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Operating Department Care Skills - 5N3767

2013

Operating Department Care Skills 5N3767

UNIT THREE: CLIENT CARE AND CLINICAL ACTIVITY

All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any format by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the proprietor and copyright owner of the course. Reproduction is prohibited. Unauthorised use may give rise to a claim for damages and/or be a criminal offence Printed and published in Ireland By The Open College Written by Siobhan Lynch Licensed holders of the copyright and publication rights for Ireland

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MODULE UNITS: 1. Safety and Health 2. Infection Control 3. Client Care and Clinical Activity 4. Communication

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UNIT 3 CLIENT CARE & CLINICAL ACTIVITY By the end of this unit you should be able to:  Assist the registered nurse in preparing the environment for receiving clients in a way that is conducive to their physical and emotional well-being, before, during and after clinical procedures.  Assist in the preparation and set up of the clinical areas for clinical procedure.  Support the registered nurse in his/her role of circulating nurse, in the following: o supporting the limb while pneumatic tourniquet and exanguination devices are being applied. o assisting in the preparation of the site of application for an electrosurgical plate. o providing supplies to the surgical team. o maintaining a sterile field. o assisting with the measuring and recording of body fluid losses.  State the role of the registered nurses count prior to discarding or removing swabs, instruments and surgical items from the operating room.  Demonstrate the procedure for shaving the operative site.  Report changes in the client’s condition and behaviours to the registered nurse.

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CARE OF CLIENT On arrival to the operating department, the patient may have their stress and anxiety heightened due to the unknown environment, fear of the surgery and unfamiliar staff. It is therefore essential that the perioperative team {nurses, HCA, anaesthetist, surgeon} communicates effectively with patients, to ensure that they understand the actions being performed.

An accurate assessment at this time by the perioperative nurse will form the basis for delivering high standards of patient care tailored to meet their needs (O’Reilly, 2001). An adult or parent may accompany a child to the operating department and therefore the perioperative care extends to the whole family. Parents themselves may be anxious as they relinquish care of their child to strangers and consideration of their needs as well as the child’s, need to be defined (NATN, 1996).

Adolescents too, may have concerns about their surgery, but be too embarrassed or scared to articulate those fears and, depending on their age and hospital policy, may be nursed in an adult or paediatric ward (Smith, 2000). An elderly patient may be confused and require additional reassurances and support from staff.

The patient should be greeted by name and then the nurse should introduce themselves to the patient. A preoperative checklist should be completed in accordance with hospital policy. At all times the patient must be treated with privacy, dignity and respect. Staff also need to provide equitable and appropriate care with respect to cultural, religious, ethnic and racial beliefs (NATN, 1999a).

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King (1998) listed those skills required by the nurse and essential to patient care in the operating room as: 

communication.

Comfort and dignity.

reassurance and explanation.

consideration of patient’s special needs.

Patients may be frightened or anxious, which can inhibit communication at this point. Barriers, such as the wearing of a mask when greeting the patient, undue background noise such as talking and telephones, and lack of explanations when performing tasks, must be removed. It is therefore essential to support and reassure the patient, offer appropriate explanations and provide care based on their needs at the time. (Taylor and Campbell, 2000b.) Patients presenting for elective surgery or in an emergency situation often feel: Anxious. Afraid. Worried. Vulnerable. Silly. Lonely. Exposed. Humiliated. Embarrassed.

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Theatre Patients need to be: Reassured. Informed. Respected. Protected. Made to feel safe. Kept safe.

The Preoperative Checklist:

Name/date of birth: To ensure that this is the correct patient with the correct notes. The date of birth acts as an additional check, as patients with the same name may be on the same ward.

Consent: Written consent is preferred as it provides documentary evidence (NATN, 1999b; Reid, 2003). The consent form should clearly state, without abbreviations, the operative procedure and should be signed by the patient (exceptions apply such as minors, life-threatening situation, legally or mentally incompetent (Hind, 2000)) and a qualified practitioner competent to carry out the procedure. For consent to be valid the patient must be informed of the procedure, its expected outcomes, benefits, potential risks and alternatives (NATN et al, 1998; Hind, 2000). The perioperative nurse must check the patient’s understanding of the procedure to safeguard their autonomy (Reid, 2003).

Procedure site, side or site: This is clearly marked with an indelible marker to avoid confusion. This should then be marked as confirmed within the patient’s notes, Xrays and the operating list. It is the responsibility of the person performing the procedure to ensure that the correct side/site is marked (NATN et al, 1998).

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Last ate or drank: Patients must fast preoperatively to minimise the risk of inhaling gastric contents while under anaesthetic, which could prove fatal (Jester, 1999; Dean and Fawcett, 2002). Dean and Fawcett (2002) recommend that fasting times for fluids should not normally be less than 2 hours or more than 4 hours, and that for solids fasting should be not less than 4 hours or more than 6 hours.

Rowe (2000) also identified that prolonged fasting preoperatively can result in dehydration, hypoglycaemia and confusion. Reducing fasting times may improve wound healing, comfort and postoperative outcomes.

