Perioperative Nursing: An OR Nurse
Perioperative Nursing: An OR Nurse
Perioperative Nursing: An OR Nurse
An OR Nurse.
Is a competent dishwasher (figuratively that is). The betadine scrub and paint could make your hands so dry, you wish you have not put any lotion on before going on duty. Instruments are being washed immediately after every case (except for those with infectious disease: the instruments are being soaked). Is a highly-paid factory worker. We are making cherries, prep balls, operative sponges & peanuts are made MANUALLY! Basically if we do not have anything to do, we sit down and fold. Is an expensively-educated janitor. We are cleaning both the patient and the room each and after operation. We are having the so-called DO DAY, rubbing every part of the operating room clean, just to make sure that the rooms are free from microorganism that can cause infection Has strong bladder control. A whole shift operation could make your urge to void disappear. One can only wish that someone would attach a catheter and relieve a full bladder. Comes to work in a full stomach. Youll never know what waits for you when you arrive in the operating room. It might be a minor operation which could last in about 30 minutes or an exploratory laparotomy that could last the whole shift. Is Ambivalent about caffeine. It can be both an enemy and a friend. An enemy because it is a diuretic and nature may call while the doctor is asking for hemostat. A friend because it can keep you awake the whole night. Is great with gift-wrapping. They can wrap an instrument or linens in a records time. It is what we do ALMOST the whole afternoon shift. I used to believe that being an OR nurse would really be a simple task. But no, when I started in the operating room, I find the job less boring and more challenging. The stress level could surge up anytime especially when the patient and the doctor gets toxic or you are too hungry to remain inside the room.The AM shift would always have cases, afternoon shifts will have cases that the morning shift cannot accommodate and some caesarean section. The night shift? Its either an exploratory laparotomy (usually this is the kind of operation done to people who have gunshot or stab wounds), caesarean section and appendectomy. If none, the night shift can sleep the night away after the routine work inside the operating room. Its really a shame that some people would underestimate our work. They never knew what happens inside the complex, unless they get inside. Right? .
STERILE TECHNIQUE
The principles of sterile techniques are considered to be the Holy Commandments inside the Operating Room and should be strictly followed at any given operation.
1. Only Sterile Technique are used within the Sterile Field 2. Sterile person are gowned and gloved 3. Tables are sterile only at table level 4. Sterile person touch only sterile items and areas. Unsterile person touch unsterile one 5. Unsterile person avoid reaching over sterile field, while sterile person avoid learning over unsterile area. 6. The edge of anything that encloses sterile contents are considered unsterile. 7. Sterile field is created as close as possible to the time of use. 8. Sterile areas are continuously kept in view. 9. Sterile person keep well within sterile area 10. Sterile person keep contact with sterile area to a minimum 11. Unsterile person avoids sterile area 12. Destruction of the integrity of microbial barriers result in contamination 13. Microorganism is kept to an irreducible minimum.
DRAPING TECHNIQUE
What is DRAPING? Draping is a procedure of covering a patient and surrounding the areas with a sterile barrier to create and maintain an adequate sterile field during operation. It is part of the job description of a peri-operative nurse to provide not just the correct instruments but as well as the correct drapes prior to a procedure. The OR nurse should first understand the fundamental principles of Draping: 1. Isolate. You need to isolate dirty from the clean and vice versa (for example: groin, colostomy and equipment from the area to be prepped). Isolation is done utilizing an impermeable drape, usually fabricated from a plastic material. 2. Barrier. This provides an impervious layer and must have a plastic film to prevent a strikethrough. 3. Sterile Field. The creation of a sterile field is through sterile presentation of the drape and aseptic application technique. If the drape used is not impervious, an additional impervious layer needs to be added. 4. Sterile Surface. Since the skin could not be sterilized, it is needed to apply an incise drape to create a sterile surface. Only an incise drape can create a sterile surface. 5. Equipment Cover. Sterile drapes cover nonsterile equipment used on sterile field. This helps to protect the patient from the equipment as well as to protect and prolong the life of the equipment. 6. Fluid Control. Collection of fluid keeps the patient dry, decreases healthcare worker exposure and lessens clean up. A fluid control system should be used anytime the procedure is known to include large amounts of body fluids or irrigating solution such as TURP.
Draping materials are selected to make and maintain an effective barrier that lessens the passage of microorganisms between nonsterile and sterile areas. There are also basic characteristics of surgical drapes, all surgical drape materials should posses these traits regardless of which materials are utilized:
Abrasion resistance Barrier properties Biocompatibility Drapeability. The ability of a material to conform to the shape of the object over which it is placed Electrostatic properties Nonflammability Nonlinting. Materials for draping should not contain or generate with normal use, free fiber particles. Tensile strength TYPES OF DRAPES Reusable Drapes The main concern about reusable drapes is the fluid impermeability under the conditions of use. Steam Sterilizing and laundering swells the fabric whereas drying and ironing shrinks the fibers. This cycle increases the propensity for loosened fibers that alter the fabric structure. Most manufacturers report a loss of barrier quality after 75 laundry or sterilization cycles. Disposable Drapes The problem with Disposable Drapes is the collection, transportation and storage of waste material. Burning or Incineration is a method for destroying waste disposables but must be properly managed to prevent environmental contamination. Plastic Incisional Drapes Impermeable polyvinyl sheeting are available in the form of sterile prepacked surgical drapes. The incision is directly made through the adherent plastic drape. This type facilitates draping of irregular body surfaces as neck and ear regions, extremities and joints. Standard Drapes Standard Drapes are whole, or plain sheet used to cover instrument tables, operating tables and body regions. The sheet should be large enough to provide enough margin of safety between the surrounding physical environment and the prepared operative field. Fenestrated or Slit Sheets are used for draping patients. They leave the operative site exposed for (laparotomy draping) abdomen, chest, flank, back and other size for limb, head and neck.
