Chapter 12
Surgical preparation, preoperative phase
Office visit Surgery scheduled Admission Anesthesia preop Pt signs consents Preop meds given Transported to OR Induction, intubation and maintenance Postioning pt Surgical prep Draping of sterile site Time out
Squaring off towels First towel is placed
On the side of the patient nearest the individual applying the drapes
Which of the following examples represents an acceptable technique when opening sterile supplies?
Open peel pack slowly balancing item within the package. Toss gently, making sure to retract hands as the item is airborne and lands on field
What is the recommendation for counting suture packs with multiple needles
Open whole pack to count
Squaring off towels The fourth towel is placed
Opposite the first towel
OR attire consists of the _________ and ____________
PPE; sterile attire
How to prevent a peroneal nerve injury, what position is this likely to occur?
Pad areas; trendelenberg
How to prevent and ulnar nerve injury, what position is this likely to occur?
Pad elbows, place armboards with palms facing upward, place arms next to patients body with palms facing inward; supine
How to prevent a sciatic nerve injury, what position is this likely to occur?
Pad pressure points; Fowler's position
Hole in glove from ESU pencil as you handle it
Pass off item, have circulator remove glove, reglove
Allis clamp repositioned securing suction
Pass off perforating clamp and cover with impermeable drape; non perforating clamp is recommended
Segments of surgery in order
Pass skin knife Hemostasis Dissection Exposure Procedure is performed Inspection of wound/hemostasis/irrigation Wound closure Counts Wound cleansing, application benzoin prn Application of dressing
Ray-tec/lap sponges
Pass unfolded or lay open on field for surgeon use
Needle holder
Pass; needle tip up and same side as surgeons thumb
What is verified during time out
Patient identity Procedure being performed Operative side and site Surgical site markings are visible Correct position All supplies available
Radiation
Patient loses body heat to enviroment
Convection
Patient loses heat through air currents
Breakdown of setup
Patient transported out PPE donned as needed Specimen cared for Sharps disposed of Instruments place in water or water with enzyme All dirty items broken down and furniture replaced Transport to decontamination PPE removed Hand washing Turnover room cleaning clean to dirty Room set up with clean linen suction for next case Verify next case/arrange room and pull case into room Open sterile supplies for next case
Scalpel passed to surgeons hand
Pencil style; be sure to remove hand from danger area up and away from the blade
Pre op responsibilities: C, S, or P Obtaining the surgical procedure consent
Physician
Pre op responsibilities: C, S, or P Positioning the patient
Physician, circulator
Pinch in the middle to
Pick up sterile towel, careful not to drip
SGT responsibilities Used sharps
Placed in needle pad on back table
Identify five ways to protect yourself from radiation
Port lead screen, lead apron, lead eternal/thyroid, leaded glasses, lead gloves, time, distance, shielding
How to prevent a brachial plexus injury, what position is this likely to occur?
Position arm board less than 90 degree and move patients arm in natural movement to place on the board; supine
Uses of prone position
Posterior cranium, dorsal body surface, spine, posterior lower extremity
What is a complication of Fowler's position?
Postural hypotension, Pressure injury-ischial tuberosities, bp changes, respiratory compromise
Neutral zone
Prevention of sharps injury
Separation of clean and dirty
Prevention technique for bowel or cancer tissue
Passing without touching surgeon
Prevents distraction of surgeon from procedure
Why is it important to secure the tubing and locate the drainage bag during transfer of the patient to the recovery stretcher?
Prevents unnecessary tension on urethra and accidental catheter removal
Double glove
Primary glove deterioration and possible contamination
Purpose of Fowler's position
Promotes venous drainage, facilitates respiration
What can be done to prevent pressure injuries?
Proper positioning, padding, no wrinkles in sheets
Anatomical position of supine position
Pt lies flat on back with arms extended on arm boards, palms facing up, armboards no more then 90 degrees
Describe how the prone position is modified for kraske
Pt's hips @ table break, tilt head downward to elevate hips
Lead apron; thyroid shield
Radiation hazard exposure
Draping of extremity is completed while double gloved
Recommended removal of outer gloves and reglove
While anesthesia is taking drape, surgical technologists right glove is touched
Remove contaminated outer right glove and reglove
How is the table set up for lithotomy position?