Allergies: Identify allergies to minimise risk for patient during surgery. These should include elastoplast, specific drugs (antibiotics, suxamethonium, or any that contain eggs or nuts), fluids such as iodine, latex, and also note patients’ adverse reactions to anaesthetic or blood transfusions (King, 1998; Phillips, 2004).

Teeth/Dentures: State of teeth. Caps, crowns, dentures or loose teeth can become dislodged or damaged during intubation and may compromise the airway (King, 1998). Dentures, if tight fitting, and if the patient does not normally remove them routinely, may be left in place throughout the procedure at the anaesthetist’s discretion.

Jewellery: Some items of jewellery are worn for religious or cultural reasons and may cause offence if removed, so perioperative nurses must respect patient needs. Some body piercings may interfere with the surgery or compromise the airway and may be removed if required. Secure all rings and other jewellery to ensure that they are not lost during positioning or moving of the patient (NATN, 1998).

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Hearing Aid/other Prosthetic: Wearing of hearing aids are essential for the patient to communicate with theatre staff, so can be left in until the patient reaches the anaesthetic room and is about to be anaesthetised. The hearing aid should then be removed and given to recovery staff so that they can insert it once the patient regains consciousness. Glasses can also be worn to theatres for the same reason.

Contact lenses should not be worn, because during the procedure there is a risk that they can become dry and may scratch the cornea. Other prostheses such as wigs, false eyes and artificial limbs should be removed prior to surgery and retained on the ward for safe-keeping.

However, patients may express anxiety and every effort should be made to preserve a patient’s dignity and respect during the perioperative period (King, 1998).

Patient Records: Medical and nursing records should accompany the patient to the operating theatre so that an accurate assessment of the patient’s history can be made for the delivery of safe perioperative care. Documentation should include results from investigations completed at preoperative assessment, blood tests, X-rays and baseline observations (NATN, 1999b).

The role of the HCA in client care during the three phases of the surgical experience include: Post Procedure:

Assist nurse to receive patients in a way that helps their physical and emotional wellbeing before, during and after clinical procedure.

Friendly, reassuring, full attention. Communicate quiet confidence and professionalism. Allow patient to talk if you see they need to.

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Show that you are listening. Do not speak amongst yourselves “across the patient”. Always refer to patient by proper name.

During the anaesthetic, care of patient will involve:

Maintaining patient confidentiality is paramount. The patient is attached to various monitors, and this should be explained to the patient. During the induction of anaesthesia it is important that all personnel are calm and that noise, disruption and disturbance are minimal, as hearing is the last sense to go when the patient loses consciousness.

Such ambience will aid the patient’s state of mind at this time (Griffiths, 2000). As a patient is being anaesthetised, holding the patient’s hand and just being a physical presence can offer additional support for the patient (Hughes, 2002). During anaesthesia the nurse will observe and monitor the patient’s well-being. Eye pads may be applied over the eyes to prevent corneal abrasions and to maintain closure of the eyelids to prevent drying of the corneas due to a reduced eye reflex.

During Procedures: Assist transfer from trolley to table as necessary. Assist with safe positioning and protection of pressure areas, limbs, correct body alignment. Respect patients' dignity and privacy regardless of loss of consciousness. Never leave patient unattended or unnecessarily exposed. Maintain sterility and asepsis. After Procedure: Assist with safe transfer to recovery area. Check all drains, etc before moving patient.

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Team communication/co-ordination. Never leave unattended. If observed, report changes in behaviour/condition to a nurse. Reassure patient when regaining consciousness. The recovery nurse assesses the patient immediately on arrival, with a focus on airway, breathing and circulation (Hatfield and Tronson, 2001; Sharp, 1998; Starritt, 2000a). The patient’s airway must be patent, clear of blood or mucus. Adequate ventilation must be achieved and this may require assistance with the position of the head/neck or an airway adjunct; e.g. guedal or laryngeal mask airway (which may be present from theatres).

The patient’s position may also affect ventilation, and therefore the patient will need to be moved. The patient should be nursed on their side or supine, depending on the anaesthetist /surgeons instructions. Oxygen therapy is commenced immediately via an oxygen mask or nasal cannulae.

A pulse oximeter is attached to monitor oxygen saturation. Once the airway has been established, blood pressure and pulse can be monitored. Assessment of perfusion status includes conscious state, skin temperature and pulse and blood pressure, as an indication of perfusion to all vital organs. Inspection of wounds and drains for evidence of haemorrhage is carried out.

Patient assessment will also include: Checking of consciousness levels and signs of protective reflexes returning. Intravenous infusions – type, rate and patency of site. Drains – types, amount draining and rate. Urinary catheters – patency, colour of drainage and amount. Temperature as hypothermia is still a risk. Pressure area care. Assessment of wound. Pain assessment and management.

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PREPARATION OF CLINICAL ENVIRONMENT In preparation for a surgical procedure, and to ensure the safety of patients, the environment must be prepared. In this section the three phases will be addressed. The theatre environment first and foremost will be clean, adhere to health and safety and infection control standards. The Anaesthetic Phase In this phase, preparation of the environment will involve many clinical skills, such as the preparation of a wide range of specialist equipment and drugs. This includes; anaesthetic machines, intravenous equipment and devices to safely secure the patient's airway during anaesthesia. The HCA will assist the nurse to ensure the anaesthetic machine is connected and calibrated and scavenging system is in good working order; ensure vaporiser bottles are present and secured; check breathing circuits and change filters.

