Etiquette in the Operating Room
What is the Trendelenburg position?
- entire bed is tilted with *head of bed lower* than foot of the bed; - facilitates venous return; can help increase low BP; used for postural drainage
who is on the anesthesiology team?
-Anesthesiologist -Anesthesiology Assistants (AA) -Certified Registered Nurse Anesthetists (CRNA)
how do you drape a patient?
-Completed by two people ◦You and the surgical tech ◦You and the MD ◦Circulator monitors the procedure -Hold drapes high enough above the table to prevent contamination -Never reach across the table -If you are handing the sterile drape to a non-sterile person (anesthesia); use the drape to cover your glove to prevent contamination -Don't touch any part of the drape that falls into a non-sterile area
what are the risks of lithotomy position?
-Extreme flexion of the hip joints can cause neural damage by stretch (sciatic and obturator nerves) -direct pressure (compression of the femoral nerve as it is passes under the inguinal ligament). -common peroneal nerve and saphenous nerve - foot drop -calf compression- DVT/PE; compartment syndrome -Crush injuries of the finger
how do we maintain sterility in the OR?
-Only the front of the gown is sterile from the axilla to the waist -Hand must be kept in front and above the waist -If sleeve becomes contaminated; sterile sleeve can be placed -Do not reach across blue sterile field if you are not sterile -If you are not sterile, walk behind those that are }When draping the patient, stand an arm's length from the OR table to prevent contamination of your gown -Sterile personnel should pass back to back -Do not lean on the instrument or OR table -Do not leave the sterile area unless necessary ◦(ex. When taking x-rays) -Do not sit or lean on a non-sterile surface unless necessary -You can lay your hands on the patient; but never lean on a patient -Think before touching anything.. Is it sterile? -If there is any suspicion that something is not sterile, consider it contaminated -Pay Attention to everything around you -The OR is a fluid environment and there is always something happening -Clip all sterile tubes and lines to the drapes -Hand ends of lines off to the circulator
how do we handle a pathology specimen?
-Placed in the appropriate container with the appropriate fixation material -Patient's name , acct number, dob, date, time, and where the sample was taken from noted on pathology slip -Intra-operative cytological examination must be pre-arranged with pathology
What are the rules for how to handle scrubs and shoes for surgery?
-Scrubs should not be worn home or laundered at home ◦Use scrubs that are from locker room -Shoes worn in the OR should not be worn outside the OR ◦If you do wear them outside, you must wear shoe overs -Scrubs worn outside of the hospital should be covered with a lab coat or jacket
which part of the table is sterile?
-Table are sterile only at the tabletop -The part of the drape that falls over the edge is not sterile
-Last year of surgical residency -Responsible for junior residents/students -Responsible for overall management of the patients -Waiting to be matched with further programs
5th year resident
on the anesthesiology team who manage patient during the surgery
AA's and CRNAs
put people to sleep and wake people up (most complications arise here)
Anesthesiologists
which areas are sterile and not sterile on your body?
Areas above your breasts and below your waist is not sterile and your back is not sterile
◦Electrocautery safe for sealing vessels up to 2mm ◦Developed in 1926 by Dr. Bovie and Dr. Cushing ◦Special attention must be paid to not touching drapes with it and ensuring surgical prep is not pooling
Bovie
who is associated with the following? ◦Performs same duties as AA ◦Generally has to do time as critical care nurse prior to going to their job training
Certified Registered Nurse Anesthetists (CRNA)
what is the difference between clipping and clamping?
Diff btw clip and clamping-clamps are temporary, clips are permanent
what is the key about using waterless hand scrubs?
FIRST SCRUB OF THE DAY MUST BE WITH TRADITIONAL AGENT
What is the lithotomy position?
Lying flat on the table with buttocks at the end of the table and feet resting in stirrups
what is jack knife position?
Lying over an exam table that is lifted in the middle in prone position
how do we apply manual pressure properly?
Must hold for 5-7 minutes with no peeking to see if it stopped
who is associated with the following? -Handles the day to day management of the operating room -Schedules staff, trouble shoots problems, and insure smooth overall operations. ◦Upper level RN with lots of OR experience ◦Must have a good demeanor and able to work with lots of different types of people Must be attention to detail
OR supervisor
unit that takes care of pt when done with them(surgery)
PACU
-Staffed by RN's -Patients go there to be "recovered" prior to being transferred to a room or discharged -Patients are monitored for hemodynamic stability, pain control, N/V control -Supervision is done by anesthesiology -Nurses will call you if your orders are incomplete
Post anesthesia care unit(PACU)
Spray and cause clotting in a diffuse area
Thrombin
how do we place pillows when supine and lateral?