Aperineal Drape Aperineal drapes are for operations on the perineum and genitalia with the patient in lithotomy position. This consists of a fenestrated sheet and two triangular leggings. Draping Procedure
Drapping is always done from sterile area to an unsterile areaand by drapping nearest first The scub nurse should never reach across an unsterile area to drape When the opposite side of the operating room bed must be draped , the scrub nurse must go around the bed to drape Do not flip, fan or shake drapes. Rapid movement of drapes creates air currents on which dust, lint and droplet nuclei may migrate Shaking a drape causes uncontrolled motion of the drape which may cause it to come in contactwith an unsterile surface or object A drape should be carefully unfolded and allowed to fall gently into position by gravity The low portion of a sheet that falls bellow the safe working level should never be raised or lifted back onto the sterile area Drape the incisional area first and then the periphery Use nonperforating towel clamps or devices to secure tubing and other items on a sterile field When sterility of a drape is questionable, consider it contaminated
GOWNING TECHNIQUE
The basic objective of gowning technique is to prevent contamination to the surgical wound and help control infection via aseptic principles. What to remember: If you are the scrub nurse, you must gown and gloved yourself first before assisting the surgeon and their assistant surgeons. (In our hospital, we do not assist the interns. They need to learn.) Gown packages are ideally placed on a separate table from the operating set to avoid any chance of contamination from dripping water. After scrubbing, hands and arms must be thoroughly dried before the sterile fawn is donned to prevent contamination of gown by strike-through of organisms from skin and scrub attire.
A towel for drying hands is placed on the top of the gown during the packaging. The towel is held away from the body, dries only when well scrubbed areas, hands first and avoids contaminating the hands on the areas proximal to elbows. Dry both hands, then one arm on one end of the towel. Utilize the opposite end of the towel for the other arm. Gowning: To don the gown, the scrub nurse should:
Lift the folded gown directly upward from the sterile package Step back from the sterile field into a clear area Carefully locate the neckband and hold the inside front of the gown just below the neckband with both hands Allow the gown to unfold while keeping the inside of the gown toward the body without touching the sterile exterior of the gown with bare hands (if the gown doesnt unfold completely, then the circulating nurse may assist by pulling down the unfolded bottom inside the gown) Hold the hands at the shoulder level and slips both arms into the armhole simultaneously Circulating nurse reaches inside the gown to the sleeve seams and pulls the sleeves over the hands to the wrists. After which, he or she will fasten the back part, ties waistband, touching outside of gown at the line of ties. Assisting Gowning Usually, the sterile scrub nurse assists the surgeon and his assistant in gowning.
Hand the towel to the surgeon, be careful not to touch his/her hand Carefully unfold the gown, holding it on the neckband Keep the hands on the outside part of the gown under the protective cuff and shoulder area. Offer the inside of the gown to the surgeon. He/she slips into the sleeves. Release the gown. The surgeon holds arms outstretched while the circulating nurse pulls the gown unto the shoulders and adjust the sleeves and cuffs. Removing the gown during the operation
Circulating nurse is the one who unfastens the neck and the waist. By grasping it at its shoulders, the gown is pulled-off inside out. The gown is always removed FIRST before the gloves. Preferably, a sterile team member may gown another person. If this is not an option, step aside and don a sterile gown again.
GLOVING TECHNIQUE
We are done with the gowning, next will be the gloving. Gloves complete the attire for scrubbed team members. It is put immediately after gowning. The purpose of gloving is to exclude the skin as a possible contaminant, create a barrier between sterile and unsterile areas and permit the wearer to handle sterile supplies or tissues of the operative wound. Sterile gloves may be put on in two ways (1) closed gloved method is a preferred method EXCEPT when changing a globe during an operation or when putting on gloves for procedures not requiring gowns (2) open glove technique. Gloving by Closed Glove Technique In this technique, the scrub persons hands remains inside the sleeves and should never touch the cuffs.
Keep both hands within the cuffs so that the hands would not touch the edges of the cuff Grasp the fold cuff of the left glove with the right hand Hold the top edge of the cuff in the left hand above the palm Place the palm of the gloves against the palm of the left hand. The glove fingers points up the forearm Grasp the back of the cuff in the right hand and turn it over the open end of the sleeve and hand while holding the top of the left glove and underlying gown sleeve with the covered right hand Pull the glove over the extended left finger unto the wrist by pushing the hand through the glove until it completely covers the cuff of the glove Glove the right hand in the same manner Inspect the gloves for integrity after donning. Gloving by Open Glove Technique What to remember: SKIN TO SKIN, GLOVE TO GLOBE TECHNIQUE. The hand, although scrubbed is not sterile and must not contact the exterior or the gloves.
