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Surgery
Surgery is the term traditionally used for treatments that involve cutting or stitching tissue. However, advances in surgical techniques have made the definition more complicated. Sometimes lasers, rather than scalpels, are used to cut tissue, and wounds may be closed without stitches. In modern medical care, distinguishing between a surgical and medical procedure is not always easy; however, making that distinction is not important as long as the doctor performing the procedure is well trained and experienced. Surgery is a broad area of care and involves many different techniques. In some surgical procedures, tissue is removed. In others, blockages are opened. In still others, arteries and veins are attached in new places to provide additional blood flow to areas that do not receive enough. Grafts, sometimes made of artificial materials, may be implanted to replace blood vessels or connective tissue, and metal rods may be inserted into bone to replace broken parts. The urgency of surgery is often described by three categories—emergency, urgent, and elective. Emergency surgery, such as stopping rapid internal bleeding, is performed as soon as possible because minutes can make a difference. Urgent surgery, such as removal of an inflamed appendix, is best performed within hours. Elective surgery, such as replacement of a knee joint, can be delayed for some period of time, until everything has been done to optimize a person's chances of doing well during and after the surgical procedure. Cosmetic Surgery Cosmetic surgery involves a wide variety of operations, including removing facial and neck wrinkles (rhytidectomy); removing fat and wrinkles from the abdomen (abdominoplasty); enlarging or reducing breasts (mammoplasty); restoring scalp hair (hair replacement surgery); altering the appearance of facial features, such as the jaw (mandibuloplasty), eyelids (blepharoplasty), and nose (rhinoplasty); removing body fat (liposuction); and eliminating varicose veins (sclerotherapy). Popular and tempting as cosmetic surgery may be, there are certain drawbacks and precautions: It is expensive. It poses risks, including serious health risks as well as the possibility that appearance may be less pleasing to the person than it was originally. Because obtaining the best results requires close adherence to instructions after the operation, cosmetic surgery is recommended only for highly motivated people. A person should choose a doctor who has met a medical specialty's standards for practice (board certification) and who has extensive experience performing the procedure. Anesthesia Because surgery is generally painful, it is almost always preceded by the administration of some type of anesthesia. Anesthesia blocks the perception of pain. Anesthesia may be local, regional, or general. Anesthesia is typically given by health care practitioners specially trained and certified in providing anesthesia. These practitioners may be doctors (anesthesiologists) or nurse practitioners (nurse anesthetists). Nurse anesthetists practice under the direction of an anesthesiologist. Local and Regional Anesthesia: These types of anesthesia consist of injections of drugs (such as lidocaine Some Trade Names XYLOCAINE or bupivacaine) that numb only specific parts of the body. In local anesthesia, the drug is injected under the skin of the site to be cut, numbing only that site. In regional anesthesia, which numbs a larger area of the body, the drug is injected around one or more nerves and numbs an area of the body supplied by those nerves. For example, injecting a drug around certain nerves can numb fingers, toes, or large parts of limbs. One type of regional anesthesia involves injecting a drug into a vein (intravenous regional anesthesia). A device such as a woven elastic bandage or blood pressure cuff compresses the area where the limb joins the body, trapping the drug within the veins of that limb. Intravenous regional anesthesia can numb an entire limb. During local and regional anesthesia, the person remains awake. However, doctors sometimes give antianxiety drugs intravenously to calm and relax the person. Rarely, numbness, tingling, or pain can persist in the numbed area for days or even weeks after the surgical procedure. Spinal and epidural anesthesia are specific types of regional anesthesia in which a drug is injected around the spinal cord in the lower back. Depending on the site of the injection and position of the body, a large area (such as from the waist to the toes) can be numbed. Spinal and epidural anesthesia are useful for operations of the lower body, such as hernia repairs and prostate, rectal, bladder, leg, and some gynecologic operations. Spinal and epidural anesthesia also can be useful for childbirth. Headaches occasionally develop in the days after spinal anesthesia but usually can be treated effectively. General Anesthesia: In general anesthesia, a drug that circulates throughout the bloodstream is given, rendering the person unconscious. The drug can be given intravenously or inhaled. Because a general anesthetic slows breathing, the anesthesiologist inserts a breathing tube in the windpipe and a ventilator breathes for the person if the operation is long. For short operations, however, such a tube may not be necessary. Instead, the anesthesiologist can support breathing by using a hand-held breathing mask. General anesthetics affect vital organs, so