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Principles of Aseptic Technique in an Operating Room Surgical asepsis, or aseptic technique, is designed to get rid of pathogenic microorganisms from

areas or objects. It is also used to keep areas and objects free of microorganisms. Surgical asepsis demands more precautions than medical asepsis. Aseptic technique is commonly used in surgery, labor and delivery, in procedures that involve puncturing the skin, when the skin's layers are penetrated by surgical incisions or burns, and during procedures that involve putting objects into normally sterile body cavities. There are nine principles that must be followed to prevent microorganisms from infecting a wound during surgery.

Sterile Fields The first principle of surgical asepsis states that all materials in a sterile field must be sterile. All objects added to your sterile field must also be sterile. If you put your hands into the sterile field, they must be covered using sterile gloving technique and the gloves should also begin in sterile packaging. The second principle states that a sterile barrier that has been compromised by punctures, tears or moisture has to be considered contaminated. If a sterile field has been set up and it is accidentally torn, the openings can allow microorganisms to invade and contaminate.

Sterile Borders The third principle states that once a package is opened, a 2.5 cm (1 inch) border around the edge is considered unsterile. For example, many procedures contain setup of sterile packaging that is opened before sterile gloves are applied. During this time the 1 inch unsterile border is the only section that can be touched. The fourth principle states that tables draped as part of a sterile field are considered sterile only at the table level. Therefore the table legs, underside of the table, or any shelves below the table level are to be considered unsterile.

Sterility Questions The fifth principle examines questions or doubts. It states that if there are any questions or doubts about an object's sterility, the object should be considered unsterile. The sixth principle states that sterile people and objects should only come into contact with sterile fields, and unsterile people and objects should only come into contact with unsterile areas, such as the 2.5 cm border.

Movement and Range of Vision

The seventh principle states that movement around or in the sterile field must not compromise or contaminate the sterile field. While performing procedures requiring

a sterile field, it is important to remember that correct sterile technique must always be followed. The eighth principle says that anything out of your range of vision or below waist level is considered contaminated and unsterile. For instance, if an object is dropped below the waist, it is no longer sterile. The backside of the body, which is out of your range of vision, is also considered unsterile. Therefore, you should never turn your back on your sterile field and bring all tables needed in procedures up to your waist level.

Air Exposure The ninth and last principle of surgical asepsis states that a sterile object or field can become contaminated by lingering exposure to air. While performing a sterile procedure, one should stay organized and finish the procedure as quickly as possible.

Preoperative care

Definition

Preoperative care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation. Purpose

Patients who are physically and psychologically prepared for surgery tend to have better surgical outcomes. Preoperative teaching meets the patient's need for information regarding the surgical experience, which in turn may alleviate most of his or her fears. Patients who are more knowledgeable about what to expect after surgery, and who have an opportunity to express their goals and opinions, often cope better with postoperative pain and decreased mobility. Preoperative care is extremely important prior to any invasive procedure, regardless of whether the procedure is minimally invasive or a form of major surgery. Preoperative teaching must be individualized for each patient. Some people want as much information as possible, while others prefer only minimal information because too much knowledge may increase their anxiety. Patients have different abilities to comprehend medical procedures; some prefer printed information, while others learn more from oral presentations. It is important for the patient to ask questions during preoperative teaching sessions.

Description Preoperative care involves many components, and may be done the day before surgery in the hospital, or during the weeks before surgery on an outpatient basis. Many surgical procedures are now performed in a day surgery setting, and the patient is never admitted to the hospital.

Physical preparation

Physical preparation may consist of a complete medical history and physical exam, including the patient's surgical and anesthesia background. The patient should inform the physician and hospital staff if he or she has ever had an adverse reaction to anesthesia (such as anaphylactic shock), or if there is a family history of malignant