They will also check airway equipment --- laryngoscope blades and masks present and of various sizes; suction machine and liner present and yanker sucker attached; O2 cylinders; monitoring equipment {BP. Temp. Oxgen sats probe}. Further equipment such as warming device, intravenous fluids, intravenous / central venous pressure kits, urinary catheters should be checked. The anaesthetist is fully responsible for performing a check of machinery prior to a patient being received in this area.

Preparing the Theatre Environment

In this phase, the HCA will assist the scrub nurse and other circulating staff to ensure the environment is clean and hygienic. A number of safety checks will be performed prior to commencement of surgery such as:

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Switch on the overhead light to ensure proper functioning. Check the operating table for proper working order. Check the suction machine, the electrosurgical unit, and other pieces of equipment in the operating room whether or not they are to be used. Gather other equipment required from store room and ensure same is in good working order. Line the kick buckets with plastic bags. Check the supply cabinets for stock. Restock, if necessary. Consult with the scrub nurse on the arrangement of the furniture for the surgical procedure. Check with the scrub nurse for any special equipment he/she may need for the case. Check that all equipment needed to position the patient is in the room. If not, get the necessary equipment {table attachments, pressure relieving devices}. Discuss with the scrub nurse the sterile supplies needed for the case. Sterile supplies and instruments are checked for integrity. Every package is checked for tears, punctures, watermarks, expiration date, and the sterilisation indicator. Tears, punctures and watermarks on a sterile pack indicate that the supplies are unsafe to use.

The surgical phase During this phase the HCA will assist the perioperative staff in ensuring a safe surgical experience for the patient and that the operation runs smoothly by: Preparing all the necessary instruments and equipment for the procedure. This may involve complex machinery including microscopes, lasers and endoscopes. Working closely with surgical team/scrub nurse, providing the correct surgical instruments and materials, in order to ensure safe and efficient completion of surgical procedures. Promoting health and safety and be responsible for ensuring that surgical instruments, equipment and swabs are all accounted for throughout the surgical procedure.

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Utilising effective communication and management skills, preparing the environment, equipment and acting as the link between the surgical team and other parts of the theatre and hospital. They should be able to anticipate the requirements of the surgical team and respond effectively.

The recovery phase During this phase, the HCA will assist the recovery nurse in the care of patients postoperatively by: Receiving, assessing and delivering patient care on their arrival into the recovery unit. Monitoring the patient's physiological parameters and supporting them, providing appropriate interventions and treatment until the patient has recovered from the effects of the anaesthesia and/or surgery and is stable. Assessing the patient in order to ensure that they can be discharged back to a surgical ward area. Evaluating the care given during the perioperative phases (anaesthetics, surgery, recovery). Accompanying patients back to ward.

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SAFE PRACTICES Throughout the intraoperative phase, safe practice in the following is fundamental to the safety of patients. Application of safe practices and close monitoring of patients is paramount to avoid adverse incidents.

APPLICATION OF PNEUMATIC TOURNIQUET

A Pneumatic tourniquet is used during extremity surgery to maintain a bloodless field and/or prevent an IV regional anaesthetic drug from exiting an extremity. The tourniquet applies pressure to the limb to occlude the blood supply to the operative limb.

The pneumatic tourniquet can cause nerve, vessel and tissue injuries to the patient, temporary or permanent, due to incorrect cuff placement, excessive tourniquet pressure, prolonged inflation and improper protection of the skin underlying the tourniquet.

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The safety of the patient is of utmost importance when using the pneumatic tourniquet.

The components of the pneumatic tourniquet consist of the:

Inflatable cuff: Consists of a rubber bladder that is within a plastic or fabric covering. Cuffs may be a single cuff that contains a single chamber for the air or a double cuff that contains two chambers. Connective tubing: Connects the cuff to the pressure device. Pressure device: Consists of the air compressor, buttons for setting the pressure, digital display of the pressure setting, and timer. The pressure device is run by electricity, therefore the unit is plugged into a wall outlet. Some units contain a battery that can run the device for a short period of time during power outages. Cuff: Different styles, types and sizes of pneumatic tourniquets are available. It is important to select the appropriate cuff style, width, and length. Limb Protection: If limb protection is to be used between the cuff and the limb, select the appropriate limb protection material for the selected cuff, some manufacturers supply a limb protection sleeve with the cuff.

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PREPARTION It is important to test the pneumatic tourniquet and inspect all of the other components before every patient use. Patient safety demands that all tourniquet parts be functioning properly before the procedure. Most modern electronic tourniquet instruments have a self-test mode that is activated when the power switch is turned on. The self-test rapidly verifies all alarm systems and the pressure accuracy of the display. If either a manual calibration test or the computerised self-test indicates that the tourniquet display is in error, do not use the unit. Before use, inspect the tourniquet instrument and mounting, connecting tubing, and cuff. Make sure that all connections are in good condition and are securely fastened. Disposable cuffs are preferred, however if re-usable cuffs are in use, check the following; Is there any physical damage such as rips, tears, holes, etc to the cuff. Use of a damaged cuff could result in one or more of the following unwanted events: 

Loss of cuff pressure.