Remove the head of the bed and place @ the foot
Cotton tip applicators
Remove umbilical detritus
Small foreign body/hair noted on drape
Remove with hemostat, pass hemostat to circulator, cover area
Opening of legging misses foot and touches stirrup
Replace drape; it is contamintated
Not recommended, unrestricted, semi-restricted, or restricted: OR attire, designated OR shoes, mask with eyewear
Restricted
Laser goggles
Retinal or corneal damage
Uses of lateral position
Retroperitoneal space, hips, and hemithorax
Pre op responsibilities: C, S, or P Completing surgical scrub-gown and glove, closed technique
Scrub
Pre op responsibilities: C, S, or P Organizing the sterile supplies for use
Scrub
Not recommended, unrestricted, semi-restricted, or restricted: Hallway when transporting patients into the OR for surgery
Semi-restricted
Not recommended, unrestricted, semi-restricted, or restricted: OR attire, hat covering donned prior to scrubs ensure ALL hair is covered
Semi-restricted
Not recommended, unrestricted, semi-restricted, or restricted: Warm up jacket when circulating
Semi-restricted, restricted
What is ordered to prevent post op thromboembolism?
Sequential compression devices
How can personal glasses be modified for wear during surgery?
Side and top shields applied or goggles
When transporting a patient on a stretcher, the patient should be transported how?
Side rails up, arms and legs inside strecher
What is the potential complication for the patient, especially the geriatric patient, if the patient is not lifted properly during transfer?
Skin tear
Describe a correct mask fit
Snuggly over mouth and nose
Why is water used to inflate the Foley catheter balloon?
So that it doesn't create pits inside balloon
Specific time or count for scrub technique
Specified by facility policy
Sequence of counts
Sponges Sharps Instruments Dressing sponges accounted for
SGT responsibilities Medications/syringes
State what you're passing; swoop and cap when placed back on mayo stand
UTI's are most common nosocomial infection, how do you prevent contamination and retrograde flow of urine?
Sterile technique, clean area before inserting catheter, place as short of time as possible
What can be used to avoid patient falls
Straps, axillary pads, bean bags, tape
Squaring off towels Second and third towels are placed
Superiorly and inferiorly
Position of the patient for lithotomy on the table, where are hips located?
Supine, hips @ table break
When opening instrument container system sets which of the following situations would indicate the item is unsterile.
The lid is removed carefully, filter is inspected, dry and intact with internal indicator noted as changed; there is a small amount of fluid noted on the instruments.
When a patient is in prone position or supine what possible problems can occur to the chest?
Venous stasis, cardio and respiratory compromise
Correct order for the counting process
Verify that circulator can see item, state the name of the item to be counted, break the tag/band or remove stringer, separate items completely as they are counted for visualization Verbalize the numbers as you count them Repeat the total at the end of the count Circulator repeats the count Circulator records the number on count sheet or board
Order of counts
When all items required on preference card are added to field Scrub nurse is relieved just after the initial incision Additional items added during delivery of the placenta prior to any closing counts Closure of hollow organ Closure of cavity Closure of fascia or layer before subq Closure of skin is initiated
How does the surgical technologist maneuver the back table into place?
With hands on top of the table-push down and move towards pt
Clean under nails
With running water
Duraprep
combination of povidone iodine and alcohol
General rule for passing all items
do not obstruct surgeon's view of operative site
Laparoscopic/endoscopic instruments
guide tip into port after passage of handle
What is needed to put patient into the lithotomy position
Candy cane style stirrups, or Allen safety stirrups
Individuals with beards should wear_____________.
Cap or hood
Movement should be slow for patient including lowering and lifting the table, what complications can occur with rapid movement?
Cardiovascular problems
Pre op responsibilities: C, S, or P Assisting with intubation and sellick's maneuver as needed
Circulator
Pre op responsibilities: C, S, or P Completing the surgical skin prep
Circulator
Pre op responsibilities: C, S, or P Counting after all items have been opened onto the sterile field.
Circulator, scrub
Pre op responsibilities: C, S, or P Opening the sterile supplies for the case.
Circulator, scrub
Pre op responsibilities: C, S, or P Pulling the case utilizing the preference card
Circulator, scrub
Pre op responsibilities: C, S, or P Quiet during induction of general anesthesia
Circulator, scrub, physician
Pre op responsibilities: C, S, or P Verifying the surgical site and patient
Circulator, scrub, physician
SGT responsibilities ESU-Acive electrode
Clean and place in holder
the best method of hair removal
Clippers
Double-gloving recommendation: describe how to double glove.
