Operating Techniques (Doc.
Pascua)
SKIN PREPARATION OF THE SURGICAL
PATIENT
PURPOSE
To render the operative site as free as possible
from transient and resident microorganisms,
dirt, and skin oil so the incision can be made
through the skin with a minimal danger of
infection from this source
WHEN TO SKIN PREP?
 Invasive surgical procedures
 Traumatic wound care
GOAL
 Prevent Surgical Site Infection (SSI)
 SSI -an infection of the tissue in or
around a surgical wound. To be
considered a surgical site infection,
the infection must occur within 30
days after surgery.
COMPONENTS
 Mechanical Cleansing
 Hair Removal
 Skin Prep
1. MECHANICAL CLEANSING
 bathing the evening/morning before
surgery with an antimicrobial soaphair
should be washed, especially for cases of
the head and neck
NOTE: abnormal skin irritation, infection, or
abrasion on or near the operative site may be a
contraindication to the performance of the
surgical procedure
2. HAIR REMOVAL
 breaks in the skin permit the entry and
colonization of microorganisms, a potential
source of infection
 hair removal should take place as close to
the time of surgery as possible, but not in
the OR suite so as to minimize
environmental contamination of the room
 an order for hair removal should be
written in the Doctor's orders
 removal techniques include:
 shaving
 clippers
 depilatory cream
3. SKIN PREP
CONCEPTS
a. mechanical cleansing
 pressure
 friction
b. chemical antisepsis
 antiseptic solution - an antiseptic is a
substance which inhibits the growth and
development of microorganisms.
Anti = meaning against
Septic = containing or resulting from disease-
causing organisms
SUPPLIES
 basins for antiseptic soap and/or solution
 applicators
 usually gauze sponges - not radio-
opaque!!!
 q-tip applicators for hard-to-reach
areas
 towels for drying
 sterile gloves
 pads to collect excess prep solution to
prevent pooling of the solutions under the
patient during surgery
 prep solutions
COMMON PREPPING SOLUTIONS
 Chlorhexidine gluconate
(less rapid reduction of microbial count and
Residual effect 4-6 hours); used for pre op
bathing.
 Contraindicated: eyes, large open
wounds or burns, genitals
 Hibiclense
 Hibitane tincture
 Iodine and iodophors
(For lodine rapid reduction of microbial count
and Remove after 2-3 minutes to avoid skin
irritation (dry/blot with sterile towel;
lodophors are less irritating to skin/no need to
remove)
 10% povidone iodine - Betadine
(most effective concentration of iodine is 1-2%)
 Shellfish allergy is NOT related to
iodine allergy
 may cause irritation/burn to skin if
warmed
 Alcohol (Alcohol based antiseptic)
 May use after iodine to provide better
adhesion of bio-drape
 If on field at start color or clearly label
to avoid confusion with other clear
medications that may be on the field
 Avoid splashing as this is a re-capped
solution.
Isopropyl 70%
 is flammable - do NOT allow to pool,
especially with ESU and LASER cases
(it should be used with the lowest
power setting to minimize the risk of
sparking and excessive temp and
creation of O2 nich atmosphere like
02 tents)
 Hexachlorophine
jaylouise
can use several days prior to surgery as builds
up a lasting or cumulative effect
 Phisohex
 Phisoderm
ANTISEPTIC SELECTION
Have a multidisciplinary team, including
perioperative RNs, physicians, and infection
preventionists, select safe and effective
antiseptic products for preoperative patient
skin antisepsis.
ANTISEPTIC SELECTION: EVIDENCE
REVIEW
 Collective Evidence
 No one antiseptic is more effective
than another for preventing SSI
 Selection of a safe and effective
preoperative skin antiseptic should be
based on individual patient need
ANTISEPTIC SELECTION: HEALTH CARE
ORGANIZATION
- Develop a mechanism for product
evaluation and selection of preoperative
skin antiseptics.
 Review current research literature
 FDA requirements
 Category I in the Tentative Final
Monograph (TFM) for Over-the-
Counter (OTC) Healthcare Antiseptic
Drug Products
 "New Drug Approval" (NDA)
 Single-use containers
 Colored or tinted
- When Class I FDA-approved antiseptic
products are usually contraindicated,
collaboratively evaluate the risks and
benefits of using Class II or Class III FDA-
approved antiseptics or other alternative
solutions (eg, soaps, saline).
CONTRAINDICATIONS
 Allergy
 Anatomical location (eye, gynecologic,
Orthopedic)
 Wounds
PRIOR TO PROCEDURE
Operating Techniques (Doc. Pascua)
 Clean surgical site prior to prep prn of dirt,
grease, etc.