With left hand, grasp the cuff of the right glove on the fold. Pick up the glove and step back from the table. Insert right hand into the glove and pull it on, leaving the cuff turned well down over hand Slip finger of the gloved right hand under the everted cuff of the left gloved. Insert hand into the left gloved and pull it on leaving the cuff turned down over the hand
With fingers of the right hand, pull the cuff of the left glove over cuff of the left sleeve. If stockinet is not right, fold a pleat, holding it within right thumb while pulling the glove over the cuff. Avoid touching your wrist Repeat the same steps for the right cuff, using the left hand. ASSISTED-GLOVING
Pick up the right glove, hold it firmly, with fingers under the everted cuff. Hold the palm of the glove toward the surgeon. Stretch the cuff sufficiently for the surgeon to insert the hand. Avoid touching the hand by holding your thumbs down Exert upward pressure as the surgeon inserts his hand into the glove. Unfold the everted glove cuff over the cuff of the sleeve slowly. Repeat for the left hand. Removing Gloves OPEN GLOVING
Hold one of the gloves and cuff and pull it partway off. The glove will turn inside out. Remember to keep the first glove partially on your hand before removing the second glove. This protects you from touching the outside of either glove with your bare hands Still having the first glove over your fingers, grasp the second glove near the cuff and pull it apart of the way off. The glove will turn inside out. Pull off both gloves at the same time. Be careful not to touch the outside surface with hands. Dispose in the properly Wash hands thoroughly. CLOSED GLOVING
Grasp outside edge near wrist Peel away from hand turning glove inside-out Hold in opposite gloved hand Slide ungloved finger under the wrist of the remaining glove, be careful not to touch the outside part of the glove Peel off from inside, creating a bag for both gloves Discard properly Wash hands thoroughly.
SURGICAL SCRUB
Surgical Scrubbing is one of the most important skills that an operating nurse should know and practice correctly. Technically, it is defined as the removal of many bacteria as possible from the hands and arms by mechanical washing and chemical disinfection before participating in an operation. Surgical scrub is performed prior to donning sterile attire preoperatively. Wearing of sterile gloves during the operation is not an excuse not to perform this activity. The moist environment underneath the surgical gloves can promote the growth of microorganism on any of the surgical teams hand. Why do you need to do surgical scrubbing? Admittedly, I hate scrubbing because it makes my hand and arms dry one of the disadvantages of being an OR nurse. I dont put on lotion during duty days, because I will just waste it since I will still wash my hands, so why the effort? First, surgical scrub removes the debris and transient microorganisms from the nails, hands and forearms. Second, it reduces the resident microbial count to a minimum and lastly, it inhibits rapid rebound growth of microorganism. What type of surgical hand scrub product should be used? An ideal surgical hand scrub product should have a broad spectrum of action, it should be fast acting and persistent and most importantly, non-irritating to the skin. Types of Surgical Scrub Procedure There are two types of surgical scrub procedure: (1) Time Method which allows each scrub to last for about three to five minutes, depending on the protocol of your institution, The complete scrub takes 5-7 minutes and done: In the morning prior to your first gowning and gloving Following a clean case if gloves have been removed accidentally, prior to the gown. After a clean case, if gloves are accidentally punctured or torn After a clean case if hands have been contaminated in any other way And prior to an emergency case anytime. A short scrub takes three (3) minutes, done after a clean case if the hands and harms have not been contaminated. This is done to remove any bacteria that have emerged from the pores and multiplied when the gloves were worn.
(2) Counted Brush-Stroke Method in which a certain number of brush strokes are designated for each finger, palm, back of the hand and arm. Nails: 30 strokes All Sides of each fingers: 20 strokes Back of the hand: 20 strokes Palm of the hand: 20 strokes Arms: 20 strokes for every 1/3 of the arm, to 3 inches above the elbow Before Scrubbing, an operating room nurse should be reminded to:
Keep his or her skin and nails clean and in good conditions and cuticles uncut. Keep his or her fingernails short and void of any nail polish. Inspect hands for any wound. Skin of the hands and forearms should be intact. Remove all finger jewelries, including your watch. Make sure that all hair is covered by headgear. Pierced ear studs must be contained as well. Make sure that youre your disposable mask is snugly and comfortably over your nose and mouth. Now, you are ready to scrub.
Wash hands and arms with antimicrobial soap. Clean fingernails using a nail file Start timing. Scrub each side of the finger, between the fingers and the back and front of the hand for two minutes. Proceed to scrub the arms, keeping the hand higher than the arms at all times. This prevents bacteria-laden soap and water from contaminating your hand. Wash each side of the arm to three inches above the elbow for one minute. Do the process on the other hand, do not forget to keep your hands above the elbows. If the hand touches anything except the brush at any time, the scrub must be lengthened by another minute for the area that contaminated. Rinse the hands and arms by passing them through the water in one direction only, starting from your fingertips down to your elbow. Do not move the arm back and forth through the water. Proceed to the operating room holding hands above your elbows. Please be careful not to splash water and wet your scrub suite at all times during the scrub procedure. Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique. Now we are done, and you are ready to don your gown and sterile gloves. Current AORN and CDC Scrubbing Recommendations Time Element AORN recommends for facilities to standardize scrub times and has presented studies to show that scrub times of three to four minutes are as effective as five-minutes scrubs.