Release of the cuff from around the patient's limb.

Movement of the cuff on the patient's limb.

Excessive leakage of cuff pressure.

Pinching of tissue under the cuff leading to injury.

The surgeon is responsible for determining the appropriate tourniquet cuff pressure. The objective is to maintain a cuff pressure that is high enough to completely suppress arterial circulation and produce a bloodless field, yet low enough to minimise the risk of neuromuscular injury.

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Applying the Tourniquet After the patient is brought into the OR, apply the tourniquet at the proper location on the limb, for an appropriate period of time, and within the appropriate pressure range. Cuff location -o Place an arm cuff midway between the shoulder and elbow. o Place a thigh cuff on the proximal third of the thigh. o Position a lower leg cuff, mid-range of the calf near the point of maximum calf circumference. Apply the appropriate limb protection material to the limb. Make sure that the limb protection material (if used) and the skin under the cuff are wrinkle-free. Position the cuff so that the hose connections are accessible under the drapes and the tubing will not be kinked or in the surgical field when the limb is positioned for surgery. Then smoothly wrap the cuff around the limb and pull snug by grasping the tie ribbon with one hand and pulling the strap end of the cuff snug with the other hand, and tie the ribbon. Connect the cuff to the tourniquet instrument, ensuring all connectors are secured. If a limb protection sleeve or stockinette material is being used, fold the portion extending beyond the distal cuff edge back over the cuff. To prevent antimicrobial skin prep solutions and other fluids from running under the cuff, cover the tourniquet cuff with a plastic drape, with the drape's adhesive edge placed over the distal edge of the cuff. Measure the limb occlusion pressure (LOP) using the applied tourniquet cuff. Exsanguinate the limb. Elevate the limb for a minimum of 2 minutes. Rapidly inflate the tourniquet to the set pressure specified by the surgeon. Make sure that the pressure display is clearly visible. IMPORTANT: Record the time of inflation, the tourniquet pressure, and the patient's blood pressure at time of inflation.

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Prepare the skin according to standard procedure and drape the operative site in preparation for the incision. During the surgical procedure monitoring of tourniquet safety parameters reduces the risk of complications. Adjust the tourniquet pressure at the surgeon's request. Monitor the cuff pressure display during surgery and immediately report any changes to the surgeon. At the surgeon’s request, deflate the tourniquet cuff. This should be performed rapidly to establish immediate venous return and prevent engorgement. Record the time of deflation. Immediately remove the deflated cuff and any underlying limb protection following cuff deflation. Even the slightest impedance of venous return by the deflated cuff or padding may lead to congestion and pooling of blood in the operative field. Record the time of cuff removal, check the circulation of the limb. Note the return of colour to the limb and any abnormalities. If full colour does not return within 3 - 4 minutes after release, place the limb slightly below body level. Inspect the cuff site and note any signs of soft tissue damage. On completion of surgical procedure, dispose of cuff, or if re-usable, clean cuff as per instructions, clean machine and tubing and return to allocated storage area. Documenting Tourniquet Use Documentation of tourniquet use is always a nursing responsibility. Documentation provides information for continuity of care, retrospective review, and research. Careful records become particularly important if a patient sustains an injury and a lawsuit is filed. Record only observable facts, rather than any judgmental opinion. Information is usually entered on a special record. Such records include, at minimum, the following items: Identification/serial number and model of the tourniquet. Identification of the person who applied the cuff. Location of the cuff.

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Times of inflation and deflation of the tourniquet. Length of tissue aeration periods, if applicable. Original tourniquet pressure. Initial systolic blood pressure. Subsequent systolic blood pressures. The fact that the surgeon was informed of elapsed tourniquet time and any alterations in systolic blood pressure. Skin and tissue integrity under the cuff before use of the pneumatic tourniquet and when the patient is sent to post-anesthesia recovery. Any abnormal or adverse occurrences.

APPLICATION OF ELECTROSUGICAL PLATE

As previously discussed in Unit one, electro-surgery/diathermy is a common piece of equipment in surgery, in this section safe practice with application and connection is discussed.

The HCA MUST apply the following practices:

Familiarise yourself with the electrosurgical unit being used. Familiarise yourself with the settings used for each procedure. Check with surgeon. Safe grounding pads must have at least 69 cm2 / 10 sq. inches of conductive area. Use an adult size pad where possible; otherwise, a paediatric size. Never cut or fold a pad to fit a site. The ideal application site must consider the procedure, patient position and current flow away from ECG electrodes. Avoid placement near scars or implant sites, if pacemaker present, extra caution must be addressed {alternative type used ie bipolar}. The application site must be clean, dry and shaved; excess hair is the most common cause of electrosurgical burns. Avoid pressure sores by ensuring the patient is not resting on the clamp.