hyperthermia. Laboratory tests may include complete blood count , electrolytes, prothrombin time, activated partial thromboplastin time, and urinalysis . The patient will most likely have an electrocardiogram (EKG) if he or she has a history of cardiac disease, or is over 50 years of age. A chest x ray is done if the patient has a history of respiratory disease. Part of the preparation includes assessment for risk factors that might impair healing, such as nutritional deficiencies, steroid use, radiation or chemotherapy, drug or alcohol abuse, or metabolic diseases such as diabetes. The patient should also provide a list of all medications, vitamins, and herbal or food supplements that he or she uses. Supplements are often overlooked, but may cause adverse effects when used with general anesthetics (e.g., St. John's wort, valerian root). Some supplements can prolong bleeding time (e.g., garlic, gingko biloba). Latex allergy has become a public health concern. Latex is found in most sterile surgical gloves, and is a common component in other medical supplies including general anesthesia masks, tubing, and multi-dose medication vials. It is estimated that 1 6% of the general population and 8 17% of health care workers have this allergy. Children with disabilities are particularly susceptible. This includes children with spina bifida, congenital urological abnormalities, cerebral palsy, and DandyWalker syndrome. At least 50% of children with spina bifida are latex-sensitive as a result of early, frequent surgical exposure. There is currently no cure available for latex allergy, and research has found that the allergy accounts for up to 19% of all anaphylactic reactions during surgery. The best treatment is prevention, but immediate symptomatic treatment is required if the allergic response occurs. Every patient should be assessed for a potential latex reaction. Patients with latex sensitivity should have their chart flagged with a caution label. Latex-free gloves and supplies must be used for anyone with a documented latex allergy. Bowel clearance may be ordered if the patient is having surgery of the lower gastrointestinal tract. The patient should start the bowel preparation early the evening before surgery to prevent interrupted sleep during the night. Some patients may benefit from a sleeping pill the night before surgery. The night before surgery, skin preparation is often ordered, which can take the form of scrubbing with a special soap (i.e., Hibiclens), or possibly hair removal from the surgical area. Shaving hair is no longer recommended because studies show that this practice may increase the chance of infection. Instead, adhesive barrier drapes can contain hair

growth on the skin around the incision.

Psychological preparation

Patients are often fearful or anxious about having surgery. It is often helpful for them to express their concerns to health care workers. This can be especially beneficial for patients who are critically ill, or who are having a high-risk procedure. The family needs to be included in psychological preoperative care. Pastoral care is usually offered in the hospital. If the patient has a fear of dying during surgery, this concern should be expressed, and the surgeon notified. In some cases, the procedure may be postponed until the patient feels more secure. Children may be especially fearful. They should be allowed to have a parent with them as much as possible, as long as the parent is not demonstrably fearful and contributing to the child's apprehension. Children should be encouraged to bring a favorite toy or blanket to the hospital on the day of surgery. Patients and families who are prepared psychologically tend to cope better with the patient's postoperative course. Preparation leads to superior outcomes since the goals of recovery are known ahead of time, and the patient is able to manage postoperative pain more effectively. Informed consent

The patient's or guardian's written consent for the surgery is a vital portion of preoperative care. By law, the physician who will perform the procedure must explain the risks and benefits of the surgery, along with other treatment options. However, the nurse is often the person who actually witnesses the patient's signature on the consent form. It is important that the patient understands everything he or she has been told. Sometimes, patients are asked to explain what they were told so that the health care professional can determine how much is understood. Patients who are mentally impaired, heavily sedated, or critically ill are not considered legally able to give consent. In this situation, the next of kin (spouse, adult child, adult sibling, or person with medical power of attorney ) may act as a surrogate and sign the consent form. Children under age 18 must have a parent or guardian sign.