the anesthesiologist closely monitors the heart rate, heart rhythm, breathing, body temperature, and blood pressure until the drugs wear off. Fortunately, serious side effects are very rare. Did You Know... Improved technologies and procedures have made serious side effects of general anesthesia vary rare. Major and Minor Surgery A distinction is sometimes made between major and minor surgery, although many surgical procedures have characteristics of both. Major Surgery: Major surgery often involves opening one of the major body cavities—the abdomen (laparotomy), the chest (thoracotomy), or the skull (craniotomy)—and can stress vital organs. The surgery usually is performed using general anesthesia in a hospital operating room by a team of doctors. A stay of at least one night in the hospital usually is needed after major surgery. Minor Surgery: In minor surgery, major body cavities are not opened. Minor surgery can involve the use of local, regional, or general anesthesia and may be performed in an emergency department, an ambulatory surgical center, or a doctor's office. Vital organs usually are not stressed, and surgery can be performed by a single doctor, who may or may not be a surgeon. Usually, the person can return home on the same day that minor surgery is performed. Surgical Risk The risks of surgery (that is, how likely surgery is to cause death or a serious problem) depend on the type of surgery and characteristics of the person. Types of surgery that have the highest risk include Heart or lung surgery Prostate gland removal Major operations on the bones and joints (for example, hip replacement) Generally, the poorer the person's overall health, the higher the risks of surgery. Some particular health problems that increase surgical risk include Severe chest pain (angina) Recent heart attack Severe heart failure Undernutrition (common among institutionalized elderly people) Severe disorders of the lungs or liver Chronic kidney disease Chronic lung disease (often smoking-related) Weakened immune system (for example, because of long-term corticosteroid treatment) Diabetes (especially if poorly controlled) Risks are often higher among elderly people (see Surgery: Spotlight on AgingSidebar); however, risks are determined more by general health than by age. Chronic disorders that increase surgical risk and other treatable disorders, such as dehydration, infections, and imbalances in body fluids and blood chemistries, should be controlled with treatment as well as possible before an operation. Second Opinion The choice to undergo surgery is not always clear. There may be nonsurgical options for treatment, and there may be several options for the kind of surgical procedure. Thus, a person may seek the opinion of more than one doctor. Some health insurance plans require a second opinion for elective surgery. However, experts may disagree on which doctor should give the second opinion. Some experts advise obtaining a second opinion from a doctor who is not a surgeon to eliminate any bias toward surgery when nonsurgical treatment is an option. Others advise that another surgeon give the second opinion, believing that a surgeon knows more about the advantages and disadvantages of surgery than would a nonsurgeon. Some experts recommend establishing up front that any surgeon giving a second opinion will not perform the surgical procedure, so that there is no conflict of interest. Surgery Through a Keyhole Technical advances now make it possible to perform surgery with smaller incisions and less tissue disruption than occurs with traditional surgery. To perform this surgery, surgeons insert tiny lights, video cameras, and surgical instruments through keyhole-sized incisions. The surgeons can then perform procedures using the images transmitted to video monitors as guides for manipulating the surgical instruments. This kind of surgery is called laparoscopic surgery when performed in the abdomen, arthroscopic surgery when performed in joints, and thoracoscopic surgery when performed in the chest. Because it causes less tissue damage than traditional surgery, keyhole surgery has several advantages, including the following: * A briefer hospital stay (in most cases) Earlier return to work A tendency toward smaller scars However, the difficulties of keyhole surgery often are underestimated by people undergoing the surgery and sometimes by surgeons. Because surgeons are using a video monitor, they are seeing only a two-dimensional view of the site on which they are operating. Also, the surgical instruments used have long handles and are controlled from outside of the person's body, so the surgeon may find that using them feels less natural than using traditional surgical instruments. For these reasons, keyhole surgery has potential disadvantages: Keyhole surgery often takes longer than traditional surgery. More importantly, especially when a procedure is new, errors are more likely to occur than with traditional approaches because of the complexity of keyhole surgery. People also should know that although keyhole surgery may cause less pain than traditional surgery, pain still occurs, often more than anticipated. Because keyhole surgery is technically difficult, people should do the following: Choose a highly experienced surgeon Establish that surgery is necessary Ask the surgeon how pain will be treated Preparing for the Day of Surgery Various preparations are made in the days and weeks before surgery. It