Report Ko Tom

8/9/2019 Report Ko Tom

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The principles of sterile technique are applied in various ways. In thefollowing paragraphs, the principles of sterile technique and examples of their application are discussed. When the OR specialist understands the principles, heshould be aware of other examples of their application.

All materials used as a part of the sterile field for an operation must besterile. Certain basic items (such as the linen, the instrument set, and the basins) may

be obtained from the supply kept in the sterile supply room. Others, such as specializedsurgical instruments, may be sterilized the night before or immediately preceding theoperation and taken directly from the sterilizer to the sterile operative field. Once anitem is removed from a sterile wrapper, it must be used or discarded.

(1) Linen used in the operating room is usually dyed green. This helps toreduce the glare from lights, thus reducing fatigue and eyestrain.

(2) Linen selected for use in the operating room should be checked toensure that the linen is not torn or frayed and that no holes are present in the cloth.Likewise, it should be handled gently to prevent lint and dust from being spread aboutthe room.

(3) Only materials known to be sterile should be used and their sterilityshould be maintained throughout the operative procedure.

(4) Sterile areas are set up just prior to use.

(5) Scrub attire should not be worn outside the surgical suite.

(6) All team members should wash hands before and after the care of each patient.

Items should be considered unsterile if there is doubt about their sterility.

(1) If a sterile-appearing package is found in an area not designated for sterile storage, it is considered unsterile and must be reprocessed and re-sterilized.

(2) If there is doubt about the timing of a sterilizer, its contents areconsidered unsterile.

(3) If an "unsterile" person brushes close to a sterile table, the table isconsidered contaminated. Also, if a "sterile" person brushes close to an unsterile table,the person's sterile gown is considered contaminated.

(4) If a sterile table or sterile items are left unmonitored, the table and

items are considered unsterile.

Types of consent


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Consent to treatment may be implied or it may be specifically expressed either orally or in writing. The clinical situation determines the approach required.

Implied consent Much of a physician's work is done on the basis of consent which is implied either by the

words or the behaviour of the patient or by the circumstances under which treatment isgiven. For example, it is common for a patient to arrange an appointment with a physician, to keep the appointment, to volunteer a history, to answer questions relating tothe history and to submit without objection to physical examination. In thesecircumstances consent for the examination is clearly implied. To avoid misunderstanding,however, it may be prudent to state to the patient an intention to examine the breasts,genitals or rectum.

The foregoing notwithstanding, in many situations the extent to which consent wasimplied may later become a matter of disagreement. Physicians should be reasonablyconfident the actions of the patient imply permission for the examinations, investigations

and treatments proposed. When there is doubt, it is preferable the consent be expressed,either orally or in writing.

Expressed consent Expressed consent may be in oral or written form. It should be obtained when thetreatment is likely to be more than mildly painful, when it carries appreciable risk, or when it will result in ablation of a bodily function.

Although orally expressed consent may be acceptable in many circumstances, frequently

there is need for written confirmation. As physicians have often observed, patients canchange their minds or may not recall what they authorized; after the procedure or treatment has been carried out, they may attempt to take the position it had not beenagreed to or was not acceptable or justified. Consent may be confirmed and validatedadequately by means of a suitable contemporaneous notation by the treating physician inthe patient's record.

Expressed consent in written form should be obtained for surgical operations andinvasive investigative procedures. It is prudent to obtain written consent also whenever analgesic, narcotic or anaesthetic agents will significantly affect the patient's level of consciousness during the treatment.

Preoperative Practices and Procedures

The most common source of pathogens that cause surgical site infections is the patient.While microorganisms normally colonize parts in or on the human body without causingdisease, infection may result when this endogenous flora is introduced to tissues exposed


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during surgical procedures. In order to reduce this risk, the patient is prepared or prepped by shaving hair from the surgical site; cleansing with a disinfectant containing suchchemicals as iodine , alcohol, or chlorhexidine gluconate ; and applying sterile drapesaround the surgical site.