Preoperative teaching

Preoperative teaching includes instruction about the preoperative period, the surgery itself, and the postoperative period. Instruction about the preoperative period deals primarily with the arrival time, where the patient should go on the day of surgery, and how to prepare for surgery. For example, patients should be told how long they should be NPO (nothing by mouth), which medications to take prior to surgery, and the medications that should be brought with them (such as inhalers for patients with asthma). Instruction about the surgery itself includes informing the patient about what will be done during the surgery, and how long the procedure is expected to take. The patient should be told where the incision will be. Children having surgery should be allowed to "practice" on a doll or stuffed animal. It may be helpful to demonstrate procedures on the doll prior to performing them on the child. It is also important for family members (or other concerned parties) to know where to wait during surgery, when they can expect progress information, and how long it will be before they can see the patient. Knowledge about what to expect during the postoperative period is one of the best ways to improve the patient's outcome. Instruction about expected activities can also increase compliance and help prevent complications. This includes the opportunity for the patient to practice coughing and deep breathing exercises, use an incentive spirometer, and practice splinting the incision. Additionally, the patient should be informed about early ambulation (getting out of bed). The patient should also be taught that the respiratory interventions decrease the occurrence of pneumonia, and that early leg exercises and ambulation decrease the risk of blood clots. Patients hospitalized postoperatively should be informed about the tubes and equipment that they will have. These may include multiple intravenous lines, drainage tubes, dressings, and monitoring devices. In addition, they may have sequential compression stockings on their legs to prevent blood clots until they start ambulating. Pain management is the primary concern for many patients having surgery. Preoperative instruction should include information about the pain management

method that they will utilize postoperatively. Patients should be encouraged to ask for or take pain medication before the pain becomes unbearable, and should be taught how to rate their discomfort on a pain scale. This instruction allows the patients, and others who may be assessing them, to evaluate the pain consistently. If they will be using a patient-controlled analgesia pump, instruction should take place during the preoperative period. Use of alternative methods of pain control (distraction, imagery, positioning, mindfulness meditation, music therapy) may also be presented. Finally, the patient should understand long-term goals such as when he or she will be able to eat solid food, go home, drive a car, and return to work.

Preparation It is important to allow adequate time for preparation prior to surgery. The patient should understand that he or she has the right to add or strike out items on the generic consent form that do not pertain to the specific surgery. For example, a patient who is about to undergo a tonsillectomy might choose to strike out (and initial) an item that indicates sterility might be a complication of the operation.

Normal results The anticipated outcome of preoperative care is a patient who is informed about the surgical course, and copes with it successfully. The goal is to decrease complications and promote recovery.

Intraoperative Care Definition The term "intraoperative" refers to the time during surgery. Intraoperative care is patient care during an operation and ancillary to that operation. Activities such as monitoring the patient's vital signs, blood oxygenation levels, fluid therapy, medication transfusion, anesthesia, radiography, and retrieving samples for laboratory tests, are examples of intraoperative care. Intraoperative care is provided by nurses, anesthesiologists, nurse anesthetists, surgical technicians, surgeons, and residents, all working as a team.

Purpose The purpose of intraoperative care is to maintain patient safety and comfort during surgical

procedures. Some of the goals of intraoperative care include maintaining homeostasis during the procedure, maintaining strict sterile techniques to decrease the chance of cross-infection, ensuring that the patient is secure on the operating table, and taking measures to prevent hematomas from safety strips or from positioning.

Precautions Patients undergoing surgery most often are given some type of anesthesia. The administration of general anesthesia has a relaxing effect on the patient's body, which can suppress cardiovascular function or heighten cardiovascular irritability. It may also result in respiratory depression, loss of consciousness, paralysis, and lack of sensation. These effects, some of which are intentional for the period of the surgery, mean the patient is in a very vulnerable position. It is the responsibility of the health care team in the operating room to maintain the patient's safety and yet facilitate surgery. In 1992 the American Association of Nurse Anesthetists (AANA) established guidelines for monitoring patients undergoing general anesthesia. The guidelines call for continuous observation of the patient by the nurse assigned to the patient. Ventilation should be assessed by continuous auscultation of breath sounds, and oxygenation should be monitored by continuous pulse oximetry. Continuos electrocardiograph (ECG) showing the patient's cardiac function should be in place, and the patient's heart rate and blood pressure should be monitored at least every five minutes. A means to monitor the patient's temperature must be available immediately for use. In case of an emergency backup personnel who are experts in airway management, emergency intubation, and advanced cardiac life support (ACLS) must be available. An emergency cart containing the necessary supplies and equipment must be immediately accessible. The ACLS equipment should be checked daily to ensure proper function. Total analgesia is a goal of general anesthesia in order to facilitate surgery. This means that the patient does not have the normal "pain" sensations that warn of potential injury. The health care team must keep this in mind when they are positioning the patient for a surgical procedure. Although it may be necessary for a patient to be positioned in an unusual way for access to a particular area during surgery, care must be taken to ensure that the patient's body is in proper alignment and that joints and muscles are not in such an unnatural position that they will be damaged if they remain in that position for a lengthy procedure. Areas of the operating table that come into contact with the patient's bony prominences must be padded to prevent skin trauma and hematomas. During a surgical procedure many instruments, drapes, and sponges are used. Also, a multitude of care providers may be working in the operative field performing different tasks. These factors, combined with the complexity and length of some surgical procedures, may provide extensive opportunity for patient trauma from equipment malfunction or the failure of the surgical team to avoid using full weight on the sedated patient. Additionally, it is the responsibility of the nurses working in the operating room to maintain an accurate count of all sponges, instruments, and sharps that may become foreign bodies upon incision closure. Nurses who fail to make accurate counts can be held legally liable. Most surgical procedures are invasive and compromise a patient's skin integrity. This increases the risk of infection. To decrease the risk, strict asepsis (sterile technique) must be followed at all times. It is recommended that the ventilation system in an operative area provide a minimum of fifteen exchanges of filtered air per hour. The temperature in