(AORN, Perioperative Standards and Recommended Practices, 2008 Edition, Denver: AORN Publications, 401.) The CDC has stated that former traditional 10 minute scrubs are not necessary and frequently leads to skin damage, and sites studies that scrubbing for 2 or 3 minutes reduced bacterial counts to acceptable levels. (Center for Disease Control Hand Hygiene Guidelines, http://www.ced.gov/handhygiene/) AORN- Surgical Scrub Brush AORN outlines that the use of a brush for surgical hand scrubs is not necessary and scrubbing with a brush is associated with an increase in skin cell shedding. (AORN, Perioperative Standards, 402). AORN published an article that states that brushless scrubbing is believed to be less caustic and abrasive to the skin than traditional scrubbing and can aid in maintaining skin integrity, even after repeated use in the preoperative setting. (Berman, Mara One Hospitals Clinical Evaluation of Brushless Scrubbing. AORN Journal, (Volume 79, No. 2), 2004) The CDC states that use of a brush results in increased shedding of bacteria from the hands. (CDC, Hand Hygiene Guidelines http://www.ced.gov/handhygiene/) Neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used. Hand Scrubbing Technique: Choose among the two hand scrub methods and apply following new guidelines: Water Based Hand Scrub Three Minute Scrub Wet hands and arms up to the elbows. Use nail pick to clean nails under running water. Wet sponge and squeeze to work up lather. Wash each finger, hand, and arm to two inches above the elbows using the non abrasive sponge for a total scrub time of three minutes Note: Use brush side only on nails and cuticles or on areas of visible soil. Rinse hands and arms from finger tips to elbows. Dry hands and arms with a sterile towel. Alcohol Based (Avagard) Apply to clean, dry hands and nails. For the first use of each day, wash hands and clean under nails with a nail stick. Note: Whenever debris is present, wash & dry hands before application. Dispense one pump (2ml) into the palm of one hand. Dip fingertips of the opposite hand into the hand prep and work under fingernails. Spread remaining hand prep from wrist to 2 above the elbow. Dispense one pump (2ml) and repeat procedure with opposite hand/arm.
Dispense final pump (2ml) of hand prep into either hand and reapply to all aspects of both hands up to the wrists. Allow to dry- Do not use towels!
METHODS OF STERILIZATION
Methods of Sterilization are one of the questions of my pre-employment exam last week. Well, usually I am not the type of person who dwells inside the testing room when I do not know the answer. I do hate to pressure my brain cells of the stuffs they technically do not know. Of course, I know the methods of sterilization. After all, they only asked three.
So what are the methods of sterilization inside the operating room? Steam Sterilization. This is the most common method of sterilization for operating room instruments. If steam alone is used, it is not enough for sterilization. But, when it is pressurized, its temperature would rise. This moist pressurized read causes the destruction of microbes by coagulation and denaturation of protein inside the cells. The relationship between the temperature, exposure time and pressure are the contributory factors in the destruction of microbes. When steam is limited in a closed-compartment and the pressure is increased, the temperature will also increase provided that the volume of the compartment remains the same. Items will be considered sterile if it is exposed long enough to steam at a specific temperature and pressure. Autoclave is a unit used to create this atmosphere of high temperature. Types of Steam Sterilizers
Gravity Displacement Sterilizer Prevacuum Sterilizer Flash Sterilizer Ethylene Oxide (Gas) Sterilization. This is considered to be one of the most cost-effective methods for sterilization. Ethylene oxide is a flammable explosive liquid that when mixed with carbon dioxide or Freon becomes highly efficient. This is usually used for equipment that could not withstand the extreme temperature and pressure of the steam sterilizer. Examples of these are endoscope, plastics, power cables, cameras, etc. How does Ethylene Oxide works? Ethylene oxide destroys microorganisms including their spores by interfering with the metabolic and reproductive processes of the cell. The process in enhance with moisture. The gas chamber is maintained at 20-40% humidity with temperature ranging from 49-600. Timing of the goods depends on the following factors: concentration of ethylene oxide, temperature, humidity and the density and type of materials to be sterilized.
The only difference between steam and gas sterilization is that the latter would require aeration to dispel any residual gas that is on the instrument or items. General rule when preparing any equipment for gas sterilization is that loose is better than restricted. Ionizing Radiation Sterilization. A prepackaged equipment from the manufacturer has already been sterilized using ionizing radiation or cobalt 60. This process is used commercially because of its cost. Sutures, sponges and disposable drapes are some of the presterilized products available in the market. Cold Chemical Sterilization. A lot of liquid chemical agents today can sterilize an item immersed in it. But, most of these chemicals are so corrosive and damaging to the equipment being sterilized that they cannot be used for this purpose. There are only two products that can be safely used:
2% solution of glutaraldehyde. Non-corrosive and provides a safe means of sterilization of delicate lensed instruments such as cystoscopes, and broncoscopes. Sterilization of an item in glutaraldehyde requires approximately 10 hours of soaking. Disinfection takes place in approximately 10 minutes. Because it is extremely difficult to thoroughly clean endoscopic accessory instruments such as biopsy brushes, these items are now available as single-use items that are disposable following surgery. Remember that disinfection is not sterilization. peracetic acid is utilized at low temperature. Caution: For any of these sterilization processes, it is always important to read and understand the instructions or manual provided by the manufacturer. WRAPPING GOODS FOR STERLIZATION Each item to be sterilized by either pressurized steam or ethylene oxide must be wrapped properly. The procedure for wrapping goods is not based on convenience or personal preference but based on one principle: enhancing the ease of sterilization and of preserving the sterility of the item. The wrapper used should