is often recommended that physical conditioning and nutrition be improved as much as possible, because good general health helps a person recover from the stress of surgery. Alcohol and Tobacco Use: Eliminating or minimizing alcohol and tobacco use before undergoing surgery that involves general anesthesia can increase safety. Recent tobacco use makes abnormal heart rhythms more likely to develop during general anesthesia and impairs lung function. Excessive alcohol consumption can damage the liver, causing heavy bleeding during surgery and unpredictably increasing or decreasing the effect of the drugs used for general anesthesia. Alcohol consumption should be decreased gradually, however, because a sudden decrease before undergoing general anesthesia can cause harmful effects, such as fever and abnormalities of blood pressure or heart rhythm. Doctors' Evaluations: The surgeon performs a physical examination and takes a medical history, which includes the person's recent symptoms, past medical conditions, past reactions to anesthetics (if any), use of tobacco and alcohol, infections, risk factors for blood clots, problems pertaining to the heart and lungs (such as cough or chest pain), and allergies. The person also is asked to list all drugs currently being taken. Nonprescription as well as prescription drugs must be disclosed because serious health problems could result. For example, the use of aspirin Some Trade Names ECOTRIN ASPERGUM , which a person may consider too trivial to mention, can increase bleeding during surgery. Additionally, the use of supplements or herbal remedies (for example, ginkgo biloba or St. John's wort) should be disclosed as well because these may have effects during or after surgery. The anesthesiologist may meet the person before the operation to review test results and identify any medical conditions that might affect the choice of anesthetic. The safest and most effective types of anesthesia may be discussed as well. Tests: Tests performed before surgery (preoperative testing) may include blood and urine tests, an electrocardiogram, x-rays, and tests of lung capacity (pulmonary function tests). These tests can help determine how well the vital organs are functioning. If organs are functioning poorly, the stress of surgery or anesthesia can cause problems. Preoperative tests occasionally also reveal an inapparent temporary illness, such as an infection, which would require the postponement of surgery. Blood Storage for Transfusion: People may wish to store their own blood in case a blood transfusion is needed during surgery. Using stored blood (autologous blood transfusion—see Blood Transfusion: Autologous Transfusion) eliminates the risk of infections and most transfusion reactions. A pint of blood can be withdrawn from the person and preserved until surgery. Blood should be withdrawn no more often than once weekly, and the last donation should probably be at least 2 weeks before surgery. The body replaces the missing blood during the weeks after the blood donation. Decision Making: Sometime before the surgery, the surgeon obtains the person's permission to perform the operation, a process called informed consent. The surgeon discusses risks and benefits of the operation, as well as alternative treatments, and answers questions. The person reads and signs a form documenting consent. In cases of emergency surgery in which the person is unable to provide informed consent, doctors try to contact the family. Rarely, emergency surgery must proceed before the family is contacted. A durable power of attorney for health care and a living will (see Legal and Ethical Issues: Living Will) should be prepared before surgery in case the person becomes unable to communicate or becomes incapacitated after surgery. Oral Intake and Laxative Use: Because some of the drugs given during surgery may cause vomiting, people should generally not eat or drink anything for at least 8 hours beforehand. For outpatient surgery, people should not eat or drink anything after midnight. Specific guidelines should be given and vary depending on the kind of surgery. People should ask the doctor which of their regularly prescribed drugs should be taken before surgery. People undergoing surgery involving the intestines are given laxatives for a day or two before the operation. Fingernails: Because the device that monitors the level of oxygen in the blood is attached to a finger, nail polish and artificial nails should be removed before going to the hospital. Then, this device can perform more accurately. Also, valuables should be left at home. The Day of Surgery Before most operations, a person removes all clothing, jewelry, hearing aids, false teeth, and contact lenses or eyeglasses and puts on a hospital gown. The person is taken to a specially designated room (the holding area) or to the operating room itself for final preparations before surgery. The skin that will be cut (operative site) is scrubbed with an antiseptic, which minimizes the number of bacteria, helping to prevent infection. A health care practitioner may shave the operative site. A plastic tube (catheter) is inserted in one of the veins of the hand or arm, through which fluids and drugs are given. A drug may be given intravenously for sedation. If an operation involves the mouth, intestinal tract, lungs or respiratory tract, or urinary tract, people are given one or more antibiotics within the hour before the operation to prevent