 May need to shave area: electric razor
preferable as iso less likely to create skin
irritation which can open an area exposing
to potential infection
 Shave should occur as close to time of
surgery as possible (surgeon preference if
removed)
 Remove all hair (use tape prn)
 May need to change a draw sheet
 Do not want hair floating around and
getting in surgical site
NOTE: OPERATIVE SITE AND SURGICAL
PROCEDURE SHOULD BE VALIDATED BEFORE
STARTING THE PREP AND PT. MODESTY
PROCEDURE
 Assemble necessary equipment
 establish a sterile field
 Pour solutions
 if not premixed, scrub solutions need
to be diluted with sterile water
 this may be done with sterile gloves
donned if the containers are sterile
also
 Expose the site to be prepped, making sure
that the johnny/ blanket will not become
contaminated with prepping solution
 Place protective pads around the patient to
collect excess prepping solution
 Don sterile gloves
open gloving without a gown
technique
 Wet the applicator with scrub solution
 areas included in the prep for each
operative procedure
PREP AREA: ABDOMEN
 Incision site to nipples and pubis,
pubis last
 May include upper thighs, still prep
groin and pubis last
PREP AREA: CHEST & BREAST
 Incision site, around to bedline, includes
shoulder and axilla
 May include arm (rare)
PREP AREA: EXTREMITIES
Considerations:
 Assistant with sterile gloves will grasp
extremity after a prepped area has been
washed and hold up for prepping
 Begin at surgical incision site and move
around circumference of extremity,
prepping groin or axilla last
 Feet or hands will be prepped separate or
last if groin or axilla not involved
Leg & Hip
 Foot Ankle: fost and entre leg ankle knee
 Hip: Hip, abdomen on affected side, entre
foot, butacks to table line, grain and pubbis
 Bilateral leg: both legs to toes or ankles to
waist lines or umbilicus, prepping groin
and pubis last.
jaylouise
Hand & Arm
 Hand: hand & arm to 3 inches above the
elbow
 Shoulder: shoulder, base of neck, chest to
midline, upper arm circumferentially, axilla
last
 Arm: entire arm circumferentially,
shoulder, hand (prn), axilla last
PREP AREA: PERINEAL
 Place drip pad under buttocks
 Begin at pubic area, move down over the
genitalia, perineum, and anus
 Discard sponge after going over the anus
 If doing an abdominoperineal procedure
should use two separate prep sets
(changing gloves in between) or prep
abdomen first, then perineal area as
described
 Should not double dip!
PREP AREA: VAGINAL
 Some surgeons may not prep the vagina
 Will need sponge stick or forceps for
internal vaginal prep
 Need pad under buttocks to catch prep
fluids
 Begin at pubis, moving over vulva,
perineum, and anus (discard after going
over anus)
 Sponge stick with prep solution inserted
into vagina to move in circular motion to
cleans vaginal vault
 Dry sponge stick should be used
afterwards in vaginal vault to internally
dry
PREP AREA: EYES, EARS, NOSE, FACE
 Eyes are protected
 Area surrounding incision site is prepped
as much as possible to hairline
 Some surgeons will not prep for eye, ear,
and nose surgeries
PREP AREA: HEAD
 Usually only the immediate area
surrounding the incision site is shaven and
prepped
Operating Techniques (Doc. Pascua)
 Used to shave entire head and prep entire
head
 May still do this occasionally
 Will begin at incision site and move around
in a circular motion away from site,
avoiding dripping into the ears, eyes,
nostrils, and mouth
PREP AREA: BACK
 Begin at incision site and move away in a
circular outward motion
 Depending on site of incision, may prep to
buttocks and or the neck to the hairline
 scrub the skin in a circular motion
 start at the incision point and work toward
the periphery
 discard the sponge after reaching the
periphery and obtain a new one to
continue
 Scrub for a minimum of five minutes or
according to hospital policy
 Dry the area with a sterile towel by placing
the towel and then patting the area, using
the cuff to lift the towel off the skin when
completed
 Apply paint solution using gauze on sponge
sticks
 working from the incision line to the
periphery
SPECIALIZED PREP AREAS
 The umbilicus is considered contaminated
 this should be thoroughly cleaned
using separate gauzes, prior to
starting the skin scrub
 Stomas, skin ulcers, sinuses and open
wounds are considered contaminated
 a one inch area around the opening is
left during the prep and that area is
cleansed with the last strokes of each
sponge
 Areas of high microbial counts are
considered contaminated and are prepped
last with each sponge
 Axilla
 Groin
 hair line
 When prepping perineum
 the mons pubis is cleansed first
 then the labia majora
 the thighs outward
 the labia minora and vestibule
 the vagina
 the rectum
jaylouise
 Skin grafts
 separate preps must be used for the
donor and recipient sites
 the donor site is prepared first
CONTAMINATED AREA: RULES OF THUMB
 Prep surrounding area first and
contaminated area last
 Use new sponge each time have passed
over contaminated area
 Use a new Skin Prep Set if there is more
than one surgical site.
 Eyes
 eyebrows are NEVER shaved!
 eyelashes may be trimmed with iris
scissors covered with vaseline jelly to
catch the lashes as they are trimmed
 the orbit is prepped with a drop of
iodine solution/saline and irrigated
with sterile saline from the nose side
to the lateral side
 lids are prepped with q-tips dipped in
solution and blotted on sterile gauze
WHERE THE PREP FALLS IN THE
SEQUENCE OF PRE-OPERATIVE
PREPARATION
 Anesthesia administered
 Urinary catheter placed
 Patient positioned
 All pre-operative procedures must occur
before the "prep" (including skin marking)
to prevent contamination of the incision
site
 Skin prep
 Draping of the patient
 Intra-operative phase begins with incision
or beginning of surgery
PROCEDURE COMPLETED
 Remove drip towels without touching
prepped area (circulator will remove
these)
 Clean up supplies
 Remove contaminated gloves
 Wash your hands
 Note or report any skin abnormalities to
the RN or MD immediately, ideally before
beginning of the prep.