the intraoperative area should be maintained at 68 73F (20 23C), and the relative humidity should be maintained at 30% 60%.

Health care personnel who work in the operating room must not be permitted to work if they have open lesions on the hands or arms, eye infections, diarrhea, or respiratory infections. Scrub attire must be worn by all personnel entering the operating room. Fresh scrub attire must be donned daily and, if heavily soiled during one case, should be changed before the next case. Most facilities provide personnel with scrub attire that is professionally laundered. Shoe covers are required and should be changed often. Head and facial hair must be completely contained in a lint-free cap or hood. Properly fitting disposable surgical masks must be worn at all times and discarded immediately after use. Sterile gloves and sterile gowns must be worn by those working in, and in proximity to, the sterile field. Careful skin preparation with appropriate antiseptic solutions is preformed on the patient's arrival to the operating area. Patients who have a known or suspected allergy to latex should be scheduled for surgery as the first case of the day whenever possible to avoid contact with airborne latex particles (often attached to powder granules from the gloves) that may be in the room from a previous surgery. These patients should also be identified (some facilities use special colored identification bands and colored tapes on the patient's medical record) so that all health care personnel can recognize them. Special care must be taken to limit the uses of equipment containing latex that will contact the patient's skin. This includes anesthesia masks, adhesive tape and dressings, injections drawn from multidose vials with rubber stoppers, adhesive ground plates for electrocautery or diathermy, and pad coverings on the operating table and arm extensions.

Description Intraoperative care includes the activities performed by the health care team during surgery that ensure the patient's safety and comfort, implement the surgical procedure, monitor and maintain vital functions, and document care given. The intraoperative time period can vary greatly from less than one hour to 12 hours or more, depending on the complexity of the surgery being performed.

Preparation Prior to surgery the patient or legal guardian must have the surgical procedure explained to them in great detail, including the expected outcomes and all possible complications, in order to give informed consent. The explanation should be given to the patient at a time when he or she is relaxed, but when judgment is not clouded by the use of any pain medication or anesthesia, which would invalidate the consent. A consent form must be signed by the patient or guardian and witnessed by a staff member as well as the surgeon performing the procedure. It is the duty of the RN admitting the patient to the surgical suite to check the patient's ID band and ensure that all records are intact and accounted for. After consent is given the patient may be taken to a holding area where a large-bore intravenous catheter is inserted into the patient's arm for use in fluid replacement and to infuse medications during the procedure. The area of the body where the incision will be made is meticulously prepared using drapes, and a skin preparation that is antiseptic and may include the use of alcohol solutions and iodophor. Monitoring devices such as continuous ECG nodes, pulse oximetry probes, and a blood

pressure cuff are usually applied prior to skin preparation. Anesthesia, also, is begun before skin prep. Surgery is then ready to begin.

Postoperative Care

The time after surgery is referred to as the postoperative period and includes the recovery and convalescence phases. The recovery phase is the time immediately after surgery when the effects of anesthesia are wearing off and the patient is waking up. The convalescence phase is spent either in the hospital, in an interim care facility, or at home depending on the procedure and the preferences of the physician and patient.