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Check the cord on corded patient plates, or the reusable cable for damage before each use. Then check the cable-electrode connection. Recheck the plate contact and cable connection after moving the patient. Make sure the patient is not in contact with any metal component. Make sure cables are not coiled up or wrapped around metal objects. Place the active electrode in a holder when not in use. REF: {3M Healthcare}

Dos and Don’ts : Positive steps towards diathermy safety REF:{3M Healthcare}

DOs ✔ DO shave, clean and thoroughly dry the patient plate site before applying the patient plate. ✔ DO position the patient plate as close to the operative site as is safe and reasonably possible. ✔ DO check all cables to active electrodes and patient plate for cracks and deterioration. ✔ DO follow manufacturer’s instructions for checking alarm systems. ✔ DO locate the patient plate over well vascularised muscular areas. ✔ DO apply the patient plate before draping the patient. ✔ DO ensure that the patient plate is in direct and complete contact with the patient to permit the flow of current. ✔ DO check the patient plate for adequate contact if the patient is moved during surgery. ✔ DO make sure the cable-to-machine and cable-to-plate connections are secure. ✔ DO check the patient plate and all connections during surgery if constant level increases are required. ✔ DO keep the active electrode blade clear of tissue build-up. ✔ DO position ECG electrodes the maximum possible distance from the surgical site. ✔ DO take time to prepare the diathermy unit and to apply patient plates carefully.

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DON’Ts in placing patient plates

✖ DON’T allow fluids to pool at the patient site. ✖ DON’T locate the patient plate over bony or hairy areas, scar tissue or implanted prosthesis. ✖ DON’T cut or fold the patient plate or make it smaller for any reason. Remember minimum safety size is 69 cm2: /10 sq. inches. ✖ DON’T use bent, scored or crumpled plates. ✖ DON’T use patient plates which have surface blemishes, or are in any way suspect in regard to their conductivity and/or patient contact. ✖ DON’T place the active electrode on grounded surfaces when in use. ✖ DON’T activate the active electrode until it is close to the surgical site. ✖ DON’T wrap the patient plate or active electrode cables around metal objects. ✖ DON’T spark the active electrode to ground to check the generator.

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MAINTAINING A STERILE FIELD The creation and maintenance of a sterile field can directly influence patient outcomes. Adherence to aseptic practices by all individuals involved in surgical interventions, aids in fulfilling the professional responsibility to protect patients from injury. Aseptic practices are implemented preoperatively, intraoperatively, and postoperatively to minimise wound contamination and reduce patient risks for surgical site infections {AORN, 2009}.

As discussed in Unit one, the sterile field during surgery is centralised around the patient, the surgical team, {ie, surgeons, and scrub nurse} and equipment. The overall objective of the sterile field is to eliminate the risk to clients/patients and allow for a safe surgical procedure.

All staff must adhere to theatre attire practices and hand hygiene practices in order to promote a safe environment.

The following guidelines from AORN Recommended Practices address how a sterile field can be maintained.

RECOMMENDED PRACTICE ONE: Scrubbed persons should function within a sterile field. Before donning sterile gowns and gloves, surgical hand antisepsis should be performed according to recommended practices for surgical hand antisepsis/hand scrubs. Surgical hand antisepsis decreases the microbial counts on the skin and will reduce the transfer of microorganisms. Staff within the sterile field should wear scrub attire, caps, masks, and sterile gowns and gloves to prevent microbial transference to the sterile field, surgical site, and patient during the surgical procedure. Scrubbed staff should don sterile gowns and gloves from a sterile area away from the main instrument table to prevent contamination of the sterile field. Materials for gowns should be selected according to the required level of barrier protection.

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Surgical gowns should be of sufficient size to adequately cover the scrubbed person. Surgical gowns should establish a barrier that minimises the passage of microorganisms between non-sterile and sterile areas. The front of sterile gowns are considered sterile from the chest to the level of the sterile field. The sterile area of the gown front extends to the level of the sterile field because most scrubbed personnel work adjacent to a sterile bed and/or table. Gown sleeves are considered sterile from two inches above the elbow to the cuff, circumferentially. The gown back is considered non-sterile because it cannot be constantly monitored. Scrubbed staff should inspect gloves for integrity after donning them. Intact gloves establish a barrier that minimises the passage of microorganisms between non-sterile and sterile areas. Policies and procedures in the practice setting should indicate when double-gloving is required to reduce the potential for hand contact with blood and body fluids. Sterile gloves that become contaminated should be changed as soon as possible.

RECOMMENDED PRACTICE TWO: Sterile drapes should be used to establish a sterile field. Surgical drapes should establish an aseptic barrier that minimises the passage of microorganisms between non-sterile and sterile areas. To prevent transfer of microorganisms from non-sterile to sterile areas, sterile drapes should be placed on the patient, furniture, and equipment to be included in the sterile field. Sterile drapes should be handled as little as possible. Rapid movement of draping materials creates air currents on which dust, lint, and other particles can migrate. Draping material should be held in a compact manner, held higher than the OR bed, and placed from the surgical site to the periphery to minimise contamination of the surgical site.

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The portion of the surgical drape that establishes the sterile field should not be moved after it is positioned. Shifting or moving the sterile drape can compromise the sterility of the field.