Close glove, then open glove
Surgical technologist dons gloves using
Closed glove technique
Choloraprep
Combination of chlorhexidine and alcohol
What complications can occur due to contact with metallic parts of the OR table?
Conduction, burn pt
Which of the following should be done first when preparing to open supplies?
Confirm Patient allergies
During abdominal skin prep, what areas are prepped first or last?
Contaminated areas are prepped last, start with the incision site and work in widening circles until the periphery is reached then work outward again
SGT responsibilities Instruments
Count, clean with water, do not lay instrument, everything in its place
Hole noted in sterile drape while opening drape
Cover hole with impermeable towel/drape
When assisting the team member to gown and glove, present the first glove
Cuffed over your spread fingers to protect your hand with a circular opening for the surgeons hand to enter; be sure the thumb of the glove is toward the surgeon
Normothermia(normal body temperature)
Decrease wound infection Reduces blood loss Shortens hospital stay Helps decrease the incidence of fatal cardiac events
which possessions the patient may take with him or her to the OR
Dentures, hearing aid
Manufacturers instructions
Determines length of time/ application technique for a specific antiseptic used
Describe your options for protective eyewear
Disposable plastic face shield, combo, eye glasses, specialized
Analyze the statement "mask is worn either on or off"
Do not have mask hanging at the neck
SGT preop responsibilities
Don OR attire and PPE Report to main OR desk to obtain assignment Wash hands and prepare OR for the procedure Gather instruments, equipment, and supplies Scrub and don sterile attire Create and maintain sterile field(open case) Prepare for and perform initial count once all items opened Organize the sterile field and instrumentation for use Assist the operative team members to enter the sterile field Expose operative site with sterile drapes Pull up back table, mayo stand, ring stand Time out
How to apply safety straps
Don't make too tight, 2 inches above the knee, 2 fingers in strap
Alternate name of the supine position
Dorsal recumbent
Suture passing, control of strand
Draped behind hand to prevent surgeon grasping strand
What equipment is routinely checked prior to the case to be sure it is functional?
Drill, saw, OR lights, ESU, tourniquit
When passing the main drape do not
Drop end if anesthesia is too slow in taking your end so you can set up ESU and suction
What items should be immediately available to the surgeon
ESU, suction, tubing
Strategic placement of the back table allows the SGT to
Easily access everything they need
Scalpel passed in neutral zone
Either surgeon or st hand is in the area, not both; observe cautiously
During what situation can counts be omitted? If counts are omitted what must happen at the end of the case?
Emergency; xray
Goggles/eyewear
Eye splash with blood or body fluids
When turning
Face the sterile field as you pass the tag or step away from the sterile field at least 12 or more inches
True or False During the drying process, it is essential to stand tall to prevent contamination of your hands.
False
True or false: The CDC recommends hair removal at all times due to the high number of microbes found on the hair shaft and follicle
False
True or false: The last moment that the patient can sign the consent form is just after the Demerol preoperative medication is given
False
The doors to the OR should be kept open until you get ready to open sterile supplies, then they should be closed to prevent air currents and flies or flying insects from entering the room. Is this a true or false statement? Why?
False. Doors should remain closed as much as possible during the sterile field so outside microbes don't come in.
Scrub technique progresses from
Fingertips to 2 inches above elbow
When scrubbing or rinsing, keep
Fingertips up, hands above bent elbows
Alcohol
Flammable antiseptic that enhances effectiveness when combined with other solutions
When applying an antiseptic, the most important principle to employ is
Following the manufacturers recommendation for application
How to prevent foot drop, what position is this likely to occur?
Foot board; supine
Counting
Foreign body retention
Surgical technologist dons gown
From a separate setup
Sequence for removing gown and gloves
Gown first then gloves
Shoe covers are worn for ____________ and must be changed when they become ___________ or removed when _______________
Gross fluid contamination; soiled; one leaves surgery
The major source of contamination in the OR is the _________ of patients and staff.
Hair
Items that may be used to drape and extremity
Half sheet, towel, extremity sheet
Describe how to prepare the draping materials for a routine exploratory laparotomy
Hand towels first to surgeon-first towel cuffed edge faces away from you, and on next three towels the edge faces toward you
Hand level when scrubbed
Hands above waist, below shoulders or in sight
Chlorhexidine gluconate 2%
Has a longer residual effect of 5-6 hours
What areas are assessed during supine after patient has been anesthetized?