infection (prophylaxis). This therapy also applies to people undergoing some other operations in which infections are particularly problematic (for example, joint or heart valve replacement). In the Operating Room The operating room provides a sterile environment in which the operating team can perform surgery. The operating team consists of the following: Chief surgeon, who directs the surgery One or more assistant surgeons, who help the chief surgeon Anesthesiologist, who controls the supply of anesthetic and monitors the person closely Scrub nurse, who passes instruments to the surgeon Circulating nurse, who provides extra equipment to the operating team The operating room typically contains a monitor that displays vital signs, an instrument table, and an operating lamp. Anesthetic gases are piped into the anesthetic machine. A catheter attached to a suction machine removes excess blood and other fluids, which can prevent surgeons from seeing the tissues clearly. Fluids given by vein, started before the person enters the operating room, are continued. If the final preparations are done in the holding area, the person is then taken to the operating room. At this point, the person may still be awake, although groggy, or may already be asleep. The person is moved to the operating table, over which are specially designed surgical lights. Doctors, nurses, and other personnel who will be near or touching the operative site thoroughly scrub their hands with antiseptic soap, which minimizes the number of bacteria and viruses in the operating room. For surgery, they also wear scrub suits, caps, masks, shoe covers, sterile gowns, and sterile gloves. Before the surgery begins, a time out is held during which the surgical team confirms the following: The person's identity The correct procedure and side (if applicable) Availability of all needed equipment Prophylaxis to prevent infection or blood clots has been given (if needed) Local, regional, or general anesthesia is given. After Surgery After the operation is completed and anesthesia begins to wear off, the person is taken to a recovery room to be closely watched for about 1 or 2 hours. Most people feel groggy when awakening, particularly after major surgery. Some people are nauseated for a short while. Some may feel cold. Depending on the nature of the surgery and the type of anesthesia, a person may go home directly from the recovery room or be admitted to the hospital, sometimes in an intensive care unit (ICU). Direct Discharge Home: A person being sent home must be Thinking clearly Breathing normally Able to drink fluids Able to urinate Able to walk Free of severe pain People who have been given sedatives and then discharged need to be accompanied home by someone else and are not permitted to drive themselves. The operative site should be free of bleeding and unexpected swelling. Hospitalization: People who are admitted to the hospital after surgery may awaken to find many tubes and devices in and on them. For example, there may be a breathing tube in the throat, adhesive pads on the chest to monitor the heartbeat, a tube in the bladder, a device attached to a finger to measure the level of oxygen in the blood, a dressing on the operative site, a tube in the nose or mouth, and one or more tubes in the veins. Pain is expected after most operations and can almost always be relieved. Drugs that relieve pain (analgesics) can be given intravenously, by mouth, by injection into the muscle, or applied to the skin as a patch. If epidural anesthesia was used, the anesthesiologist may leave the plastic tube through which the anesthesia was given in the person's back. Opioid analgesics, such as morphine Some Trade Names MS CONTIN ORAMORPH , can be injected through the tube. People staying in the hospital may be given a device that continuously injects an opioid analgesic into a vein, which also can deliver a small additional amount of analgesic when people press a button (patient-controlled analgesia). If pain persists, additional treatment can be requested (see Pain: Treatment). Repeated use of opioid analgesics often causes constipation. To prevent constipation, a stimulant laxative or stool softener may be given. Proper nutrition is critical for rapid healing and minimizing the chance of infection. Nutritional needs increase after major surgery. If surgery makes eating impossible for more than several days, an alternative source of nutrition can speed recovery and prevent problems. People whose digestive tracts are functioning but who are otherwise unable to eat may be given nutrients through a tube placed into the stomach. Such a tube may be passed through the nose, mouth, or abdominal wall. Rarely, people who have had surgery of the digestive tract and cannot eat for extended periods may be given nutrients through one of the body's large veins (parenteral nutrition—see Undernutrition: Intravenous Feeding). Complications: Complications such as fever, blood clots, wound problems, confusion, difficulty urinating or defecating, and muscle loss can develop during the days after surgery. Fever has several common causes, including an inflammatory response to the trauma of an operation; a high metabolic rate that occurs with the stress of an operation, which causes the body to burn more calories and generate more heat; and infections, such as pneumonia, urinary tract infections, and infections at the operative site. Pneumonia may be prevented by periodically breathing