Protect the item from vermin, penetration and dust. Resistant to tearing or delamination (separation of layers) Easy to handle to facilitate wrapping and delivery
Fabric Wrappers are made from high-quality cotton muslin which is commonly referred to as linen. Muslin has sufficient density to protect goods from contamination and yet it is porous enough to allow the penetration of steam or gas. Paper and Unwoven Fabrics. For instance those utilized in the manufacturing of disposable drapes are also used. Non-fabric wrappers should be durable and flexible. These wrappers are intended for one time use only. If it is already used in sterilization, they may lose their ability to prevent contamination. IDENTIFICATION OF PACKAGES Whatever the type of the packaging your operating room has, each package must be marked by the current date and the date of expiration, including the item name. In our hospital, we also signed in our names so in any case that (for instance) I labelled a certain instrument wrong; they could throw the blame into my court. STORAGE AND HANDLING OF STERILE SUPPLIES The rule of this is first in, first out. Shelf Life This is defined as the length of time a wrapped sterile package remains sterile when in storage. This is dependent on a lot of factors. Whether the package remains sterile depends completely on the conditions under which the item was stored and on the handling of the item. Another factor is the type of thickness of the packaging material. This also determines how strong the barrier it provides. The packages that offers the most resistance to contamination is the heat-sealed plastic and the plastic-paper packages. Under the ideal condition, these packs may remain sterile for about a year. Environmental conditions such as temperature, humidity, and air turbulence are important in maintaining ideal shelf life. Excessive temperatures can cause sweating and condensation around packs. Any moisture can wick bacteria from a nonsterile surface through a wrapper and contaminate the contents of the package. Air turbulence such as that near doorways or halls can sweep bacteria-laden particles over sterile supplies and diminish their shelf life. Other sources of humiditysuch as aerosol effect from sinks or cleaning areas may also contaminate wrapped goods. The package closure also affects shelf life. Heat-sealed packages have a longer shelf life than those that are sealed with tape. Dust covers likewise prevent particulate material from entering the pack. Items that are seldom used can be over wrapped with a plastic dustcover to prevent the need for frequent sterilization.
Linen (140-thread-count, four thicknesses) (280)-thread-count, two thicknesses) 7 weeks Linen-wrapped items, heat sealed in dust covers after sterilization 9 months Linen-wrapped items, tape sealed in dust covers after sterilization 3 months Paper 9 weeks Plastic-paper, combination, heat sealed 1 year Plastic films, tape sealed 3 months Plastic films, heat sealed 1 year Nonwoven fabrics 30 days From Groah L: Operating Room Nursing: Perioperative Practice, 2nd ed.Norwalk CT, Appleton& Lange, 1991. The storage system, whether in the form of open or closed cabinets or open or closed bins, often determines shelf life. Remember the basic rule inside the operating room, when in doubt, throw it out. Trust your surgical instinct and conscience because it will never fail you.
Head of the surgical team Perform operative procedure safely and correctly Visits the patient before anesthesia is inducted, if needed, assist in the positioning of the patient Responsible for being certain that all team members are aware of what they need during the procedures and that all necessary equipments are available. If he/she is responsible to give the anesthesia (in cases of local anesthesia), it will either be given before scrubbing or after the patient has been draped After the operation: surgeon secures the dressings in place After the anesthesiologist gives his/her permission, the surgeon should assist in moving the patient to the stretcher to be brought to the Post Anesthesia Care Unit (PACU) ANESTHESIOLOGIST/ANESTHETIST
Must be properly attired in the operating room, although there is no need to scrub Responsible for making sure that all equipment and supplies necessary for the induction of anesthesia are available and then checks the patient and the chart for any last minute changes Monitoring equipments such BP apparatus, cardiac monitor are attached to the patient Helps position the patient During the surgery: monitors the patients vital signs, reponsible for keeping the surgeon aware of the condition of the patient, he/she gives the fluids and blood transfusion needed during the operation Responsible to inform the operating nurse of the time for the next patient to be pre-medicated Determines if the patient is to be brought to the PACU after surgery is completed. Usually checks the patients airway or vital signs before moving the patient to PACU ASSISTANT SURGEON
Help the surgeon in any way possible Must be properly attired May help with the drapes and final placement of equipment and supplies May close the incision and help with the dressing In our hospital, the assistant surgeons are usually the residents. CIRCULATING NURSE
He/she does not need to scrub, but a good hand washing technique should be done In charge of the over all running of the OR before, during and after surgery One of the most important duty: Sterility is maintained at all times Preparing the operating room Assisting the scrub nurse, especially during sponge count Caring for the patient before and after the operation Assisting the anesthesiologist Positioning the patient and preparing the operative site Assisting the scrub team before and during surgery Caring for the patient after surgery Cleaning the operating room after the surgery has been completed SCRUB NURSE
Must be properly attired, scrubbed, gowned and gloved Assist the circulating nurse in the preparation of the operating room Must familiarize itself with the procedure and supplies & equipments needed to avoid delay Set up back table Assist surgeon & assistant surgeon in their gowns and gloves,
Drapes the operative site Should anticipate the surgeons needs Wash the instruments
SURGICAL POSITIONS
There are various surgical positions during operations. OR nurses need to be equip with the knowledge which among these positions are appropriate during surgeries. Here are some quick guidelines for surgical positions:
The OR nurse should check the table and gather all the necessary equipment to be used in the surgery before the patient enters the room. It is never a sin to ask for assistance Check with the anesthesia team before moving the patient. Do not forget your body mechanics Move the patient carefully. Remember, you need to keep the patient safe Watch out for IV lines, drains and other lines attach to the patient. You dont want them pulled out right before surgery. Check the patient again once you have positioned him/her. Do not stare alone at the surgical site. Look at the patient as a whole. Here are the most common Surgical Positions:
1. Supine or Dorsal Position The legs are uncrossed, slightly apart and both arms are at the side or at the arm boards. The palms of the hands should be facing the body to prevent unnecessary muscle strain on the arms. This type of surgical position is used during the induction of general anesthesia, abdominal surgeries, open-heart surgeries, surgeries on neck, face and mouth, and most surgeries on extremities. The following equipment are needed for this type of position: (1) pillow & padding materials (2) shoulder roll for modifications that require hyperextension of the patients neck (3) padded footrest available for reverse trendelenburg. There are also disadvantages or possible hazards which may include skin breakdown, lumbar strains, circulatory compromise and nerve injury. 2. Prone Position
The patient is primarily positioned in supine and then log-rolled onto abdomen after the induction of anesthesia. The patients arms are either on the side or at the arm boards. Those patients who are having surgery on the posterior part such as back or spine or at the back of his or her leg are placed in prone position. The following equipment are needed for this type of position: (1) chest rolls (2) pillows and padding materials (3) headrest or support of head. Possible danger to the patient may include: skin breakdown, reduced respiration, eye or ear damage, reduced circulation, damage to breast or genitals 3. Modified Trendelenburg Position The modified trendelenburg position is usually used for lower abdominal surgery to allow gravity to assist in maintaining the intestines in the upper part of the abdominal cavity. This position is also used in lower extremity surgery to aid in hemostasis. The patient is positioned in supine position and the operating table is slightly tilted in order for his head to be lower than his feet by 1-5 degrees. 4. Modified Reverse Trendelenburg Position Modified Reverse Trendelenburg position is generally used for upper abdominal surgery and for the surgery of neck and face.This position allows improved operative exposure because gravity retains the intestines in the lower part of the abdomen. 5. Jackknife or Kraske Position The patient is placed on supine position and log-rolled into abdomen. OR table is flexed approximately 90 degrees. Arms are placed at the side or at the arm boards. This position is almost exclusively used for rectal surgeries. The equipment needed during the surgery is the same as that of the prone position, but there is a need for a wide adhesive tape. 6. Lithotomy Position This position is commonly used in operation requiring a perineal approach such as genito-urinal or gynecologic surgery. Patient is placed on supine position and both legs are lifted together into the stirrups. You will need stirrups, stirrup holders and paddings for this surgical position. Possible hazards could be respiratory compromise, skin breakdown, nerve damage and muskuloskeletal injury.
7. Lateral Position The lateral position is used for operations on the kidney, chest hips or lungs. The patient is positioned supine and then rolled into his side with the operative side up. The top leg is straight and the bottom is flexed. Both arms are placed on the arm board with the upper arm on special arm support or pillow. Head supported in alignment with the body. You need bean bag or other stabilization device, pillows/any padding materials, axillary roll, and headrest/head support. Possible dangers could be skin break down, nerve injury and reduced respiration. 8. Modified Fowlers Position The Modified Fowlers position or the sitting position is mostly used in neurosurgery. This position is used to facilitate surgical access to the cranium, neck, or shoulder and to promote drainage from the surgical site. Possible complications may include air embolism, pneumocephalus, nerve damage, systemic hypotension, pressure ulcers, midcervical quadriplegia and face, tongue or neck edema due to prolonged neck flexion. There are so many more surgical positions, and modifications. It will all depend on the surgeons preference which to place the patient. OR nurses should make sure that whatever position the patient is placed, he or she is not compromised.
Lap Sponges = 5/package 4 x 4 sponges = 10/package Cottonoids = 10/package Peanuts or Kittners = 5/package Suture Boots = 10/package Recommended Practices on Sponge Count
1. Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained. When to Count: Before the procedure starts Before the closure of a cavity within a cavity Before wound closure begins At the skin closure or end of procedure At the time of permanent relief of either the scrub person or circulating nurse The same goes with all the sharps and instruments, they should be counted in every procedure. Legal accountability for sponge counts during a surgery is a primary responsibility of the perioperative nurse. Performing counts creates a proactive injury-prevention strategy. These are some procedures which sponge count may not be necessary:
X-ray or fluoroscopy is taken as soon as before the wound is closed and the attending surgeon makes the determination that there are no more retained instruments in the surgical wound Superficial procedures which the length of the wound is <10cm and the depth is <5cm, superficial skin procedure such as I&D, bur procedures Gynecologic procedure with vaginal approach Genito-urinal procedure: circumcision, vasectomy, TURP, brachytherapy Closed procedures using a flexible or rigid camera or scope Foot/hand surgery, perc punning, total joints with the exception of a total hip surgery Life or limb-threatening situation
1. Initial sponge counts should be taken on all procedures. 2. Sponges should be separated, counted audibly, and concurrently viewed during the count procedure by two individuals, one of whom should be a registered nurse.