Head and neck, anterior upper extremity, chest/breast, abdomen, pelvis, anterior lower extremity
Ringed instruments
Held by box lock; passed into palm to elicit grasp reflex
Nail polish should be removed due to the use of
Noninvasive pulse oximeter
Fiber optic placement when on
Nonionizing radiation fire when activated on drapes
Non perforating clamp clamp used to secure suction
Not a problem-situation sterile
Not recommended, unrestricted, semi-restricted, or restricted: Artificial nails during surgical procedures
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: Beard covered by mask and skullcap with eyewear
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: Dangling earring or necklaces
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: OR attire, shoe covers, mask, no eyewear during invasive surgery
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: Operating room designation during an invasive surgical procedure
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: Scrubs wet or soiled covered with impervious cover-ups prior to case
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: Scrubs worn in from home not covered by lab coat
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: Shoes previously worn to work in the garden
Not recommended
Not recommended, unrestricted, semi-restricted, or restricted: Storage of supplies in shipping boxes in OR suite
Not recommended
How to prevent crushing injuries of the extremities when there is movement of the operating table, such as dropping of the foot section or flexing to the table for positions such as the lithotomy or the kraske.
Observe the patient when moving so as not to crush
When to remove hair
CDC recommends not removing the hair unless necessary
Which leg is flexed to stabilize the patient on the OR table?
Bottom leg
Preoperative medication to prevent nausea and reduce anxiety are usually given
1-2 hours prior to surgery
How to prevent back, knee, and hip pain from muscle strain or back injury that may occur with the lithotomy position?
Buttock resting completely on table, stirrups @ equal length and height, raise and lower legs slowly and simultaneously
When arranging furniture for the case, you must position your back table and mayo for the sterile field, basic concepts used when positioning the sterile field for setup.
12 inches from the walls, OR table in the middle of the room under OR lights- mayo + BT positioned furthest from the door
Minimum number of personnel to move an awake mobile patient
2
How many people does it take to put the legs in stirrups? How are the legs placed in stirrups. Which nerve can be injured along the calf of the legs?
2; slowly and simultaneously, hips rotated externally; peroneal nerves
Minimum number of personnel to move an unconscious or immobile patient
4
ESU active electrode in holder
Accidental patient burn due to activation
Alcohol based solution must
Air dry
Curved instruments
Aligned with the curve of the surgeon's hand/fingers
The best time to remove hair
Always just prior to the surgical prep
Who controls the timing when moving the patient?
Anesthesia or CRNA
What areas have to be monitored for pressure?
Any body part that is pushed against the bed
Drape is upside down, feet and armboards are exposed
Ask for half-sheets to cover exposed areas
Surgeons sleeve touches IV pole
Ask for sterile sleeve cover or assist to regrown/reglove
Where does the preparation begin and how does it extend?
At the incision site toward the periphery
Circulator secures the gown
At the neck edge and back tie
How are the tubes and cords secured to the sterile field drapes?
Atraumatic diapered clamps(edna)
Order of opening sterile supplies
Back table pack Basin set and instruments Peel packed items Peel packed long tubing with dangling ends
When positioning the patient, how do you prevent shearing
Be mindful and careful when moving patient
When are masks changed?
Between cases
Four methods of maintaining a normal core temperature
Blankets Thermal caps Temperature controlled enviroment Booties
Evaporation
Body loses heat through perspiration/repiration
Conduction
Body loses heat to cooler surface
Effects of hypothermia
High BP Shivering Rapid breathing Constricted blood vessels Apathy and fatigue
Two conditions that can cause a rise in temperature
Infection Malignant hypothermia
Potential hazard if patient is not kept in anatomical alignment during movement?
Injury, soreness
Why is there great care in the prevention of pooling of the antiseptics under the patient?
Irritation, chemical burn, laser burn
Closing counts first to last
Items in use at sterile field Items on mayo stand Back table Kick bucket Surgeon notified something missing Recount starting at sterile field Room search including trash X ray taken
Alternate name for kraske
Jackknife
Rationale for preserving the sterile field after surgery
Just in case of emergency and the surgeon needs to go back in.