In all clinical settings, handwashing is an important step in asepsis. The "2002 Standards,Recommended Practices, and Guidelines" of the Association of Perioperative Registered Nurses (AORN) states that proper handwashing can be "the single most importantmeasure to reduce the spread of microorganisms." In general settings, hands are to bewashed when visibly soiled, before and after contact with the patient, after contact withother potential sources of microorganisms, before invasive procedures, and after removalof gloves. Proper handwashing for most clinical settings involves removal of jewelry,avoidance of clothing contact with the sink, and a minimum of 1015 seconds of handscrubbing with soap, warm water, and vigorous friction.

A surgical scrub is performed by members of the surgical team who will come into

contact with the sterile field or sterile instruments and equipment. This procedurerequires use of a long-acting, powerful, antimicrobial soap on the hands and forearms for a longer period of time than used for typical handwashing. Institutional policy usuallydesignates an acceptable minimum length of time required; the CDC recommends at leasttwo to five minutes of scrubbing. Thorough drying is essential, as moist surfaces invitethe presence of pathogens. Contact with the faucet or other potential contaminants should

be avoided. The faucet can be turned off with a dry paper towel , or, in many cases,through use of a foot pedal . An important principle of aseptic technique is that fluid (a

potential mode of pathogen transmission) flows in the direction of gravity. With this inmind, hands are held below elbows during the surgical scrub and above elbows followingthe surgical scrub. Despite this careful scrub, bare hands are always considered potential

sources of infection.Sterile surgical clothing or protective devices such as gloves, face masks, goggles , andtransparent eye/face shields serve as barriers against microorganisms and are donned tomaintain asepsis in the operating room. This practice includes covering facial hair,tucking hair out of sight, and removing jewelry or other dangling objects that may harbor unwanted organisms. This garb must be put on with deliberate care to avoid touchingexternal, sterile surfaces with nonsterile objects including the skin. This ensures that

potentially contaminated items such as hands and clothing remain behind protective barriers, thus prohibiting inadvertent entry of microorganisms into sterile areas. Personnelassist the surgeon to don gloves and garb and arrange equipment to minimize the risk of contamination.

Donning sterile gloves requires specific technique so that the outer glove is not touched by the hand. A large cuff exposing the inner glove is created so that the glove may begrasped during donning. It is essential to avoid touching nonsterile items once sterilegloves are applied; the hands may be kept interlaced to avoid inadvertent contamination.Any break in the glove or touching the glove to a nonsterile surface requires immediateremoval and application of new gloves.
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Asepsis in the operating room or for other invasive procedures is also maintained bycreating sterile surgical fields with drapes . Sterile drapes are sterilized linens placed onthe patient or around the field to delineate sterile areas. Drapes or wrapped kits of equipment are opened in such a way that the contents do not touch non-sterile items or surfaces. Aspects of this method include opening the furthest areas of a package first,

avoiding leaning over the contents, and preventing opened flaps from falling back ontocontents.

Equipment and supplies also need careful attention. Medical equipment such as surgicalinstruments can be sterilized by chemical treatment, radiation, gas, or heat. Personnel cantake steps to ensure sterility by assessing that sterile packages are dry and intact andchecking sterility indicators such as dates or colored tape that changes color when sterile.

Pre-Operative Checklist

Please be aware of the following information:

Insurance information and I.D.(for ex, a driver's licence must be available at the time of registration.

Consume no solid food, no milk, and/or no orange juice after midnight before surgery. Do not smoke,chew gum or suck on hard candy sfter mightnight before surgery. Stay away from asprin/aspirin products. No Advil or anti-inflammatory drugs at least 7-10

days prior to surgery.

On the Day of Surgery, please:

Wear NO makeup or nail polish. Wear NO jewelry. Leave valuable at home. We are not responsible for personal items, money,credit cards,

wallets, jewelry, etc. Bring a case for contact lenses and/or glasses. Feel free to wear your dentures to the operating room. Wear no metal hair accessories. Wear loose fitting clothing appropriate for the type of surgery being performed.

