Periop 101 Final Exam

What is an example of self-determination?

Based on premise of respect and the patients right to make informed choices based on truthful information

Counting of Sponges

Before, during and after surgical procedures Separate as you count Two people, one of whom is RN should count

Clinical setting culture is affected by?

Beliefs (about the patient and periop setting) Attitudes (desire to provide effective care, engage in critical thinking) Values (fairness, equitable care Skills (demonstrate critical thinking/clinical reasoning by problem-solving, situational awareness, collaboration, conflict resolution, decision-making, leadership)

Activities that are made possible with periop nursing documentation

Billing for finance and accounting Supply and equipment inventory Communication of patient care by caregivers Planning perioperative care Evaluation of care rendered

What are the different types of surgical specimens?

Biopsy - microscopically studied by pathologist for histologic or cystologic analysis Frozen Section - tissue is frozen and sliced into thin strips for examination under microscope Cytology - specimens obtained for studying cells Routine - not immediate Culture - specimen or tissue that might be infected

What are the Surgical Powered Cutting Instruments?

Bone reamers, variable speed saws, tissue shavers

Important points about Sterile Gowns

Can be re-usable or disposable, required by sterile team and resistant to strike-through by fluids

What is the procedure for removing the sterile gown at end of procedure?

Circulator unfastens neck and back closure ties of gown Scrub grasps shoulders of own gown and pulls downward turning sleeves inside out Remove gown by folding contaminated area to inside Use the glove to glove and skin to skin technique to remove gloves

What is a class I wound?

Clean - not infected, not inflamed (blunt trauma, thyroidectomy)

What is a class II wound?

Clean contaminated - evidence of infection or contamination (spillage from GI tract, appendectomy/ruptured appendix)

What is the first step in the sterilization process?

Cleaning - removing gross soil and moistening soil at the point of use improves effectiveness of next step, decontamination

How should sterile fields be monitored?

Constantly, do not leave unattended until procedure is completed; direct observation increases likelihood of detecting a breach in sterility

What is a class III wound?

Contaminated - NON-purulent inflammation (no pus, open fresh wound)

Important points about perioperative personnel's hair

Cover BEFORE surgical attire is donned, no skull caps unless covered by bouffant, wear in areas where equipment is processed and stored

Describe the draping procedure

Cuff over gloved hands Drape from operative to periphery Sterile to unsterile by draping nearest first Extra material may be needed for extremities Walk around when draping opposite side

What is the second step in the sterilization process?

Decontamination - open box locks and disassemble instruments Use enzymatic detergent on heavily soiled instruments Wear PPE Flush lumens with water or detergent solution

What is general hand hygiene?

Decontamination of hands by antimicrobial or plain soap and water OR Use of antiseptic hand rub, alcohol based product Wash hands for at least 15 seconds (reduces soil, spores, and microorganisms on hands)

What is Standardized Care?

Derived from body of scientific knowledge developed through research and clinical practice such as counting sponges

What is a Neutral Zone?

Designated area on surgical field where scrub and surgeon place all sharp instruments

What is a class IV wound?

Dirty/Infected - old wounds, presence of pus, retained devitalized tissue like gangrene

What should happen to any drapes that fall below waist level or are incorrectly positioned?

Do not move any drape after it is placed, discard them!

Thermal Methods of Hemostasis

ECU via coagulation, bipolar sealing devices, lasers, ultrasonic energy, Argon gas

Circulating RN responsibilities include?

Emotional support during induction Ongoing patient assessment Accurate and complete prep of supplies, instruments, and equipment preop for each pt Implementing/enforcing policies and procedures Preparing specimens Coordinating nursing care from other health care team members Communicating info to family and other health care team members Documenting

Documentation provides a basis for future reference for things like?

Ensure quality of patient care Reconstruct a personal experience record Evidence in a court of law

What is the Semi-Restricted Zone?

Equipment and sterile supply storage, SPD

What is the perioperative nurse's role in patient and family education?

Explaining what the patient will experience Emotional support to enhance coping Teaching skills that a patient will need to perform postop

What are the desired characteristics of antiseptic hand scrub agents?

FDA compliant Documented ability to kill organisms immediately upon application Antimicrobial persistence to reduce regrowth Cumulative effect over time

Major components of medical video imaging include:

Fiber optic light cable, Camera Control Unit (CCU)

What is the drawbacks to using reusable drapes?

Fibers loosen over time (fibers swell and shrink with washing), decrease in barrier quality after 75 to 100 sterilization cycles

What are the special guidelines for handling forensic specimens?

Forensic specimens include but are not limited to hair, fibers, debris, body fluids, and foreign bodies Hospitals need to have policies to give guidance to periop nurse in management of forensic specimens Forensic specimens require special handling when the surgeon is using metal instruments Critical evidence could be lost, discarded or mishandled if not handled properly

What are the Critical Concepts to the Periop Environment

Geographic isolation Bacteriologic isolation through specific practices (attire, delivery/disposal systems) Centralize equipment and supplies

Questions a competent nurse might ask?

How does the conduction system work?