3. Perioperative personnel should not assume that the count on prepackaged sterilized sponges is accurate. Any package containing an incorrect number of sponges should be removed from the field, bagged, labeled, and isolated from the rest of the sponges in the operating room. 4. Sponge counts should be performed in the same sequence each time. The count should begin at the surgical site and the immediate surrounding area, proceed to the Mayo stand and back table, and finally to sponges that have been discarded from the field. 5. All sponges used during a surgical procedure should be x-ray detectable. Sponges should be left in their original configuration and should not be cut. 6. All counted sponges must remain within the operating room and/or sterile field during the procedure. Linen and waste containers should not be removed from the room until counts are completed and resolved. 7. Only non-x-ray-detectable sponges should be used as dressings. 8. Contaminated sponges should be handled and disposed of according to Occupational Safety and Health Administration (OSHA) guidelines, AORNs Recommended practices for environmental cleaning in the surgical practice setting, and institutional policies and procedures. Counting of Sharps has the same guidelines save the following: 1. Suture needles should be counted according to the number marked on the outer package and verified by the scrub person and circulating nurse when the package is opened. 2. Linen or waste containers should not be removed from the operating room until all counts are completed and resolved and the patient has been taken from the room. 3. Used needles on the sterile field should be kept in a disposable, puncture-resistant needle container. Counting of Instruments also has the same set of guidelines except for the following: 1. Instrument sets should be standardized with the minimum types and numbers of instruments needed for the procedure. Instruments that are not routinely used on procedures should be deleted from sets. 2. Pre-printed count sheets that are identical to standardized sets should be used for documenting counts. 3. Pre-printed instrument count sheets expedite the counting process. 4. Members of the surgical team should account for disassembled or broken instruments in their entirety, including all parts of the instrument(s). It is also important to that the sponge, sharp and instrument counts should be documented on the patients intraoperative record.
Types of count and number of counts Names and titles of personnel performing the counts Results of surgical item counts Notification of the surgeon Instruments remaining with the patient or sponges intentionally retained as packing Actions taken if count discrepancies occur Rationale if counts are not performed or completed as dictated by policy Memoirs: There was a time when a surgeon would love to throw things and had caused us a missing needle. The circulating nurse in-charge was very assertive and demanded the surgeon not to close the operative site unless the needle was found. The surgeon was pissed, but he really didnt care. He and the scrub nurse tried to look for it only to find it near the surgeons feet. That caused another scandal erupting in the operating room of the hospital. It is understandable for most nurses, especially the new graduates to be overwhelmed by the surgeon inside the operating room, the stress is present and you could see your favourite surgeon at its worse. But remember, your primary duty is to your patient and his safety. Sponge count should be taken seriously by the operating room nurses, not only because it could cause them a revocation of their license, but for the safety of their patient who entrust his/her care into their capable hands.
MIDLINE Midline abdominal incision is one of the most common and versatile incisions for abdominal surgery because this allows access to nearly all of the organs in the abdomen and the retroperitoneum, if deemed necessary. After the skin and subcutaneous are cut, the linea alba is opened. Linea Alba is one of the advantages in this type of incision since this is relatively avascular and avoids damage to any muscles or nerves, it is also strong enough to allow secure closure. There are two types of Midline abdominal incisions Lower Midline
Used for complex appendicitis Sigmoid, colonic, rectal, urological, and gynecological procedures Generally, this incision are well tolerated by patients but can be painful. The weight of the abdominal contents and an obese abdominal wall may add strain, increasing the risk for hernia formation. Upper Midline
Incision can be extended superiorly for processes or operations that involve the upper abdominal viscera or require additional exposure. Best exposure of the pelvis is gained by a lower midline incision to the pubis Access to the esophagus, hiatus, stomach and duodenum, pancreas and hepatobiliary system If extended: major hepatic resection, adrenalectomy, splenectomy Can be very painful and restrict pulmonary function particularly vital capacity by about 50% Subcostal incision is preferred by a lot of surgeon for patients with pulmonary problems TRANSVERSE Transerse abdominal incision crosses fewer dermatomes. This is made above the umbilicus and divides one or both sides of the rectus muscle as necessary. Most commonly used for access to the right colon, duodenum, access to the pancreas where the incision is carried across the midline Excellent exposure to subhepatic space and Upper GIT Lesser pain than midline incision However, currently, a lot of surgeons have preferred midline incisions extended as necessary to gain lateral access to the abdominal and retroperitoneal viscera SUBCOSTAL
Subcostal abdominal incision is also known as Kochers incision. Right subcostal is mainly used for open cholecystectomy and left subcostal is for splenectomy. A combination of both is called a roof-top incision, useful in gastric and hepatopancreatobiliary surgery. Mercedez-Benz Incision roof-top incision is extended up to the midline, which is often done for liver implants. It resembles the companys logo. Major advantage over the upper midline incision is greater lateral exposure and lesser pain. Disadvantage could be that the operation may be longer because there are more layers to close. RIGHT ILIAC FOSSA This abdominal incision is mainly used to do an appendectomy, although it can also be utilized to perform caecal decompression, appendicostomy and caescostomy. Types of eponymous incisions exist
McBurneys Incision 1/3 of the way along the line from the anterior superior iliac spine to the umbilicus The Rocky Davis Incision is another incision for appendectomy. Unlike the prior one, this is a straight transverse at the skin and splits the muscle. Again, either incision is made as long as necessary to achieve adequate exposure. + Lanz incision PFANNENSTIEL Pfrannensteil abdominal incision is a horizontal at the skin but divides at the fascie and muscle of the abdominal cavity wall vertically in the midline. This is used for caesarian sections and urological surgery because they minimize scarring. But, large skin flaps are developed under incisions and with contamination, they may be prone to complications. Should be avoided in patients who are obese, those requiring extensive deep pelvic dissection and those with prior lower abdominal midline incisions where scar is already present
2. SUBCUTANEOUS. This is also known as the fatty layer since most of the bodys stored fats is found here. 3. FASCIA. This covers the layer of abdominal muscles. It tends to constrict the muscles to help in the proper contraction. This is the toughest among the five layers. 4. MUSCLE. As the name says, this is the layer that contains the muscles. There are groups of muscles in this layer that are responsible for the shape of the abdomen and can be stretched due to age or pregnancy. 5. PERITONEUM. This is a thin one-cell thick membrane that lines the abdominal cavity and indirectly covers some of the most vital organs in the abdomen.