SGT responsibilities Used sponges
Kick bucket, replace with clean
Variations of lateral position and tools used
Kidney: patients flank is located over kidney lift of OR table, kidney rests are place behind and in front of patient Sims: patient is place on left side, apply padding to knees, ankles, and elbows if needed
Identify the alternate name for lateral position
Lateral recumbent, lateral decubitis
Three basic positions
Lateral, supine, prone
Surgeon skullcap-type hair covers, they must be _____________ and made of _____________.
Laundered; densely woven lint free material
If the patient is having a right thoracotomy, what position is he or she placed in?
Left lateral
How are patients arms moved onto the armboards?
Lowered to floor using normal motion placed over head
Gown glove separate setup
Main instrument table contamination
How to remove the drape after the case
Make sure everything is removed from, then slowly roll down and discard
Labeling of medications and solutions
Medication error prevention
How many items placed on the mayo stand
Mentally review the steps of the procedure and identify instruments likely to be used Prepare a mental picture of final mayo setup and move the totem one time into place using that mental picture Prepare a towel roll/instrument stand Inspect instruments as chosen-cleanliness, damage, and function Close items on first ratchet and place on towel roll in even numbers Place additional sponges, dissecting sponges, suture, ligatures, prepared hypodermic syringes with local, etc According to hospital time out policy, place prepared scalpel on mayo stand
As passed to surgeon, counted
Moist laps or sponges used for packing inside patient
After initial placement, drapes are never ________; if contaminated the drape is ________by the circulator and it is __________
Moved; removed; discarded
Which mask is worn for a patient with tuberculosis
N95 respirator Hepafilter
While the patient is in preoperative holding, the circulator will assess the patient. Identify what relevant information is gathered to determine the patients care during the procedure
Name, DOB, surgery, where, what, allergies, doctor preference
Purpose of kraske postion
To access anus
Purpose of lithotomy position
To access vagina, urethra, perineum, anus, rectum
Why is it important for the surgical technologist to understand anatomy, normal variations, pathological or problematic variations, the normal steps to the procedure, and instrumentation for the procedure
To anticipate and to help surgeon and surgical team
Why do you use 10 cc of water in a 5 cc capacity balloon?
To compensate for the fluid that remains in the inflation channel
Purpose of trendelenberg position
To displace abdominopelvic organs to provide for better visualization of organs
Why do you pretest Foley catheter balloon?
To make sure it is intact and will function properly
What is the purpose of the axillary roll?
To prevent compression of the dependent brachial plexus
Why is it better to double glove than single glove?
To protect from pricks and sticks
Goal for positioning
To provide the best possible access and visualization of the surgical site while causing the least possible compromise in physiological function
Why do you wear eyewear?
To reduce bodily fluids in eyes
Describe the strategic considerations for positioning of the mayo stand for the surgical procedure
Tray portion is placed over patient so that SGT can adjust as needed, SGT faces the instruments and supplies to allow for efficient passing of instruments
Why is it important for anesthesia to control the movement of the patient?
Tubing and intubation
Povidone-iodine
Two-step prep with scrub and then "paint"
Not recommended, unrestricted, semi-restricted, or restricted: Locker room designation of surgical unit and delivery areas
Unrestricted
Not recommended, unrestricted, semi-restricted, or restricted: Street clothes can be worn
Unrestricted
Drapes and towels are not passed over ________ areas. It will be necessary to pass the drape to the surgeon from the ________ side of the OR table.
Unsterile; same
To rescrub an area contaminated
Use 10 strokes to area and gloves
What can be done to prevent venous stasis with resultant possible thrombus formation and pulmonary embolus
Use antiembolic devices
Tape remover
Used for ECG lead removal to ensure antiseptic skin contact
Flank, kidney
Used for access to the retroperitoneal space, requires a kidney rest
Sims
Used for endoscopy
Assisted gowning/gloving technique
Used for other team members by surgical technologist
Kraske
Used for pilonidal or anal access
Prone
Used for spinal or dorsal body surface access
Supine
Used for the administration of anesthesia
Lithotomy
Used for urethral, vaginal or rectal case access
Lateral
Used to access the retroperitoneal space, hip or thorax
Fowlers
Used to access the shoulder, head
Purpose of reverse trendelenberg position
Used to displace abdominal organs
Reverse trendelenberg
Used to displace abdominal organs; visualize gallbladder
Trendelenberg
Used to displace abdominal organs; visualize pelvic organs
Skin degreaser
Used to remove skin oils
Counted scrub technique
Uses 30 strokes for nails; 20 for other areas