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Friday, 26 June 2015
Thursday, 25 June 2015
Principles of Sterile Technique – Gowning & Gloving in the OR
Principles of Sterile Technique
1.
All articles used in an operation
have been sterilized previously.
2.
Persons who are sterile touch
only sterile articles; persons who are not sterile touch only unsterile
articles.
3.
Sterile persons avoid leaning
over an unsterile area; non-sterile persons avoid reaching over a sterile
field. Unsterile persons do not get closer than 12 inches from a sterile field.
4.
If in doubt about the sterility
of anything consider it not sterile. If a non-sterile person brushes close
consider yourself contaminated.
5.
Gowns are considered sterile only
from the waist to shoulder level in front and the sleeves to 2 inches
above the elbows.
1.
Keep hands in sight or above
waist level away from the face.
2.
Arms should never be folded.
3.
Articles dropped below waist
level are discarded.
6.
Sterile persons keep well within
the sterile area and follow those rules from passing:
1.
Face to face or back to back.
2.
Turn back to a non-sterile person
or when passing.
3.
Face a sterile area when passing
the area.
4.
Ask a non-sterile person to step
aside rather than trying to crowd past him.
5.
Step back away from the sterile
field to sneeze or cough.
6.
Turn head away from sterile field
to have perspiration mopped from brow.
7.
Stand back at a safe distance
from the operating table when draping the patient.
8.
Members of the sterile team
remain in the operating room if waiting for the case.
9.
Do not wander around the room or
go out in the corridors.
7.
Sterile persons keep contact with
sterile areas to a minimum.
1.
Do not lean on the sterile tables
or on the draped patient.
2.
Do not lean on the nurse’s mayo
tray.
8.
Non-sterile persons — when
you are observing a case, please stay in the room until the case is
completed. Do not wander from room to room as traffic in the operating
room should be kept as a minimum. Patient privacy needs to be respected.
9.
Keep non-essential conversation
to a minimum.
10.
The circulating nurse is in
charge of the room — if you have any questions, please refer them to her,
the supervisor or your instructor. Ask circulating nurse when it is an
appropriate time to ask questions so that explanations/rationale can be
given.
Sterile Members
1. Surgeon
The surgeon is “in charge” of the surgical team. He or she is the person who performs the operation and directs the activities of other members of the surgical team. Surgeons usually specialize in the treatment of specific surgical conditions, like orthopedics or cardiac surgery. Becoming a surgeon involves 4 years of college, 4 years of medical school, then 3 to 5 years of specialized residency.
The surgeon is “in charge” of the surgical team. He or she is the person who performs the operation and directs the activities of other members of the surgical team. Surgeons usually specialize in the treatment of specific surgical conditions, like orthopedics or cardiac surgery. Becoming a surgeon involves 4 years of college, 4 years of medical school, then 3 to 5 years of specialized residency.
2. Certified Surgical Technologist
The surgical technologist is responsible for the preparation of the sterile supplies, equipment and instruments, then assists the surgeon in their use. The surgical technologist most frequently serves as instrument handler, setting up the instruments, then “passing” them to the surgeon. Surgical technologists also serve as second assistants, utilizing instruments to perform tasks such as retracting incisions, cutting suture and manipulating tissue. With advanced training or education, some surgical technologists act as first assistants. This role may also be preformed by another physician, a physician assistant or a registered nurse. Becoming a surgical technologist involves 1 to 2 years of college or specialized training.
The surgical technologist is responsible for the preparation of the sterile supplies, equipment and instruments, then assists the surgeon in their use. The surgical technologist most frequently serves as instrument handler, setting up the instruments, then “passing” them to the surgeon. Surgical technologists also serve as second assistants, utilizing instruments to perform tasks such as retracting incisions, cutting suture and manipulating tissue. With advanced training or education, some surgical technologists act as first assistants. This role may also be preformed by another physician, a physician assistant or a registered nurse. Becoming a surgical technologist involves 1 to 2 years of college or specialized training.
Non Sterile Members
1. Anesthesiologist
The anesthesiologist is a physician who specializes in administering drugs to the patient so he or she is pain free during the operation. They monitor the patient’s response to anesthesia.
The anesthesiologist is a physician who specializes in administering drugs to the patient so he or she is pain free during the operation. They monitor the patient’s response to anesthesia.
