEMENTS OF PRINCIPLE

BOX 1-11 » INFLUENCES FOR CHANGE IN NURSING PRACTICE