RECOMMENDED PRACTICE THREE: Items used within the sterile field should be sterile. To ensure that only sterile items are presented to the sterile field, all items should be inspected immediately before presentation to the field for proper packaging, processing, seal, package container integrity, and inclusion of a sterilisation indicator that has changed colour demonstrating that sterilisation parameters were met. If an expiration date is provided, the date should be checked before opening the package and delivering the contents to the field. Outdated items should not be used.

RECOMMENDED PRACTICE FOUR: All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain item sterility and integrity. Un-scrubbed/circulating staff should open wrapped sterile supplies by opening the wrapper flap farthest away from them first to prevent contamination by passing an unsterile arm over a sterile item. Next, open each of the side flaps. The nearest wrapper flap should be opened last. All wrapper edges should be secured when supplies are presented to the sterile field. Securing the loose wrapper edges prevents them from contaminating the sterile field. Sterile items should be presented to the scrubbed nurse or placed securely on the sterile field. Items tossed onto a sterile field may roll off the edge, create a hole in the sterile drape, or cause other items to be displaced, leading to contamination of the sterile field. Sharps and heavy objects should be presented to the scrubbed nurse or opened on a separate surface. These heavy items may penetrate the sterile barrier if dropped onto the sterile field. Peel pouches should be presented to the scrubbed nurse to prevent contamination of the contents.

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Container systems should be opened on a separate surface. The lid should be lifted toward the staff opening the container and away from the container. All items should be delivered to the surgical field in a manner that prevents nonsterile objects or staff from extending over the sterile field. Skin is a source of bacteria and scurf shedding; therefore, maintaining distance from the sterile field can decrease the potential for contamination when items are passed from an unsterile to a sterile area. When dispensing solutions, the solution receptacle on the sterile field should be placed near the table’s edge or held by the scrubbed nurse. The entire contents of the container should be poured slowly to avoid splashing. Medications should be delivered to the sterile field in an aseptic manner. Stoppers should not be removed from vials for the purpose of pouring medications. Sterile transfer devices (eg, sterile vial spike, filter straw, plastic catheter) should be used to dispense medications to the sterile field.

RECOMMENDED PRACTICE FIVE: A sterile field should be maintained and monitored constantly. The sterile field should be prepared in the location in which it will be used. Open sterile supplies should only be exposed to one patient at a time. Opening several cases/sets in a room at one time exposes the sterile field to more than one patient. Sterile fields should be prepared as close as possible to the time of use. The potential for contamination increases with time because dust and other particles present in the ambient environment settle on horizontal surfaces over time. Sterile fields should not be covered. Although there are no research studies to support or discount the practice, removing a table cover may result in a part of the cover that was below the table level being drawn above the table level or air currents drawing microorganisms from a non-sterile area to the sterile field. Conversations in the presence of a sterile field should be kept to a minimum to reduce the spread of droplets.

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Air contains microorganisms on airborne particles, such as respiratory droplets. The primary source of airborne bacteria is health care personnel. Surgical equipment (eg, cables, tubing) should be secured to the sterile field with non-perforating devices. Perforations in a barrier provide portals of entry and exit for microorganisms, blood, and other potentially infectious body fluids. Non-sterile equipment (eg, Mayo stands) should be covered with sterile barrier material(s) before being introduced to, or brought over a sterile field. Only sterile items should touch sterile surfaces. The Mayo stand should be covered with a barrier material on the top, bottom, and all sides. Sterile barrier material also should be applied to the portion of the Mayo stand or other equipment that will be positioned immediately adjacent to the sterile field.

RECOMMENDED PRACTICE SIX: All personnel moving within or around a sterile field should do so in a manner that maintains the sterile field. Scrubbed staff should remain close to the sterile field. Walking outside the sterile field’s periphery or leaving the OR in sterile attire increases the potential for contamination. Scrubbed staff should move from sterile areas to sterile areas to prevent contamination. If they must change position, they should turn back to back or face to face while maintaining safe distances from each other and the sterile field. Un-scrubbed staff/circulating staff should face sterile fields on approach, should not walk between two sterile fields, and should be aware of the need for distance from the sterile field. Scrubbed staff should keep their arms and hands above the level of their waist at all times. Hands should be clasped in front of the body above waist level. Contamination may occur when arms and hands are moved below waist level. Arms should not be folded with the hands in the armpits. This area has the potential to become contaminated by perspiration allowing for strike-through of the gown and, ultimately, contamination of the gloved hands.

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The number and movement of individuals involved in a surgical procedure should be kept to a minimum. When a break in sterile technique occurs, corrective action should be taken immediately unless the patient’s safety is at risk. If the patient’s safety is at risk, correct the break in technique as soon as it is safe to do so. When a break in sterile technique occurs and cannot be corrected immediately, it should be recorded on a form internal to the organisation, such as an incident/occurrence report.

MEASURING & RECORDING BODY FLUID LOSSES

Fluid balance is a term used to describe the balance of the input and output of fluids in the body to allow metabolic processes to function correctly (Welch, 2010). During the operation, anaesthesia and surgery affects fluid balance. During surgery, the patient will receive fluid replacement therapy intravenously. The aims of fluid therapy are to maintain hydration and electrolyte balance:

The HCA has a responsibility to assist the surgical team and scrub nurse in measuring and recording fluid losses during surgery, to ensure accurate fluid replacement and prevent adverse events and to maintain patient safety. During surgery, the following losses must be monitored and recorded: 

Blood loss.