STERILE TECHNIQUE AWARENESS
 Keep your front towards the sterile field
when passing
 Do not reach over the field
 Pour solutions at the closest end of the
field
 Breaks in sterile technique affect wound
classifications
 Without constant monitoring the field isn't
considered sterile
 Scrub and Nurse provide double check for
each other
DOCUMENTATION
 should include:
 skin condition
 hair removal technique
prep solutions
 person performing the prep
Operating Techniques (Doc. Pascua)
SURGICAL DRAPING
Draping is" The procedure covering and
surrounding areas with sterile impervious
barriers to create maintain sterile field during
operation."
PURPOSE
 Serve as a barrier from sterile to
nonsterile.
 Used to isolate the operative site from
contaminants.
 Prevents SSI's
DRAPE CHARACTERISTICS
 Lint free to prevent contaminates from
entering the wound.
 Fluid resistant (Impervious)
 Antistatic to prevent sparking
 Tear and puncture resistant
 Free of toxic materials
 Porous to retain enough body heat to keep
patient from hypo/hyperthermia.
 Color finish that will not reflect surgical
lights.
 Flame retardant so they do not ignite with
laser and ESU usage.
 Drape Materials
 Nonwoven Fabrics
 Woven Textile Fabrics
 Plastic Adhesive
 Incise drapes
 Aperture drapes (mata&ilong)
NONWOVEN FABRICS
 Disposable, compressed nylon or polyester.
 Does not require washing, folding, or
re-sterilizing.
 Light but strong material.
 Reinforced layers around fenestration.
 Equipped with special tags that serve as
attachments for suction or ESU.
WOVEN TEXTILE FABRICS
 Reusable cotton drapes
 Advantages:
 Cheaper
 Impermeable to liquids
 Disadvantages
 Must be washed, folded, inspected,
and sterilized.
 Puts SPD personnel at added risk.
PLASTIC ADHESIVE DRAPES
 Clear, thin, plastic material with an
adhesive backing.
 INCISE DRAPE
- Applied to the incision area after
placement of wound towels.
- Prepped area must be dry for drape to
stick to the skin.
- May be impregnated with antimicrobial
iodine solution.
- Incision is made thru drape.
 APERTURE DRAPE
- Clear plastic drapes with openings
surrounded by adhesive backing.
- Examples:
 Eye drapes
 Hip fracture drapes
DRAPE TYPES
jaylouise
 Drapes may have openings for exposure of
the area to be incised, called fenestrations
- One piece sheet should be long enough to
cover patient from head to toes.
 Some drapes have no fenestrations and are
used to cover unaffected body areas.
FENESTRATED DRAPES
Specific drapes are made with openings to
access specific body areas:
 Abdomen - Laparotomy Sheet
 Thorax and Kidney - Transverse Lap Sheet
 Neck - Thyroid Sheet
 Extremities - Extremity Sheet
 Hip - Hip Sheet
 Perineum - Perineal Sheet
 Cranium - Crainotomy sheet
Laparotomy Sheet
NONFENESTRATED DRAPES
 Used to custom drape an odd area of the
body or cover an unaffected area.
 Rectangular shaped drapes:
 Minor or Medium sheets
 Half or Three quarter sheets
 LITHOTOMY
 Used to drape a patient in lithotomy
position.
 Under buttocks, Leggings, Abdominal
drape
 SPLIT SHEETS
 U shaped drape with “tails” used to
drape extremities.
 STOCKINETTE
Operating Techniques (Doc. Pascua) jaylouise

 Unrolled to cover extremities.

 May be covered in plastic.

CUSTOM PACKS
 Opened on the back table to create initial
sterile field.
 Customized to contain drapes and supplies
for an area of the body, specific procedure,
or specific facility.
 Example: Open Heart Pack

DRAPING TECHNIQUE
1. Sterile drape should be placed on the
patient, the furniture, and equipment to be
included in the sterile field.
2. Sterile drapes should be handled as little as
possible because the rapid movement
creates air currents on dust, lint and
droplet.
3. Never reach across the operating table to
drape the opposite side or touch the
patients body.
4. Carry folded drapes to the operating table.
Watch the front of the sterile gown, it may
bulge and touch the non-sterile items.
Stand well back and remain a safe distance
to avoid gown contamination.
5. Draping material should be compact,
higher than the OR bed, and draped from
the operative site to the periphery.
6. During draping, sterile gloves should be
protected by cuffing the draping material
over the hands.
7. Once the sterile drape is positioned, it
should not be removed because shifting the
drape can compromise the sterility of the
field.
8. If the drape contaminated, discard.
9. If in doubt to sterility, consider it becomes
contaminated.
10. If unwanted substance present on the
drape, remove it and cover the area with a
new drape.