2. Registered Nurse
The Registered Nurse role is generally that of the
“circulator”. The circulator is responsible for the patient care during the operation.
He or she assesses the patient, assists the anesthesiologist, completes
operating room records and dispenses items to the sterile team. Becoming a
nurse in the operating room requires 2 to 4 years of college, then specialized
training on the job to learn surgical patient care.
Gowning and
Gloving
If you are the scrub corpsman, you will have opened
your sterile gown and glove packages in the operating room before beginning
your hand scrub. Having completed the hand scrub, back through the door holding
your hands up to avoid touching anything with your hands and arms. Gowning
technique is shown in the steps of figure 2-4. Pick up the sterile towel that
has been wrapped with your gown (touching only the towel) and proceed as
follows:
1.
Dry one hand and arm, starting
with the hand and ending at the elbow, with one end of the towel. Dry the other
hand and arm with the opposite end of the towel. Drop the towel.
2.
Pick up the gown in such a manner
that hands touch only the inside surface at the neck and shoulder seams.
3.
Allow the gown to unfold downward
in front of you.
4.
Locate the arm holes.
5.
Place both hands in the sleeves.
6.
Hold your arms out and slightly
up as you slip your arms into the sleeves.
7.
Another person (circulatory) who
is not scrubbed will pull your gown onto you as you extend your hands through
the gown cuffs.
To gown and glove the surgeon, follow these steps:
1.
Pick up a gown from the sterile
linen pack. Step back from the sterile field and let the gown unfold in front
of you. Hold the gown at the shoulder seams with the gown sleeves facing you.
2.
Offer the gown to the surgeon.
Once the surgeon’s arms are in the sleeves, let go of the gown. Be careful not
to touch anything but the sterile gown. The circulator will tie the gown.
3.
Pick up the right glove. With the
thumb of the glove facing the surgeon, place your fingers and thumbs of both
hands in the cuff of the glove and stretch it outward, making a circle of the
cuff. Offer the glove to the surgeon. Be careful that the surgeon’s bare hand
does not touch your gloved hands.
4.
Repeat the preceding step for the
left glove.
The two techniques of gloving:
1.
Open Gloving
2.
Closed Gloving
Post-operative care in nursing aspect
Post-operative
care
1. Definition
The postoperative
phase of the surgical experience extends from the time the
client is transferred to the recovery room or postanesthesia care unit (PACU)
to the moment he or she is transported back to the surgical unit, discharged
from the hospital until the follow-up care.
2.
Goals
During the
postoperative period, reestablishing the patient’s physiologic balance, pain
management and prevention of complications should be the focus of the nursing
care. To do these it is crucial that the nurse perform careful assessment and
immediate intervention in assisting the patient to optimal function quickly,
safely and comfortably as possible.
1.
Maintaining adequate body system
functions.
2.
Restoring body homeostasis.
3.
Pain and discomfort alleviation.
4.
Preventing postoperative complications.
5.
Promoting adequate discharge planning
and health teaching.
The mnemonic
“POSTOPERATIVE” may also be helpful:
·
P – Preventing and/or relieving
complications
·
O – Optimal respiratory function
·
S – Support: psychosocial well-being
·
T – Tissue perfusion and cardiovascular
status maintenance
·
O – Observing and maintaining adequate
fluid intake
·
P – Promoting adequate nutrition and
elimination
·
A – Adequate fluid and electrolyte
balance
·
R – Renal function maintenance
·
E – Encouraging activity and mobility
within limits
·
T – Thorough wound care for adequate
wound healing
·
I – Infection Control
·
V – Vigilant to manifestations of
anxiety and promoting ways of relieving it
·
E – Eliminating environmental hazards
and promoting client safety
To PACU
Patient Care during Immediate
Postoperative Phase: Transferring the Patient to RR or PACU
3.
Patient
Assessment
Special
consideration to the patient’s incision site, vascular status and exposure
should be implemented by the nurse when transferring the patient from the
operating room to the postanethesia care unit (PACU) or postanesthesia recovery
room (PARR). Every time the patient is moved, the nurse should first consider
the location of the surgical incision to prevent further strain on
the sutures. If the patient comes out of the operating room with drainage
tubes, position should be adjusted in order to prevent obstruction on the
drains.