For 24 Hours After surgery, it is suggested that you:

Do not make critical decisions. Do not drink alcoholic beverages. Do not drive a motor vehicle. Do not operate machinery or potentially dangerous machinery. Have an adult stay with you. This is strongly advised.
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How to Perform Surgical Scrub

Step 1Remove all jewelry on your hands and wrists.

Step 2Adjust the water to a warm temperature and wet your hands and forearms thoroughly.

Step 3Clean under each fingernail with a stick or brush. It is important for all surgical staff tokeep their fingernails short.

Step 4Holding your hands up above the level of your elbow, apply the antiseptic. Using acircular motion, begin at the fingertips of one hand and lather and wash between thefingers, continuing from fingertip to elbow. Repeat this for the second hand and arm.Continue washing in this way for 3-5 minutes.

Step 5Rinse each arm separately, fingertips first, holding your hands above the level of your elbow.

Step 6Using a sterile towel, dry your arms--from fingertips to elbow--using a different side of the towel on each arm.


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Step 7Keep your hands above the level of your waist and do not touch anything before puttingon sterile surgical gloves.

PROCEDURE--Gowning

a. With one hand, pick up the entire foldedgown from the wrapper by grasping thegown through all layers, being careful totouch only the inside top layer, which isexposed (see Figure 1-15). Step back fromthe table to allow other team membersroom to maneuver.

Figure 1-15

b. Hold the gown in the manner shown inFigure 1-16, near the gown's neck, andallow it to unfold, being careful that it doesnot touch either your body or other unsterileobjects.

c. Grasp the inside shoulder seams andopen the gown with the armholes facingyou.

Figure 1-16
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d. Slide your arms part way into the sleevesof the gown, keeping your hands atshoulder level away from the body (seeFigure 1-17).

Figure 1-17

e. With the assistance of your circulator,slide your arms further into the gownsleeves; when your fingertips are even withthe proximal edge of the cuff, grasp theinside seam at the juncture of gown sleeveand cuff using your thumb and index finger.Be careful that no part of your handprotrudes from the sleeve cuff (see Figure1-18).

Figure 1-18

f. The circulator must continue to assist atthis point. He positions the gown over your shoulders (see Figure 1-19) by graspingthe inside surface of the gown at theshoulder seams.

1. The Circulator adjusts the gown over theScrub's shoulders.

2. Note that the Circulator's hands are incontact with only the inside surface of thegown.

Figure 1-19.1
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Figure 1-19.2

NOTE: For the reusable cloth gown (which is rarely used), use the proceduresgiven in steps a through f. The circulator then prepares to tie the gown. The neckand back ties are tied in an up-and-down motion. He then ties the belt by graspingthe gown at the back as the scrub leans forward. The circulator leans down andgrasps the distal end of one belt tie; this enables the circulator to handle the beltwithout touching any part of the gown that should remain sterile. The circulator then brings the belt tie to the back of the gown. The scrub then swings toward theopposite side so that the circulator can grasp the other belt in the same manner.The circulator will then tie the belt in an up-and-down motion; this reduces thearea of contamination on the gown. The circulator will then tuck the ends of thebelt inside the gown at the back. Then the scrub; proceeds to the glovingprocedure.

g. The circulator then prepares to securethe gown. The neck and back may besecured with a Velcro tab or ties (seeFigure 1-20). The circulator then ties thegown at waist level at the back. Thistechnique prevents the contaminatedsurfaces at the back of the gown fromcoming into contact with the front of thegown.

Figure 1-20

Procedure gloving CLOSED CUFF METHOD

a. Discussion. The closed cuff method of gloving is preferable to the open cuff method when thespecialist must glove himself. The closed cuff method eliminates potential hazards in the gloveprocedure as follows:

(1) The danger of contamination of gloves caused by the glove cuffs rolling on skin is eliminatedbecause the skin surface is not exposed.