What is the importance of patient and family education?

Improvement in quality of care Improves patient satisfaction Increased adherence Ethical, legal and regulatory mandates

What is a fomite?

Inanimate object that can harbor/transmit infectious organisms from one individual to another (such as fabric stethoscope covers)

What is the goal of patient and family education?

Increase knowledge and satisfaction in order to achieve long-lasting changes in patient health status and knowledge that will allow them to make autonomous decisions and to take ownership of care as much as possible to ultimately improve outcomes

Patient involvement in their care in the periop arena via HCP/physician entails what?

Information received from surgeon regarding nature of impending procedure Risks and benefits Alternative treatments or interventions to procedure Patient has signed the consent form

What statements reflect the concept of critical thinking?

Informed practice Holistic thinking Unbiased thinking Reasoned application of a step by step process

RN responsibilities in Sponge Counts

Initiate count (any team member can initiate count??), perform count, document count activities, reporting count deficiency

Commonly accepted nursing tools:

Nursing process PNDS (Perioperative Nursing Data Set) WHO (World Health Organization)/Joint Commission/AORN surgical safety checklists

What is strike-through?

Organisms traveling from wet skin and soaking through and contaminating an object, be sure to thoroughly dry hands before donning sterile gown

Where is bone wax used?

Ortho, neuro, and the sternum during heart procedures

Types of Drains

Penrose, nasogastric, T-tube, suction drains, chest tubes

Chemical Methods of Hemostasis

Pharmocological methods (meds such as epi, vit K, protamine, lysine, tranexamic acid) Topical methods (thrombins, collagen gelatins, phenol sealants)

Special considerations when using a endoscopic light source are:

Place in "standby" mode, do not turn on until light cable is connected to the telescope, set according to manufacturer's parameters

Where is a pledget most commonly used?

Vascular closure, septal repair, heart repair and hepatic repair

How should air be cleaned in OR rooms?

Via HEPA filter, under POSITIVE pressure and by 20 air exchanges per hour (minimum of 4 exchanges from outdoor air)

What are the steps to a surgical hand scrub?

Wash hands and forearms with soap/water before starting scrub (dry with sterile cloth towel) Dispense scrub according to manufacturers directions Clean subungual areas of both hands with nail cleaner Visualize each finger, hand and arm as having four sides, repeat on other hand Rinse thoroughly

Question a advanced beginner might ask?

What does this patient need to support his cardiac function?

Question a novice nurse might ask?

Whats the anatomy and physiology of the heart?

What is open assisted gloving?

When team members gown sleeves are pulled up so hand and fingers are exposed (should be used every time gloves are changed during a case) should only be used when closed assisted gloving is not possible or practical

When can sterile fields be covered?

When there is an unanticipated delay or during periods of increased activity

What is a Crile?

A hemostat used to control bleeders in SQ tissue

What is a Kelly?

A hemostat used to control bleeders in muscle tissues

What is a Mosquito?

A hemostat used to control superficial bleeders in delicate surgery (hand/plastic)

What is bone wax?

A mixture of beeswax, isopropyl, and a softening agent

What are the organizations that provide guidance in reference to surgical tissue banking?

AORN (has guidelines for autologous tissue such as replantation or auto-transplantation AATB (American Association of Tissue Banks) FDA

What is biological monitoring in the sterilization process?

Absence of growth indicates appropriate parameters for sterilization have been met; no growth, no color change, or no fluorescence demonstrates negative response

Drainage is achieved by ________ or ___________ means

passive (gravity) or active (suction)

What is "surgical conscience"?

Requires mental alertness to errors and ability to speak out Involves ability to set personal preferences and prejudices aside in order to provide optimal patient care Allows for no compromise

What are the two types of microorganisms found on skin?

Resident - organisms normally found on the skin, require chemical agents to eliminate them and prevent regrowth for a period of time Transient - organisms that are not normally found on the skin, on top layers, easily removed by mechanical cleansing

What is surgical tissue banking?

Retrieval, processing, preserving, and storing human tissue for later transplant back into patient or another patient

What is a major potential source of microbial contamination in the surgical environment?

SKIN

Special considerations when using laparoscopic instruments

Scrub should inspect more closely because of unapparent defects that may not be apparent with casual observation, focus on insulation because of risk for thermal burns if not intact

Advantage of endoscopic surgery versus open surgery

Smaller incisions

What are the characteristics of disposable drapes?

Soft, lint-free, static-free, compact, lightweight, and moisture repellency and resistance to strike through of fluids

What are the elements of infection?

Source/reservoir Susceptible host Method of transmission

What are some important documentation required for surgical specimens?

Specimen identification including pertinent info such as location of suture tags (no abbreviations) Pathology requisition Date time with notation of markers or tags such as clips or sutures with statement of what they represent

What is the process for specimen collection and labeling?

Specimen is identified by surgeon first, then passed off field to circulating nurse Fill out lab/path requisition form Label specimen description to include type and site (laterality if appropriate) Patient name and unique identifier (MRN) Date/time of collection Diagnosis Surgeon name Presence of chemical preservatives or biohazardous material

What are the automated cleaning and decon machines?