Under knees in supine position Between legs in lateral position
what type of suture ligatures do we use?
absorbable
who is associated with the following? ◦medical doctor who completed a residency in anesthesiology ◦coordinates the team ◦must be present at induction ◦helps manage post-op pain
anesthesiologist
who manages post-op pain in the PACU?
anesthesiologist
who is in control when moving the patient from stretcher to table?
anesthesiologist -move on their count
who is associated with the following? ◦27-month curriculum ◦present at induction and monitors patient during surgical procedure ◦equal to CRNA
anesthiosolgy assistant(AA)
requires the recognition, control, and eradication of conditions that promote bacteria growth
asepsis
in a private practice who is responsible for the following? ◦Leader of the team ◦Direction taken from him ◦Responsible for everything *Carrier of the malpractice insurance* *Pays for stupid mistakes by nurses/PA's/MA's*
attending surgeon
in an academic setting who is responsible for the following? ◦Responsible for the surgical team and the patient ◦Responsible for training of surgical residents ◦Responsible for performing surgeries as well as training
attending surgeon
examples of waterless hand scrub?
avagard or surgicept
how should you pass people in the surgical suite?
back to back
when should we change our masks?
between procedure
◦More directed than using a bovie
bipolar cautery
used to stop bone bleeding
bone wax
why do we not want to abduct arms more than 90 degrees?
can result in brachial plexus injury- hand dysfunction
top dog of 5th year residents
chief residents
which person in the operating room is not sterile that can run around and grab things?
circulating nurse
who is associated with the following? -Supervise the activity of each member of the team in the OR; invaluable -Provide assessment and care to the patient in the pre-op area, surgical suite, and until transferred to PACU -Assist with positioning of the patient on the table; gets right table in the room -Preps patient -Assist with prep of instruments, equipment, and supplies prior to and during the procedure; trouble shoots equipment -Responsible for time-out, instrument, & needle count; all intra-operative paperwork
circulating nurse
permanently occludes artery
clipping
who is associated with the following? -Generally an RN -Like an air traffic controller -Responsible for where each staff member goes, when they go, and how assignments are made and changed. -Can make or break the day
control room supervisor
designed to create a sterile area around the incision
draping
who's job is infection control?
everyone's
what is included in proper surgical attire?
eye protection beard covered ears covered surgical mask disposable head covering badge placement jacket stethoscope in pocket shoes with no holes
what is reverse trendelenburg? what are the risks of it?
feet lower then the head of the bed while supine. Risks: ◦Hypotension ◦Increased risk of venous air embolism
Medical doctor who has completed a surgical residency and is continuing to train for a surgical specialty
fellow
where do most gloves tear? what is second most common?
finger tips 2nd most=@wrist
◦Provide maximum sensitivity with maximum protection ◦ones that fit properly will make or break you ◦Can cause dermatitis due to the talc or latex ◦Different brands will fit differently
gloves
what is good etiquette in regards to the PACU?
go to PACU with pt
◦Prevents body fluids from splashing in your eyes ◦Commercial eye glasses are not enough ◦Must extend around the side of your face to provide complete protection
goggles
who is associated with the following? -RN -Works closely with the floor supervisor to provide good flow of patients in and out of the room -Knows everything that is going on -Liaison between staff and surgeon
head nurse
Control of iatrogenic contamination
infection control
where must nipples be in regard to chest rolls?
inside chest rolls
which area is a well marked area; restricted to personnel dressed in hospital scrubs; no street clothes beyond this point?
intermediate zone
-Responsible for minute by minute care of the patient -Learning how to do surgery -Helps train interns -Spends time in ICU and ER
junior resident
◦A major source of contamination is respiratory droplets from the oral & nasal pharynx ◦Covers mouth and nose ◦Molds around the nose; strings tie in back of head and behind neck ◦Properly fitting masks prevent condensation of eye protection lenses May want to tape at nose
mask
◦Responsible for basic care of the patient ◦Both will be learning to do basic procedures such as IV's, emergency procedures, dressing changes, basic surgical technique. You may know more then medical students Work Together/Learn Together
medical students/PA students
what do we need to know about agents for surgical hand washing and skin prep?
multiple options, surgeon has a preference and you choose based on pt's allergen profile
what should be done with surgery for excision of a malignancy? why?
new sterile instrumentation should be used if doing more than on procedure ◦Ex. Mastectomy with breast reconstruction }All scrubbed personnel should change out gloves Reason: possible transmission of microscopic malignant cells to other locations
what is the second most common cause of glove tears?