(2) The gown cuffs can be anchored securely by the gloves without the danger of contaminationthat exists when gloves are donned by the open cuff method.

b. Procedure.
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(1) Take a tuck in each gown cuff if thecuffs are loose. Make the tuck bymanipulating the fingers inside the gown

sleeve; do not expose the bare handswhile tucking the gown cuffs.

(2) The circulator opens the outer wrapper of the glove package and flipsthem onto the sterile field.

Watch a video demonstrating the surgical glove flip or drop onto a

sterile field

(3) Open the inner package containing

the gloves and pick up one glove by thefolded cuff edge with the sleeve-covered hand (see Figure 1-21).

Figure 1-21

(4) Place the glove on the oppositegown sleeve, palm down, with the glovefingers pointing toward your shoulder

(see Figure 1-22). The palm of your hand inside the gown sleeve must befacing upward toward the palm of theglove.

Figure 1-22

(5) Place the glove's rolled cuff edge atthe seam that connects the sleeve tothe gown cuff (see Figure 1-23). Graspthe bottom rolled cuff edge of the glovewith your thumb and index finger.

Figure 1-23
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(6) While holding the glove's cuff edgewith one hand, grasp the uppermostedge of the glove's cuff with theopposite hand (see Figure 1-24). Takecare not to expose the bare fingerswhile doing this.

Figure 1-24

(7) Continuing to grasp the glove (seeFigure 1-24); stretch the cuff of theglove over the hand (see Figure 1-25).

Figure 1-25

(8) Using the opposite sleeve- coveredhand, grasp both the glove cuff andsleeve cuff seam and pull the glove ontothe hand (see Figure 1-26). Pull anyexcessive amount of gown sleeve fromunderneath the cuff of the glove.

Figure 1-26

(9) Using the hand that is now gloved,put on the second glove in the samemanner. When gloving is completed, nopart of the skin has touched the outsidesurface of the gloves. Check to makesure that each gown cuff is secured andcovered completely by the cuff of theglove (see Figure 1-27). Adjust thefingers of the glove as necessary sothat they fit snugly. Figure 1-27

NOTE: The scrub should don the first glove in accordance with the hand he uses most of thetime, i.e., a right-handed specialist can perform the closed cuff gloving procedure more quicklyand efficiently by putting on the left glove first. A left-handed specialist will facilitate the procedurefor himself by putting on the right glove first.


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PROCEDURE Serving gowns and gloves to surgeons

a. Unfold a towel so that it is folded in half lengthwise and hand it to the scrubbed team member.

While he is drying his hands, unfold his gown.

Grasp the gown near the neckbandusing the thumb and index finger of each hand and roll the gown so that theoutside surface is over (protecting) your gloved hands (see Figure 1-35). Thearm holes of the gown are facing theteam member being gowned. Offer theinside of the gown to the scrubbed team

member and allow him to slip his armsinto the gown sleeves (see Figure 1-35). Figure 1-35

b. The scrub pulls the gown over theteam member's shoulders (see Figure1-36). The circulator then secures theneck of the gown and ties the insidewaist tie.

Figure 1-36

c. Grasp the right glove firmly at waistlevel. Keeping your thumbs extendedand covered by the glove cuff, stretchthe cuff so that he can introduce hishand without touching your gloves (seeFigure 1-37).

1 Assisting the team member in donningthe first glove. Note that the scrub hasspread the cuff wide to permit the teammember to introduce his hand withouttouching the scrub's gloves.

2 Note also that the scrub protects hisgloved fingers by holding them beneaththe cuff of the glove, and his thumbs byholding them away from the partly-gloved hand.

Figure 1-37.1
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Figure 1-37.2

While you are stretching the glove open,stand with one foot forward and one footto the rear (see Figure 1-38). Thisstance will help you from being thrownoff balance. (DO NOT snap the glove;bring it upward gently over the cuff of the gown.)

