Operating Room Standards

Roquee Hospicio H. Paragoso

Perioperative Period
Client’s total surgical experience

Phases
a. Preoperative – decision  OR table
b. Intraoperative – OR table  PACU/RR
c. Postoperative – PACU/RR  full recovery
Goal of Peri-Operative Nursing
Provide SAFEST possible envt to ensure RAPID
RECOVERY by PREVENT POST-OP
INFECTION & other untoward complications

SSI
serious concern in OR

Infectious Disease
#1 cause of death worldwide
Infection Control Principles & Practices
Principles of Sterility
“Sterile to sterile, unsterile to unsterile”
Use sterile items ONLY in sterile field
Sterile persons are GOWNED & GLOVED
Sterile ONLY at table level
Sterile touch ONLY sterile (same w/ unsterile)
Sterile persons should be WITHIN sterile area
Sterile should keep MINIMUM CONTACT w/ sterile
items
Unsterile AVOID sterile areas
Edges of sterile packs are UNSTERILE
Create sterile field AS CLOSE AS POSSIBLE to
procedure
DOH Nosocomial Infection Control Program
1. Endogenous bacteria – most common cause of
SSI
a. Shower w/ shampoo – w/in 12° pre-op
b. Best hair-removal method – depilatory agent
c. Shaving - immediately pre-op in OR
d. Skin drapes – sterile, packed, stored, handled
e. Skin antiseptics – Povidone, Chlorhexidine,
Hexachlorophene
f. Proper attire – Camisa, NO underwear, Cap
2.  Hospital stay =  r/f SSI
a. Admit NEAR TIME of surgery
3. Drains, tubes, caths, devices =  r/f SSI
a. Strict asepsis & anti-sepsis during insertion
4. Antibiotic prophylaxis =  SSI
a. Pre-Op, single dose
5.  Op length =  r/f SSI
a. Proper surgical technique, asepsis,
hemostasis, avoid tension & dead space,
gentle tissue handling, electrocoagulation,
drains
6. Personnel are sources of SSI
a. Prescribed: Scrub suit, cap (hair), mask
(nose & mouth), clean slippers/shoe cover
b. NO street attire UNDERNEATH
c. PROPER closed gloving technique
d. DON’T recycle gloves
e. DON’T scrub if you have RTI or skin
lesions
f. Limit personnel
g. Keep nails short & polish-free
7. OR equipment & supplies = source of SSI
a. Design/Traffic Patterns
Location: away from corridor traffic,
near RR, accessible to CSR, Path, Rad,
Blood, CCU, separate entrances for
staff & pts
3 Zones:
1. Unrestricted – street clothes
2. Semi-restricted – gown & cap
3. Restricted – mask, gown, cap
Change area first before surgical lounge/office
Remove outer covering of sterile packs before
storage
Floors, walls, ceilings – seamless, fire-resistant,
smooth, hard, non-porous
Transfer pts from ward stretcher to OR stretcher
Close OR doors
Effective ventilation system w/ aircon
Central desk officer – controls in/out traffics
b. Sanitation
1. Before 1st op: Damp-dusting (disinfectant)
2. After op: Clean-up & proper disposal
3. At day’s end: Terminal disinfection (“D&C”)
c. In-hospital packaging material
1. Compatible w/ sterilization process
2. Cost-effective barrier
3. Allows ease in aseptic presentation
4. Non-toxic w/ non-fast dyes
5. Non-abrasive
d. Sterilization & Disinfection
1. Single-use items
2. Arrangement = equal sterilization
3. Chemical indicators – undergone sterilization
4. Recommended procedures:
a. Saturated steam under pressure
b. Ethylene oxide (ETO)
5. Date, autoclave no., sterilizer used
6. Damaged integrity = contaminated
7. Flash sterilization – emergency only
Types of Surgery
1. According to purpose
Diagnostic – to diagnose
Palliative – to relieve
Ablative – to remove
Constructive – to restore/repair
Transplant – to replace
Prophylactic – to prevent
2. According to risk involved
Major – w/ body cavities;  r/f complications
Minor – w/o body cavities; same-day; ambulatory
Types of Surgery
1. According to degree of urgency
Optional – client’s discretion
Elective – client’s convenience
Required – w/in weeks
Urgent/Imperative – w/in 24-48 hours
Emergency – STAT!
Perioperative Team
1. Surgeon – “Captain of the Ship”
2. Anesthesiologist – “Guardian of the Patient”;
plans for type of anesthetic; evaluates status
before, during & after, gives green light for op
3. Circulating RN – “Guardian of the SAFETY of
the Patient”; monitors OR eqpt, conditions,
activities
4. Scrub RN – set up sterile table & eqpt
5. PACU RN – care for pt until stable, emergence,
no hemorrhage
Pre-op Meds
Goals – aid in anesthetic admin,  secretions &
HR changes, relaxation, anxiety relief
Types
Opiates – relax;  anesthesia; morphine
Anticholinergics -  secretions & HR changes
Barbs/Tranquilizers – night before to  sleep
Antibiotics – prophylaxis; 1 hr before
 MEDICATION PURPOSE SIDE EFFECTS