1.
Assess air exchange status and note
patient’s skin color
2.
Verify patient identity. The nurse must
also know the type of operative procedure performed and the name of the surgeon
responsible for the operation.
3.
Neurologic status assessment. Level of
consciousness (LOC) assessment and Glasgow Coma Scale (GCS) are helpful in determining
the neurologic status of the patient.
4.
Cardiovascular status assessment. This
is done by determining the patient’s vital signs in the immediate postoperative
period and skin temperature.
5.
Operative site examination. Dressings
should be checked.
4.
Positioning
Moving a patient
from one position to another may result to serious arterial hypotension. This
occurs when a patient is moved from a lithotomy to a horizontal position, from
a lateral to a supine position, prone to supine position and even when a patient
is transferred to the stretcher. Hence, it is very important that patients are
moved slowly and carefully during the immediate postoperative phase.
5.
Promoting Patient Safety
When transferred
to the stretcher, the patient should be covered with blankets and secured with
straps above the knees and elbows. These straps anchor the blankets at the same
time restrain the patient should he or she pass through a stage of excitement
while recovering from anesthesia. To protect the patient from falls, side rails
should be raised.
Safety checks
when transferring the patient from OR to RR:
·
S – Securing restraints for I.V. fluids
and blood transfusion.
·
A – Assist the patient to a position
appropriate for him on her based on the location of incision site and presence
of drainage tubes.
·
F – Fall precaution implementation by
making sure the side rails are raised and restraints are secured well.
·
E – Eliminating possible sources of
injuries and accidents when moving the patient from the OR to RR or PACU.
6. Postoperative Nursing
Care
Airway
·
Keep airway in place until the patient is fully awake and tries to
eject it. The airway is allowed to remain in place while the
client is unconscious to keep the passage open and prevents the tongue from
falling back. When the tongue falls back, airway passage obstruction will
result. Return of pharyngeal reflex, noted when the patient regains
consciousness, may cause the patient to gag and vomit when the airway is not
removed when the patient is awake.
·
Suction secretions as needed.
Breathing
·
B – Bilateral lung auscultation
frequently.
·
R – Rest and place the patient in a
lateral position with the neck extended, if not contraindicated, and the arm
supported with a pillow. This position promotes chest expansion and facilitates
breathing and ventilation.
·
E – Encourage the patient to take deep
breaths. This aerates the lung fully and prevents hypostatic pneumonia.
·
A – Assess and periodically evaluate the
patient’s orientation to name or command. Cerebral function alteration is
highly suggestive of impaired oxygen delivery.
·
T – Turn the patient every 1 to 2 hours
to facilitate breathing and ventilation.
·
H – Humidified oxygen administration.
During exhalation, heat and moisture are normally lost, thus oxygen
humidification is necessary. Aside from that, secretion removal is facilitated
when kept moist through the moisture of the inhaled air. Also, dehydrated
patients have irritated respiratory passages thus, it is very important make
sure that the inhaled oxygen is humidified.
Circulation
·
Obtain patient’s vital signs as ordered
and report any abnormalities.
·
Monitor intake and output closely.
·
Recognize early symptoms of shock or
hemorrhage such as cold extremities, decreased urine output – less than 30
ml/hr, slow capillary refill – greater than 3 seconds, dropping blood pressure,
narrowing pulse pressure, tachycardia – increased heart rate.
Thermoregulation
·
Hourly temperature assessment to detect
hypothermia or hyperthermia.
·
Report temperature abnormalities to the
physician.
·
Monitor the patient for postanethesia
shivering or PAS. This is noted in hypothermic patients, about 30 to 45 minutes
after admission to the PACU. PAS represents a heat-gain mechanism and relates
to regaining the thermal balance.
·
Provide a therapeutic environment with
proper temperature and humidity. Warm blankets should be provided when the
patient is cold.
Fluid Volume
·
Assess and evaluate patient’s skin color
and turgor, mental status and body temperature.
·
Monitor and recognize evidence of fluid
and electrolyte imbalances such as nausea and vomiting and body weakness.
·
Monitor intake and output closely.
·
Recognize signs of fluid imbalances.