SURGICAL SUTURES
Surgical suture is a medical device utilized to hold body tissue together either after suffering from an injury or surgery. It is usually consists of a thread attached to a needle. There are numerous shapes, sizes and thread materials that have been developed over the years.
An ideal surgical suture should have the following characteristics: (1) sterile (2) universal (its material can be used in any surgical procedure) (3) causes less tissue injury or reaction (4) easy to handle (5) high tensile strength (6) holds securely when knotted (7) good absorption profile and (8) resistant to infection. However, at the moment, no single material possesses all the mentioned characteristics. Every surgical suture should be made to assure a number of important characteristics: (1) sterility (2) same size and diameter (3) elasticity for easy handling and securing of knot (4) uniform tensile strength of suture size and type (5) freedom from irritants or impurities that would cause tissue reaction. Suture Size The surgical suture size is the diameter of the suture strand. It is denotes as zeroes. The more zeroes it has, the smaller the diameter strand is (for example, 1-0 or 0 is bigger than 2-0 or 00). The smaller the suture, the lesser is the tensile strength of the strand. Types of Surgical Suture The different kinds of surgical sutures used differ on the operation, with the major criteria being the demands of the location and environment and on the discretion and professional experiences of Surgeons. Absorbable Suture & Non-Absorbable Sutures
Absorbable Suture These are surgical sutures that are absorbable and will break down safely in the body over time without intervention. Utilized internally because it would require a re-opening if they were to be removed. NATURAL
Polyglactin 910 (Vicryl) Poliglecaprone 25 (Monocryl) Polysorb Polydioxanone (PDS II) A barbed suture (V-Loc, Covidien Inc) Caprosyn Maxon
Non-Absorbable Suture These are surgical sutures that must be removed manually if they are not left for an indefinite period of time. Often used in sutures located in a stressful environment, for instance the heart since there is a steady movement and pressure or the bladder because of adverse chemical presence. It may require specialized or stronger materials hold it together. Usually, these types of non-absorbable surgical sutures are specially treated or made of special materials to lessen the risk of degradation. Used externally and can be removed within minutes without reopening the wound. NATURAL
Nylon
Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated]) Polybutester Suture (Novafil) Coated Polybutester Suture (Vascufil) Polypropylene (Prolene) Surgipro II Monofilament and Multifilament Sutures Surgical sutures can also be divided into two kinds base on the material structure. Monofilament This type of surgical suture allows a better passage through the tissues because it is made up of a single strand. This kind of structure is more resistant to harbouring microbes. Usually, Monofilament sutures bring out lower tissue reaction than braided sutures.
Polypropylene sutures Catgut Nylon PVDF Stainless steel Poliglecaprone Polydioxanone sutures
Multifilament or Braided Sutures This type of suture provides a better knot security since it is composed of numerous filaments twisted or braided together. It is less stiff but has a higher coefficient of friction. Since its materials have increased capillarity, the increased absorption of fluid may cause introduction of pathogens. PGA sutures Polyglactin 910 Silk Polyester sutures Selecting surgical sutures depends on the training and preference of the surgeon. Many suture materials are available individual surgical location and surgical requirement. Usually, the surgeon chooses the smallest surgical suture that effectively holds the healing wound edges. The tensile strength of the suture should never surpass the tensile strength of the tissue. As the operative site heals, the relative loss of surgical suture strength over time should be slower than the gain of tissue tensile strength.
5 kochers straight, 5 bobcock,5 allis, 5 round nose, 5 straight clamp, 10 hemostats, 5 towel clips Operating Room Instruments:
Kocher (Ochsner). Used to grasp heave tissue and can be also used as a clamp. Its jaw can be straight or curve, we also utilize this to hold a peanut. Bobcock forcep. Utilized to grasp delicate tissue such as intestine, fallopian tube, ovary, appendix, also available in long sizes Allis Forcep. Used to grasp tissue and is available also in long sizes. Round Nose (kelly curve). Use to clamp larger tissues or vessels. Hemostat (snap/curve/straight). Use to clamp blood vessels or tag sutures. It may be straight or curve Backhaus towel clip. Used to hold drapes, most especially towels in place
The sharps (16): tumbler, pool suction, long thumb, 2 tissue forcep, 2 thumb forcep, army navy, 2 blade holders #4, metz,mayo, 2 suture scissors, 2 needle holders
Thumb Forceps. They looked like tweezers. They are tapered and have serrations or grooves at the tip. They can be short or long, straight or bayonet (angled), and delicate or heavy Toothed Forceps. Unlike the thumb forceps with serrations, they have row of multiple teeth at the top or single tooth on one side that fits between the two teeth on the other side. This kind of forceps provide a strong hold on tough tissues, most especially the skin. Army Navy Retractor (also called right angle retractor/US Army retractor). Use to retract superficial or shallow incision. Blade 4 (for Blades Size 20 and above). Use to cut the skin Suture Scissor. Use to cut suture and supplies Mayo Scissors (curve). Use to cut heavy tissues such as fascia, muscle, uterus, breast) - we often use this during OB-Gyne Procedure Metzenbaum Scisoors (Metz). Utilized to cut delicate tissues