↓ anxiety and
TRANQUILIZER (Valium) Confusion, dizziness
apprehension

SEDATIVES (Promethazine, ↓ anxiety and emesis, Hypotension,

Secobarbital Na) promote sedation disorientation

↓ pain, anxiety and

ANALGESICS (Morphine, Demerol) RESPI DEPRESSION
sensation

ANTICHOLINERGICS (Atropine Excessive dryness of

Control secretions
SO4) mouth, ↑ HR

↓ gastric acid
H2 RECEPTOR BLOCKERS (-tidine) Mild dizziness, diarrhea
production
Anesthesia
Goals
1. Analgesia
2. Sedation
3. Muscle relaxation
4. ANS control
Anesthesia Techniques
1. Regional – close to target nerves; lidocaine
2. Spinal – intrathecal; nerve roots & dorsal
ganglia blockage; paralysis & analgesia BELOW
level of injection
3. Epidural – similar to spinal
Spinal Epidural
Subarachnoid Epidural
Faster onset Slower onset
Lesser dose Higher dose
 Spinal headache  Spinal headache
4. Peripheral nerve blocks
5. Conscious sedation -  anxiety, LOC, pain
perception; can respond, CP & reflexes intact
6. Monitored anesthesia care – local anesth + O2 +
sedation + analgesia
7. General – inhaled or IV;  CNS: analgesia,
amnesia, unconsciousness
Colors of Flowmeters
Gases
Green – oxygen
Blue – nitrous oxide
Liquids
Violet – Isoflurane
Blue – Desflurane
Red – Halothane
Orange – Enflurane
Yellow – Sevoflurane
 STAGES Characteristics Interventions
1: Induction/Analgesia

IV – ultra-short-acting
barbiturates (ketamine,
etomidate, benzodiazepines)
Inhalation – via mask; nitrous
oxide, halothane, enflurane,
isoflurane, desflurane
2: Excitement/ Delirium
Drowsiness,
MAINTAIN AIRWAY!
hallucinations,
Close OR door, keep quiet!
amnesia
Irregular RR & HR,
Remain quiet, Restrain
uncontrolled mov’ts,
patient, Remain at pt’s side
vomiting
 STAGES Characteristics Interventions
3: Surgical Anesthesia
IV – sodium thiopental,
methohexital, etomidate,
diazepam, lorazepam,
midazolam, ketamine, Keep quiet, begin prepping
propofol RR becomes regular, the client for surgery
Neuromuscular blockade – HR slows, reflexes Obtain fluid, drugs, & blood
short-acting agents disappear, surgery is products
(succinylcholine), performed in this Send blood specimens to lab
intermediate-acting stage Monitor blood loss
(mivacurium, atracurium, Monitor urine output
vecuronium, rocuronium),
long-acting (d-tobucarine,
pancuronium, metocurine,
pipecuronium, doxacurium)
Respiratory failure,
What are you waiting for?
4: Danger possible cardiac
CPR!!!
arrest
 STAGES Characteristics Interventions
Assess pt’s readiness for
Pt maintains extubation (peripheral nerve
Emergence & Extubation of adequate ventilation stimulation, head lifting,
Trachea & responds to verbal squeezing a hand)
command Assist with airway control,
prevent shivering, facilitate
transport to PACU
Suturing
Dr. William Halsted – “gentle tissue handling”
1. Interrupted sutures are better
2. Fine but strong sutures
3. Cut close to knots
4. Separate needles for each stitch
5. Eliminate dead space
6. Use 2 sutures instead of 1 for larger wounds
7. No tension on tissue
Types of suture material
1. Absorbable – digested by enzymes; derived from
healthy mammals or synthetic; surgical gut,
plain surgical gut, chromic surgical gut,
collagen (ophtho), synthetic: monocryl, vicryl
(CS/abdominal mm)
2. Non-absorbable – resist enzymatic digestion;
silk, dermal silk, cotton, linen, steel, synthetic:
nylon, polyester
Types of needles
1. Cutting – skin; lesser scars
2. Round – soft tissues; round holes on skin
3. Atraumatic/Swaged – keloid formers
Sponge, Sharp, Instrument Count
Scrub & Circu RN – accountable for counts
*should count audibly & concurrently
*verbally report count to surgeon, surgeon
verbally acknowledges
*count ALL items used including added items
*no interruptions; start counting from last
recorded item
4 Counts:
1st – before the start of the procedure
2nd – before closure of a cavity w/in a cavity
3rd – before peritoneal closure
4th – before skin closure
Count discrepancy:
1st – Inform surgeon
2nd – thorough search (OR table, mayo table, kick
bucket, floor, etc)
3rd – plain X-ray (microscope for small objects)
4th – document; investigate; account everything as
much as possible before ending the procedure
The End