Ultrasonic cleaner - removes fine debris through cavitation Wash decon/disinfetor - hands-free processing Washer/sterilizer - processes instruments through several cycles (NOT considered prepared for use)

How should masks be worn/handled in the OR

Use fresh clean mask for every procedure Do not hang masks from neck Remove mask via mask ties only

What is "sterile technique"?

Use of specific actions/activities to prevent contamination and maintain sterility of areas and instruments

What are the primary goals of aseptic technique?

Minimize length of recovery Optimize primary wound healing Prevent surgical site infection

Correct fluid management procedures in MIS

Monitor overload of IV/irrigation fluids dispensed and returned during procedure (prevent hypervolemia/fluid overload)

What are the different types of surgical interventions to collect specimens?

Needle Aspiration - fine gauge needle and syringe used to aspirate sample Incisional Biopsy - small portion of tissue is incised and sent for examination Excisional Biopsy - a entire section of tissue is sent for examination

Participation in Sponge Counts

All personnel in case are responsible for counts including remaining aware of location of sponges

What is a ligature?

Also known as a tie, strand tied around a blood vessel to occlude bleeding; large vessels may require transfixion suture (crosscriss stitch)

Care and handling of powered cutting instruments?

Always hand to surgeon with safety on, always use with drill guard in place, always have irrigation ready because of heat generation

Special considerations when using insufflation (establishing a pneumoperitoneum)

Always have a backup tank available, position at the level of the patients heart or higher to prevent gases from contaminating the device, make sure alarm is on and audible, maintain pressure under 12 mm/Hg

What are some barriers to effective patient and family education in the periop setting?

Anxiety about outcome Discomfort/pain Fear of the unknown Limited time for assessment/teaching

What would be a example of violating a patients right to self-determination?

Automatic suspension of DNR orders during periop experience, required reconsideration is an integral component however

What is a pledget?

Non-absorbable suture support used when possibility of sutures tearing through tissue

What are the types of drapes and their uses?

Laparatomy sheet - abdominal areas Thyroid sheet - neck Breast sheet - breast or chest Extremity sheet - arm boards, pieces of furniture, extremities

Types of Surgical Sponges

Laps, tonsils, neuro-patties, dissector sponges, raytecs (4x4)

What is the procedure for donning sterile gown?

Lift the gown upward Step back from table into unobstructed area to let gown unfold Locate neckband and hold gown inside just below neckband Let gown unfold while keeping inside of gown toward body Hold hands at shoulder level and slip both arms in simultaneously Fasten gown completely including ties in back BEFORE donning sterile gloves**

Important points about the 2 Piece Scrub Suit

Lint free, minimize bacterial shedding; secure at waist, tuck into pants and fit closely to the body to prevent skin cells from shedding

What is the Restricted Zone?

Located in the semi-restricted area and only accessible via semi-restricted area; includes actual OR

What are the two most common MDRO's (Multi-drug resistant organisms)

MRSA and VRE

Mechanical Methods of Hemostasis

Manual pressure (sponges), hemostatic clamps, sutures, staples, clips, ligatures, and/or pledgets

What is the Unrestricted Zone?

Pre-Op Holding Area, Waiting Rooms, Blood/Specimen processing

Special considerations for patient undergoing MIS/Endoscopic Surgery

Previous incisions (Hasson minilap) that may require additional sterile supplies, hx of DVT, consent for possibility of open procedure, voiding to empty bladder and prevent puncture during trocar placement/unnecessary catheterization

What is a mentor?

Provides encouragement and acts as a guide and facilitator while modeling professional nursing behaviors (guide through wide range of professional activities)

Expected outcome of primary importance when draping a patient?

Pt is free from s/s of infection

What is Individualized Care?

Reflects art of nursing, meets individual needs of pt, provide comfort measures

What are Suction Drains and their purpose?

Remove blood, pus, necrotic material from wounds via suctions (Jackson-Pratt for abdominal/breast, Hemovac for ortho)

What is the purpose of the surgical hand scrub?

Remove debris and transient microorganisms from nails, hands, and forearms Reduce resident microbial count to a minimum Inhibit rapid rebound regrowth of microorganisms

What is the most effective ways to prevent disease transmission/control infections?

Standard Precautions (hand hygiene, PPE, patient resuscitation, environmental control) Nurse should wash hands prior to greeting patient in pre-op area

What is a preceptor?

Teaches, counsels, inspires, serves as a role model, and supports growth and development for FIXED period of time (guide through defined clinical activities)

What should temperature/humidity be maintained at in the OR?

Temp between 68 and 75 degrees Under positive pressure, HEPA filter with 20 air exchanges per hour (minimum of 4 exchanges from outdoor air) 20-60% humidity

How should sterile items be stored?

Temp between 72 and 78 degrees 4 air exchanges per hour 60-70% humidity Stored in a manner that allows for adequate air circulation, ease of cleaning and compliance with fire codes

What is surgical hand antisepsis?

The surgical scrub or antiseptic hand rub performed before donning sterile attire preoperatively