Urine output {where a catheter is present}.

Wound drainage {if drain present}.

Estimating blood loss can be difficult due to occult bleeding into the wound or under the surgical drapes. Accuracy however, is important to guide fluid therapy and transfusions. The most commonly used method for estimating blood loss is measurement of blood in the surgical suction container and weighing the blood on surgical sponges.

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Weigh the blood-soaked swabs as soon as they are discarded and subtract their dry weight (1 ml of blood weighs approximately 1 g). If irrigating solutions are used the HCA/circulating nurse must record the amount used and subtract from the remaining volume at end of surgery. Throughout the surgery any major losses must be relayed to the anaesthetist, so corrective action can be taken. All body fluid losses must be recorded at the end of the surgery and information passed onto recovery team.

PREPARATION OF OPERATIVE SITE

Preparation of the operative site is more commonly known as "skin-prep". The purpose of preparing the site is to render that area as free as possible from transient and resident microorganisms, dirt, and skin oil. All or any of these could infect an open wound. The goal of this preparation is to allow the surgical procedure to be performed with a minimal danger of infection.

Prepare the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol-based) preparation: povidone-iodine or chlorhexidine are most suitable. {NICE Guidelines, 2009.} Prior to surgery, the patient where possible is advised or assisted with a shower to remove debris from skin. This will assist with reducing the risk of wound contamination by decreasing organic debris on the skin and removing transient micro-organisms from the skin. Assessment and documentation of the operative site is made before the skin is surgically prepared to note: 

Skin integrity.

Presence of lesions - moles, warts, rashes etc.

Hair removal from operative site occurs only if necessary. Determining factors include: 

Amount of hair.

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Operating Department Care Skills - 5N3767 

Location of incision.

Type of surgical procedure to be performed.

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Where hair removal is indicated the removal is performed: 

According to the surgeon's orders or hospital policy.

By skilled staff.

In a manner that ensures skin integrity is preserved.

Clippers and/or depilatory agents are recommended (skin testing is required before using depilatory agents).

As close to the time of surgery as possible.

To minimise the time available for wound colonisation of micro-organisms at the surgical site.

Selection of the anti-microbial agent is based on: 

Patient sensitivity.

Anti-microbial agents used on skin with a known hypersensitivity. Reactions may cause adverse patient outcomes - agents may be absorbed by skin or mucous and cause toxic reactions.

Skin condition at operative site; examples: Burn site - normal saline. Colostomy site - isolated or covered with anti-microbial soaked sponge. Mucous membranes - anti-microbial agent or antiseptic agent only.

Skin preparation requires consideration of: 

Length of initial incision.

Requirement to extend initial incision and/or make additional incisions.

Drain sites required.

Drape fenestration size.

Preservation of skin integrity.

Maintenance of aseptic technique.

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Prevention of pooling/reduction of hazards.

Record of skin preparation may include, but is not limited to: 

Skin condition/cleanliness.

Hair removal (if performed) including method of removal and area.

Skin preparation used i.e. cleansing agent, solvent, antiseptic agent.

Person undertaking the prep.

Onset and details of any hypersensitivity reactions.

SURGICAL COUNT

Registered nurses and all personnel involved in the intra-operative journey are accountable to the patients for the nursing care delivered and, as such, they must ensure that no harm occurs through negligence, such as leaving foreign objects within patient cavities during clinically invasive procedures.

The purpose/principle of the surgical count is to ensure that all swabs, instruments and sharps are accounted for at all times during invasive surgical procedures and to prevent retention of foreign material which would cause harm to the patient.

The count must be audible to those counting and be conducted by two members of staff, one of whom MUST be a registered member of the perioperative team (i.e. a registered nurse).

A count must be undertaken for all procedures in which the likelihood exists that swabs, instruments and/or sharps could be retained. Countable items may include, but are not limited to:

X-ray detectable gauze swabs. Packs – vaginal/abdominal. Lahey swabs (peanuts, pledgets). Gauze strips.

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Neuro patties. Needles. Instruments, including screws or detachable parts, blades. Infiltration needles. Tapes, liga-reels, slings, sloops, shods, bulldogs, sponges. Red swab/packs ties. Cotton wool balls.

GUIDELINES FOR SURGICAL COUNTS AS PER AORN RECOMMENDATIONS:

At the beginning of each case a swab, instrument and needles count will be performed between the scrub and circulating person, they will be checking that there is a radiopaque line in the swab, and that all bundles of swabs are secured with a red string. Instruments must also be checked for integrity. The swabs/needles etc must be recorded on the white board in multiples of 5s e g. 5 + 5 + 5, as subsequent packs are opened. Extra instrumentation must be recorded on the white board and preoperative checklist chart. The red string tags around the swab packs must be retained by the scrub person as an additional check of numbers of swabs. The swabs used for preparing the skin will be handed to the circulating person who will keep them until he/she has the required number of five. The scrub person will retain all used swabs, needles and instruments from the operation, in a sterile container, safely avoiding blood spillage and splashing. Swabs considered dirty, e.g. faecal contamination should be dropped into a conveniently placed bowl. The scrub person will indicate to the circulating person at any appropriate time when 5, or multiple of, swabs have accrued. The circulating person will have a clear plastic bag available and marker pens so that the bags will be marked as they are used, with the number and types of swabs within the bag.