HYPOVOLEMIA: decreased blood pressure, decreased urine output, increased pulse
rate, increased respiration rate, and decreased central venous pressure (CVP).
HYPERVOLEMIA: increased blood pressure and CVP, changes in lung sounds such as
presence of crackles in the base of both lungs and changes in heart sounds such
as the presence of S3 gallop.
Safety
·
Avoid nerve damage and muscle strain by
properly supporting and padding pressure areas.
·
Frequent dressing examination for
possible constriction.
·
Raise the side rails to prevent the
patient from falling.
·
Protect the extremity where IV fluids
are inserted to prevent possible needle dislodge.
·
Make sure that bed wheels are locked.
GI Function and Nutrition
·
If in place, maintain nasogastric tube
and monitor patency and drainage.
·
Provide symptomatic therapy, including
antiemetic medications for nausea and vomiting.
·
Administer phenothiazine medications as
prescribed for severe, persistent hiccups.
·
Assist patient to return to normal
dietary intake gradually at a pace set by patient (liquids first, then soft
foods, such as gelatin, junket, custard, milk, and creamed soups,
are added gradually, then solid food).
·
Remember that paralytic ileus and
intestinal obstruction are potential postoperative complications that
occur more fre-quently in patients undergoing intestinal or abdominal surgery.
·
Arrange for patient to consult with the
dietitian to plan appealing, high-protein meals that provide sufficient
fiber, calories, and vitamins. Nutritional supplements, such as Ensure or
Sustacal, may be recommended.
·
Instruct patient to take multivitamins,
iron, and vitamin C supplements postoperatively if prescribed
Comfort
·
Observe and assess behavioral and
physiologic manifestations of pain.
·
Administer medications for pain and
document its efficacy.
·
Assist the patient to a comfortable
position.
Drainage
·
Presence of drainage, need to connect
tubes to a specific drainage system, presence and condition of dressings
Skin Integrity
·
Record the amount and type of wound
drainage.
·
Regularly inspect dressings and
reinforce them if necessary.
·
Proper wound care as needed.
·
Perform hand washing before and after
contact with the patient.
·
Turn the patient to sides every 1 to 2
hours.
·
Maintain the patient’s good body
alignment.
Assessing and Managing Voluntary Voiding
·
Assess for bladder distention and urge
to void on patient’s arrival in the unit and frequently thereafter
(patient should void within 8 hours of surgery).
·
Obtain order for catheterization before
the end of the 8-hour time limit if patient has an urge to void and
cannot, or if the bladder is distended and no urge is felt or patient
cannot void.
·
Initiate methods to encourage the
patient to void (eg, letting water run, applying heat to perineum).
·
Warm the bedpan to reduce discomfort and
automatic tightening of muscles and urethral sphincter.
·
Assist patient who complains of not
being able to use the bedpan to use a commode or stand or sit to void
(males), unless contraindicated.
·
Take safeguards to prevent the patient
from falling or fainting due to loss of coordination from medications or
orthostatic hypotension.
·
Note the amount of urine voided (report
less than 30 mL/h) and palpate the suprapubic area for distention or
tenderness, or use a portable ultrasound device to assess residual volume.
Encouraging Activity
·
Encourage most surgical patients to
ambulate as soon as possible.
·
Remind patient of the importance of
early mobility in preventing complications (helps overcome fears).
·
Anticipate and avoid orthostatic
hypotension (postural hypotension: 20-mm Hg fall in systolic blood
pressure or 10-mm Hg fall in diastolic blood pressure, weakness,
dizziness, and fainting)
·
Assess patient’s feelings of dizziness
and his or her blood pressure first in the supine position, after patient
sits up, again after patient stands, and 2 to 3 minutes later.
·
Assist patient to change position
gradually. If patient becomes dizzy, return to supine position and delay
getting out of bed for several hours.
·
When patient gets out of bed, remain at
patient’s side to give physical support and encouragement.
·
Take care not to tire patient.
·
Initiate and encourage patient to
perform bed exercises to improve circulation (range of motion to arms,
hands and fin-gers, feet, and legs; leg flexion and leg lifting; abdominal
and gluteal contraction).
·
Encourage frequent position changes
early in the postoperative period to stimulate circulation. Avoid positions
that compromise venous return (raising the knee gatch or placing a pillow
under the knees, sitting for long periods, and dangling the legs with
pressure at the back of the knees).