Complications Intraoperative complications are surgery related, anesthesia related, or position related. One complication occurring during the intraoperative period that is not common but can be life threatening is an anaphylactic (allergic) reaction to anesthesia. The intraoperative staff is trained extensively in the treatment of such a reaction, and emergency equipment should always be available in the event it is needed for this purpose. Another anesthesia-related complication is called "awareness under anesthesia." This occurs when the patient receives sufficient muscle relaxant (paralytic agent) to prohibit voluntary motor function but insufficient sedation and analgesia to block pain and the sense of hearing. Patients are aware of being "awake" because they hear the sounds and conversation in the room and, in some cases, can feel the pain associated with the skin incision and surgery. However, they cannot respond to these sensations in a way not even with so small a motion as blinking the eyelid that will tell someone what they are sensing. This condition creates an exaggerated fear response that can affect hemodynamics and vital signs. Another complicating reaction may be that of malignant hyperthermia. This is a chain reaction triggered in susceptible people by commonly used general anesthetics. Signs include greatly increased body metabolism, muscle rigidity, and eventual hyperthermia which may exceed 110F(43.3C). Death may be caused by cardiac arrest, brain damage, internal hemorrhage, or failure of other body systems. Complications of surgery include, but are not limited to, hypovolemic shock (due to blood loss during surgery), injuries from poor positioning during surgery, infection of the surgical wound, fluid and electrolyte imbalances, aspiration pneumonia, blood clots, and paralytic ileus (paralysis of the intestines, causing distention).

Results The results of a surgical procedure depend greatly on the procedure preformed, the skill of the surgeon, the general health of the patient preoperatively, and the ability of the patient's body to recover from the procedure. Some surgeries cure a condition (e.g., an appendectomy for an inflamed appendix). Others are only one step in a long process to cure a disease or repair an injury (e.g., discectomy for a patient suffering from back pain). Still others are performed as palliative measures rather than as a cure. An example of palliative surgery would be the removal of a metastatic abdominal tumor to relieve abdominal pressure. In this example removing the abdominal tumor is not going to cure the cancer that exists in other parts of the patient's body; it is simply going to relieve the discomfort caused by the abdominal mass.

Health care team roles Nurses may fill two different roles in the operating room. The scrub nurse is responsible for providing the surgeon with instruments and supplies and maintaining the sterile field. This role also may be assumed by a scrub or surgical technician. The second role nurses have in the operating room is that of circulating nurse. The circulating nurse is first the patient's advocate, with primary concern and responsibility for the patient's safety and welfare. In addition, the

circulating nurse is responsible for anything related to the patient that is not directly contingent to the sterile field. That means all activities necessary to prepare the patient and the operative site for surgery, and assistance required by anesthesia personnel. Of crucial import is that the circulating nurse must be certified to give intravenous medication to the patient in case of an emergency. Finally, nurses must document and process tissue specimens for pathology. KEY TERMS Anaphylactic reaction (anaphylaxis) A hyper-sensitive reaction to an antigen resulting in life-threatening, progressive symptoms. Anesthesia A classification of medications that are intended to cause the loss of normal sensation. Aseptic technique Strict sterile procedures instilled to decrease the risk of contamination of a surgical site or open wound. ECG Abbreviation for electrocardiograph. Electro-cardiograph is a tracing of the electrical activity of the heart obtained through electrodes placed on a person's skin in certain areas where electrical activity can be easily be detected. Hypovolemic shock A state of shock caused by the sudden loss of large amounts of blood. Informed consent Written or oral permission given by a patient or guardian for medical or surgical treatment after a complete explanation is given and any questions the patient has are answered. If consent is given orally, documentation must have two witnesses. Intraoperative care Care provided to a patient during surgery that is ancillary to the surgery. Malignant hyperthermia A chain reaction triggered in susceptible people by commonly used general anesthetics. Signs include greatly increased body metabolism, muscle rigidity, and eventual hyperthermia which may exceed 110F(43.3C). Death may be caused by cardiac arrest, brain damage, internal hemorrhage, or failure of other body systems. Pulmonary function tests Tests used to determine ventilation and perfusion capabilities of the lungs. Pulse oximetry A method of measuring a patient's blood oxygenation status. A measure of 100% is optimal.