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The circulating person; whilst wearing gloves will present an opened clear plastic bag to the scrub person, who will count out 5 or appropriate numbers to accrue 5 swabs of equal size. The bag should be clearly marked and tied accordingly. The swabs should be weighed at this point, if required, and the accumulated totals recorded on the count board and blood loss form. Swabs that have already been placed in a clear plastic bag and labelled appropriately, can be placed in a SEPARATE marked yellow bag (NOT THE CLINICAL WASTE YELLOW BAG), which must remain in theatre throughout the case. With instructions from the scrub person, the count on the board will be adjusted to indicate that these swabs have been counted down e.g. 5 + 5 + 5 etc. Packages containing an incorrect number of sponges should be bagged, marked, and isolated from the rest of the sponges. Sponges should be attached to an instrument when used within a cavity. Sponges and attached tapes should not be cut. Only X-ray detectable sponges should be used and X-ray detectable sponges shall not be used as dressings, and should not be used as packing to remain in the patient. If used and left in the patient as packing intentionally, the number and type shall be documented on the count sheet and on the patient's record. Needles should be contained in a needle counter/container, loaded on a needle driver, or sealed packages. Needles should be handed to the surgeon on exchange basis. Hands free/no touch technique is recommended for passing scalpels. Used needles, blades should be contained in a disposable puncture resistant container. All parts should be accounted for if a needle or blade breaks. If a needle puncture occurs, the needle, glove(s) should be removed from the sterile field. Policy for puncture wounds should be followed. The final swab, instruments and needles count will include only the remaining swabs, instruments discarded on the floor or handed out, and needles in circulation, i.e. swabs not crossed through on the white board should be counted in multiples of 5.

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All instruments used initially and subsequent additions are counted as per instrument checklist. Swabs, instruments and needles checks must take place at: o Closure of an organ i.e. stomach or uterus. o Closure of peritoneum. o Closure of any layer as appropriate. o Final closure of skin layer. DOCUMENTAION: Counts should be recorded on a count sheet as per hospital policy. Names and titles of staff performing the counts should be recorded on the count sheet and the patient's record. Results of surgical counts shall be recorded as correct or incorrect. Instruments and sponges specifically left with the patient should be documented on the count sheet, register and the patient's records. Any action taken in the event of a count discrepancy should be documented on the patient's record. Count Discrepancies When the count is incorrect: 

Perform a recount.

Notify the surgeon and supervisor.

Conduct a search (floor, garbage, linen).

Request X-ray to be taken.

Document results on the count sheet, and patient's record.

REPORTING CHANGES IN CLIENT CONDITION

The operating theatre is a critical care area, and complex circulatory and metabolic changes occur in the patient. A common procedure can change instantaneously into a critical event.

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Awareness of adverse incidents that can occur and their management is crucial for patients' safety.

Monitoring the patient's clinical observations {blood pressure, oxygen saturations, heart rate, temperature}, fluid loss, blood loss, skin reactions, consciousness levels and pain level is a fundamental care skill of the perioperative staff. In this section, a number of potentially serious situations that could occur will be discussed.

Hypothermia: Inadvertent hypothermia – i.e. unintended loss in body temperature – is a potential problem for all patients undergoing a surgical procedure. The main contributory factors are: 

The ambient temperature.

Use of fluids at room temperature.

Unnecessary exposure of the patient before the surgical team is ready.

The patient’s age (very young or very old).

Type and length of procedure.

Effects of anaesthetic agents.

Hypothermia, defined as a patient core temperature of less than 36ºC (Vaughan et al, 1981), is a common side effect of anaesthesia.

Methods of preventing and treating hypothermia:

 Forced-air system (for example, Bair HuggerTM).  Warming of intravenous and/or irrigation fluids.  Warming under-blankets and table pads.  Pre-warmed blankets to cover the patient.  Deliberate control of ambient temperature.  Use of ‘space’ blankets in recovery.

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In the recovery ward, low temperatures can sometimes be accompanied by shivering, which not only increases oxygen demand, but can also be distressing for the patient. However, the absence of shivering does not mean that hypothermia is not present.

Tympanic thermometers are one of the most effective methods of measuring core temperature, which should always be monitored as routine practice. {Ref: Royal College of Nursing, 1999.}

The detrimental effects of hypothermia include increased rates of wound infection, increased blood loss and increased length of stay in recovery and hospital.

Adverse reactions

Anaphylaxis is a potential hazard for all patients, but this is exacerbated during the perioperative phase, not only because of the invasive nature of surgery – many products contain latex, but also because of the complex drug regimens which are administered.

Perioperative staff must be vigilant in the early identification of adverse reactions through close observation, and information about any known allergies should always be communicated to the perioperative team.

This is the End of Unit 3.

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NOTES:

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Unit 3 Operating Department Care Skills 5N3767