NOTE: Always offer the right glove first.Be careful that you do not get thrown off balance while the other team member introduces his hand into the glove (seeFigure 1-38).

Figure 1-38

d. Repeat the technique described inparagraph c above for the left hand. Theteam member can assist with donningthis glove (see Figure 1-39). Give theteam member a moistened salinesponge so that he can remove excesspowder from his gloves if the gloves arepowdered.

NOTE: The scrub should remove thepowder from his gloves again.

Figure 1-39
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e. The circulator will readjust the neckfastener if needed and assist scrubbedteam member with tying the outsidewaist tie of the gown. After the tie issecured, the gown is adjusted at thebottom (see Figure 1-34). Figure 1-40shows a gloved and gowned teammember.

Figure 1-40

Pre surgical preparation of patients Preparing for surgery frequently seems complicated. Patients are given a lengthy list of things that must be done or avoided before a scheduled operation and frequently forget toask for explanations of preoperative procedures because they are preoccupied with thesurgery itself.

Surgery Preparation

Preoperative procedures are designed to improve the outcome of the surgery, decrease therisk for complications, and make the surgery as safe and effective as possible.

Patients who receive general anesthesia, which renders them unconscious, must refrainfrom eating or drinking for at least 8 hours before surgery. Most instructions indicate thatnothing is to be taken by mouth after midnight, on the night before the procedure. It mayseem harsh, not to be able to have a sip of water, but this precaution minimizes the risk for complications such as vomiting during surgery.

Discontinuing prescription and over-the-counter medications that "thin" the blood , such

as aspirin is necessary prior to surgery. Whether a drug is held or administered is basedon the patient's medical condition, the type of drug, and the scheduled surgical procedure.Patients who take prescription medications on a regular basis must discuss this with thesurgeon.

Preparation for surgery may begin days before the procedure. Surgeries involving thedigestive system require special drinks, laxatives, and an altered diet. The digestive tract
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must be as empty as possible before surgery to prevent leakage of its contents into theabdominal cavity.

Arrival at the Hospital or Surgical Center

If surgery is being done on an outpatient basis, the patient must arrange for someone to be with them upon discharge. Even though the anesthesia has worn off, grogginess canlast several hours and it is unsafe to drive. Also, the patient may need assistance whenthey get home.

If surgery is being done on an inpatient basis, the patient checks into a room. Most patients return to their room after surgery, but those undergoing complex surgical procedures and those who have complications may go to the intensive care unit (ICU).Outpatients usually go to an area designated for same day surgery.

After arrival, time is needed to prepare the patient for the procedure and sometimes, the

time of surgery is changed due to cancellations or emergencies.

All patients must sign an informed consent form acknowledging that they are aware of risks and complications, that they know they will be receiving anesthesia, and that thesurgeon has explained the operation to them. The surgery will not proceed unless theconsent form is signed.

Patients are usually asked to remove personal items (e.g., jewelry, eyeglasses,hairpieces, contact lenses, dentures) before surgery. This policy protects the patient and

prevents the items from being lost or damaged. Depending on the procedure, eyeglassesor hearing aids may be worn.

Different staff members may ask the same questions . The clerk who checks the patientin asks several questions, as does the admitting nurse and the anesthesiologist. Thesequestions may be the same or similar and this may seem tedious, but the informationmust be checked and double-checked to avoid errors and omissions.

Before Surgery

The doctor who administers the anesthesia (anesthesiologist) performs a brief physicalexamination; takes a patient history; and obtains information regarding medication usedon a regular basis, drug allergies, and prior adverse reactions to anesthesia. This

information helps the anesthesiologist select the most suitable anesthetic agents anddosages to avoid complications.

Patients are usually taken to a preoperative or holding area before surgery. Anintravenous line (IV) is started here if the patient does not already have one. A sedativemay be given by injection, through the IV, or occasionally, orally, to help the patientrelax.


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