Anesthesia - Types of Anesthesia Anesthesia involves the use of medicines to block pain sensations (analgesia) during surgery and other medical procedures. Anesthesia also reduces many of your body's normal stress reactions to surgery. The type of anesthesia used for your surgery depends on:

1. Your medical history, including other surgeries you have had and any conditions you have (such

as diabetes). You will also be asked whether you have had any allergic reactions to any anesthetics or medicines or whether any family members have had reactions to anesthetics.

2. The results of your physical exam. A physical exam will be done to evaluate your current health and identify any potential risks or complications that may affect your anesthesia care.

3. Tests such as blood tests or an electrocardiogram (EKG, ECG), if needed. 4. The type of surgery that you are having.

a. You need to be able to lie still and remain calm during surgery done with local or regional anesthesia. b. Young children usually cannot stay still during surgery and need general anesthesia. c. Adults who are extremely anxious, in pain, or have muscle disorders also may have difficulty remaining relaxed and cooperative.

d. Some surgical procedures require specific positions that may be uncomfortable for long periods if you are awake. e. Some procedures require the use of medicines that cause muscle relaxation and affect your ability to breathe on your own. In such cases, your breathing can best be supported if general anesthesia is used. 5. Based on your medical condition, your anesthesia specialist may prefer one type of anesthesia over another for your surgery. When the risks and benefits of different anesthesia options are equal, your anesthesia specialist may let you choose the type of anesthesia. Anesthesia methods There are several ways that anesthesia can be given.

1. Local anesthesia involves injection of a local anesthetic (numbing agent) directly into the surgical area to block pain sensations. It is used only for minor procedures on a limited part of the body. You may remain awake, though you will likely receive medicine to help you relax or sleep during the surgery.

2. Regional anesthesia involves injection of a local anesthetic (numbing agent) around major nerves or the spinal cord to block pain from a larger but still limited part of the body. You will likely receive medicine to help you relax or sleep during surgery. Major types of regional anesthesia include:

3. Peripheral nerve blocks. A local anesthetic is injected near a specific nerve or group of nerves to block pain from the area of the body supplied by the nerve. Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face.

4. Epidural and spinal anesthesia. A local anesthetic is injected near the spinal cord and nerves that connect to the spinal cord to block pain from an entire region of the body, such as the belly, hips, or legs.

5. General anesthesia is given into a vein (intravenously) or is inhaled. It affects the brain as well as the entire body. You are completely unaware and do not feel pain during the surgery. Also, general anesthesia often causes forgetfulness (amnesia) right after surgery (postoperative period). For some minor procedures, a qualified health professional who is not an anesthesia specialist may give

some limited types of anesthesia, such as procedural sedation. Procedural sedation combines the use of local anesthesia with small doses of sedative or analgesic agents (painkillers) to relax you. Medicines used for anesthesia A wide variety of medicines are used to provide anesthesia. Their effects can be complex. And they can interact with other medicines to cause different effects than when they are used alone. Anyone receiving anesthesia-even procedural sedation-must be monitored continuously to protect and maintain vital body functions. The complex task of managing the delivery of anesthesia medicines as well as monitoring your vital functions is done by anesthesia specialists. Medicines used for anesthesia help you relax, help relieve pain, induce sleepiness or forgetfulness, or make you unconscious. Anesthesia medicines include:

1. Local anesthetics, such as bupivacaine or lidocaine, that are injected directly into the body area involved in the surgery.

2. Intravenous (IV) anesthetics, such as fentanyl, propofol, or sodium thiopental, that are given through a vein.

3. Inhalation anesthetics, such as isoflurane and nitrous oxide, that you breathe through a mask. 4. Other medicines that are often used during anesthesia include:

5. Muscle relaxants, which block transmission of nerve impulses to the muscles. They are used during anesthesia to temporarily relax muscle tone as needed.

6. Reversal agents, which are given to counteract or reverse the effects of other medicines such as muscle relaxants or sedatives given during anesthesia. Reversal agents may be used to reduce the time it takes to recover from anesthesia.