·
Apply antiembolism stockings, and assist
patient in early ambulation. Check postoperative activity orders before
get-ting patient out of bed. Then have patient sit on the edge of bed for
a few minutes initially; advance to ambulation as tolerated
Gerontologic Considerations
Elderly patients
continue to be at increased risk for postoperative complications. Age-related
physiologic changes in respi-ratory, cardiovascular, and renal function and the
increased incidence of comorbid conditions demand skilled
assessment to detect early signs of deterioration. Anesthetics and
opioids can cause confusion in the older adult, and altered
pharmacokinetics results in delayed excretion and prolonged
respiratory depressive effects. Careful monitoring of electrolyte,
hemoglo-bin, and hematocrit levels and urine output is essential
because the older adult is less able to correct and compensate for
fluid and electrolyte imbalances. Elderly patients may need
frequent reminders and demonstrations to participate in care effectively.
·
Maintain physical activity while patient
is confused. Physi-cal deterioration can worsen delirium and place patient
at increased risk for other complications.
·
Avoid restraints, because they can also
worsen confusion. If possible, family or staff member is asked to sit with
patient instead.
·
Administer haloperidol (Haldol) or
lorazepam (Ativan) as ordered during episodes of acute confusion;
discontinue these medications as soon as possible to avoid side effects.
·
Assist the older postoperative patient
in early and progressive ambulation to prevent the development of
problems such as pneumonia, altered bowel function, DVT,
weakness, and functional decline; avoid sitting positions that
promote venous stasis in the lower extremities.
·
Provide assistance to keep patient from
bumping into objects and falling. A physical therapy referral may be
indicated to promote safe, regular exercise for the older adult.
·
Provide easy access to call bell and
commode; prompt void-ing to prevent urinary incontinence.
·
Provide extensive discharge planning to
coordinate both professional and family care providers; the nurse, social
worker, or nurse case manager may institute the plan for continuing care.
Evaluation
Patients in PACU
are evaluated to determine the client’s discharge from the unit. The following
are the expected outcomes in PACU:
1.
Patient breathing easily.
2.
Clear lung sounds on auscultation.
3.
Stable vital signs.
4.
Stable body temperature with minimal
chills or shivering.
5.
No signs of fluid volume imbalance as
evidenced by an equal intake and output.
6.
Tolerable or minimized pain, as reported
by the patient.
7.
Intact wound edges without drainage.
8.
Raised side rails.
9.
Appropriate patient position.
10. Maintained
quiet and therapeutic environment.
To Surgical Unit
Patient Care during Immediate
Postoperative Phase: Transferring the Patient from RR to the Surgical Unit
To determine the
patient’s readiness for discharge from the PACU or RR certain criteria must be
met. The parameters used for discharge from RR are the following:
1.
Uncompromised cardiopulmonary status
2.
Stable vital signs
3.
Adequate urine output – at least 30 ml/
hour
4.
Orientation to time, date and place
5.
Satisfactory response to commands
6.
Minimal pain
7.
Absence or controlled nausea and
vomiting
8.
Pulse oximetry readings of adequate
oxygen saturation
9.
Satisfactory response to commands
10. Movement
of extremities after regional anesthesia
Most hospitals
use a scoring system to assess the general condition of patient in RR or PACU.
Observation and evaluation of the patient’s physical signs is based on a set of
objective criteria.
The evaluation
guide used is a modification of the APGAR scoring system used for newborns.
Through this, a more objective assessment of the patient’s physical condition
is guaranteed while recovering the RR or PACU.
The perfect
possible score in this modified APGAR scoring system is 10. To be discharge
from RR or PACU the patient is required to have at least 7 to 8 points.
Patients with
score less than 7 must remain in RR or PACU until their condition improves.
Areas of assessment in PACU or RR evaluation guide are:
1.
Respiration – ability to breathe deeply
and cough.
2.
Circulation – systolic arterial pressure
>80% of preanesthetic level
3.
Consciousness Level – verbally responds
to questions or oriented to location
4.
Color – normal skin color and
appearance: pinkish skin and mucus
5.
Muscle activity – moves spontaneously or
on command
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