occurs when you are holding intstruments
who is associated with the following? -Responsible for the overall operational and fiscal management of the operating room -May or may not be someone with significant medical experience ◦RN/MBA -Responsible to the Chief of Surgery -Who the surgeon goes to when they are really mad
operating room director
what is the goal of infection control?
perform surgery in a field without living microorganisms
in which area of the operating room is unrestricted, is not sterile, and family members are allowed with staff permission ◦E.G. Pre-op area
periphery
who is associated with the following? -Assists surgeon by providing instruments, sutures, and supplies as needed -Anticipates the needs of surgeon and first assists by understanding the procedure and monitoring the progress of the procedure -Can assist with retracting tissues, cutting sutures, suctioning, etc.... -Responsible for maintaining counts in the sterile areas
scrub nurse
◦Protects surgical suite from being contaminated by outside sources; protects your footwear ◦Should be removed before leaving suite
shoe covers
aka service coordinator
specialty supervisor
who is associated with the following? -RN who knows the ins and outs of a particular specialty such as ortho, neuro, cardiothoracic -Responsible for maintaining equipment and instruments specific to that specialty -Helps train new members of the team in that particular specialty -Meets with the supervisors to ensure that their specialty area has everything the surgeon needs -First person the surgeon goes to when something goes wrong with equipment
specialty supervisor
in which operating area is marked with a RED line; must have on scrubs, shoe covers, masks and hats?
sterile zone
Penetration of moisture through protection with microbial transmission Notify surgeon you have experienced it
strike-through
◦Principle barrier to disease transmission
surgical gowns
First Year Resident ◦Does a lot of everyday (boring) tasks such as admitting and discharging patients, writing orders, doing basic procedures, reviewing results of test
surgical intern
who is associated with the following? -Trained by AMA approved program and meets rigid certification examination -Responsibilities are similar to scrub nurse -Assists surgeon by anticipating needs and providing instruments and supplies as needed -Organizes sterile back table and prepares for each procedure depending on the requests of the surgeon -They know instruments
surgical technologist
when are you more likely to tear your gloves?
when retracting tissues
what are the different methods of achieving hemostasis?
}Manual Pressure }Energized systems }Surgical Tie }Vascular stapler/clips
who are the players in the operating room?
}attending surgeon }fellow }5th year resident }junior resident }intern }student
what are the risks of jack knife position?
◦Airway accessibility ◦Facial skin breakdown ◦Decreased blood pressure/chest movement ◦Femoral artery occlusion ◦Brachial plexus injury
what are the lateral decubitus position risks?
◦Check down ear ◦Axillary roll can cut off circulation
what are the risks of trendelenburg position?
◦Diaphragmatic movement is limited severely by the weight of the abdominal viscera ◦Raised intracranial pressure ◦Raised intraocular pressure ◦Increase risk of regurgitation
how do we properly position a pt for surgery when moving from stretcher to table?
◦Lock the table/Lock the stretcher ◦Maintain proper anatomical alignment of patient ◦Move on anesthesia's count ◦Place pillow ◦Pad bony prominences ◦Thorax of prone patient must be supported with foam pillows (chest rolls) to allow for adequate ventilation ◦Never cross a patient's legs in supine position ◦Pay close attention to joints when moving patients ◦Pad all fixed instrumentation ◦Strap patient to the bed
what are the risks of beach chair/semi-fowler position?
◦Nerve compression: sciatic nerve (need bend in knees), ulnar nerve, cervical nerve ◦Potential for loss of airway ◦Ocular pressure
why would we want to double glove?
◦Single gloves failure- 51% Visible glove failure or when there is blood on the hand after removal Studies show decrease risk of contamination with double gloving Significant decrease of finger contamination From 51% down to 7% ◦Makes placing dressing easier
how do you hand equipment off the field?
◦Tubes and lines are secured to the drape with a towel clip or allis clamp ◦Hand the appropriate end to the circulator ◦When in doubt what the appropriate end is, ask the scrub tech!
what can pressure on proximal calf lead to?
◦can damage peroneal nerve leading to foot drop Also can cause venous stasis- DVT/PE
what can be a result of abnormal pressure on nerves for extended periods of time?
◦can result in palsy or irreversible paralysis/loss of sensation
what are the risks of being in prone position?
◦decrease expansion of chest and compromise to circulation ◦brachial plexus injury ◦Necrotic nipples ◦Pressure on eye ◦Pressure on bony prominence ◦Dislodged airway tube "lots of pressure points in prone position"
what do AA and CRNAs NOT do?
◦does NOT perform regional anesthesia Central- epidural anesthesia Peripheral- brachial plexus block
what can unnecessary pressure on ulnar nerve lead to?
◦hand dysfunction