forcefully in and out of a hand-held device (incentive spirometry) and coughing as needed. Blood clots in the legs or pelvic veins (deep vein thrombosis) can develop, particularly if people lie immobile during and after surgery, have had surgery on their lower extremities or pelvic region, or both. The clots can dislodge and travel through the bloodstream to the lungs, where they can block blood from circulating through the lungs (pulmonary embolism). As a result, the oxygen supply to the rest of the body may be decreased, and sometimes blood pressure may fall. For certain operations after which blood clots are particularly likely, and for those people who are likely to have to lie still without much movement, doctors give preventive drugs that keep the blood from clotting (anticoagulants), such as low-molecular-weight heparin, or put compression stockings on the person's legs to improve blood circulation. However, anticoagulants may not be recommended for operations in which these drugs may cause bleeding. People should begin moving their limbs and walking as soon as it is safe for them to do so. Wound complications may include infection and separation of the wound edges (dehiscence). To decrease the risk of infection, the surgical incision is dressed after surgery. The dressing includes a sterile bandage and usually includes an antibiotic ointment. The bandage keeps bacteria away from the incision and absorbs fluids that ooze from the incision. Because these fluids can encourage bacteria to grow and infect the incision, the dressing is changed often, usually daily. The wound is examined whenever the dressing is changed, sometimes more often. Occasionally, infection develops despite the best wound care. An infected site becomes increasingly painful 1 or more days after surgery and can become red and warm or drain pus or fluid. Fever can develop. If symptoms of dehiscence or infection develop, the doctor should be seen as soon as possible. Delirium (confusion and agitation) can develop, particularly among the elderly. Drugs with anticholinergic effects (such as confusion, blurred vision, and loss of bladder control), opioids, sedatives, or antihistamine (histamine-2) blockers may contribute, as may too little oxygen in the blood. Drugs that can cause confusion should be avoided in the elderly when possible. Difficulty urinating and difficulty defecating (constipation) can develop after surgery. Factors that contribute can include use of drugs with anticholinergic effects or opioids, inactivity, and not eating or drinking. Urine flow may become completely blocked, distending the bladder. Blockage can lead to urinary tract infections. Sometimes pressing on the lower abdomen while trying to urinate may relieve blockage, but often a catheter needs to be inserted into the bladder. The catheter is sometimes left in place and sometimes is removed as soon as the bladder is emptied. Frequently sitting up may help prevent blockage. People who develop constipation and whose surgery did not involve the intestinal tract can be given laxatives that stimulate the intestines, such as bisacodyl Some Trade Names DULCOLAX , senna, or cascara. Stool softeners such as docusate Some Trade Names COLACE do not help. Loss of muscle (sarcopenia) and strength occur in all people subject to prolonged bed rest. With complete bed rest, young adults lose about 1% of their muscle per day, but the elderly lose up to 5% per day because of lower levels of growth hormone, which is responsible for maintaining muscle tissue. Adequate amounts of muscle are important for recovery. Thus, people should sit up in bed, move, stand, and exercise as soon as and as much as is safe for them. Discharge Home After Hospitalization: Before leaving the hospital, people are responsible for Scheduling a follow-up visit with the doctor Knowing what drugs to take Knowing what activities to avoid or limit Examples of activities that may need to be avoided temporarily include climbing stairs, driving a car, lifting heavy objects, and having sexual intercourse. A person should know what symptoms necessitate contacting the doctor before the scheduled follow-up visit. Resuming normal activity during recovery from surgery should occur gradually. Some people need rehabilitation, which involves special exercises and activities, to improve strength and flexibility (see page 39). For example, rehabilitation after hip replacement surgery can involve learning ways to walk, stretch, and exercise. 
OPERATING ROOM ORIENTATION MANUAL Goals & Objectives After 30 minutes of orientation, the JMS should be able to: Discuss the principles of aseptic technique Demonstrate surgical scrub, gowning, and gloving Identify hazards in the surgical setting Identify the role of the scrub person, circulating nurse, and medical student Discuss ways the JMS can participate in the care of the patient and thereby become an active, useful member of the surgical team Lockers Lockers are available for your use during the hours between 0700-1800 while you are in the operating room. You must bring your own lock. Locks must be removed by 1800. Any locks not removed between 1800-0700 are subject to being cut and contents removed for later disposition. UTMB Surgical Operating Suites DRESS CODE - SURGICAL ATTIRE 1. All persons who enter the semirestricted and restricted areas of the surgical suite should be in hospital laundered surgical attire intended for use only within the surgical suite at UTMB. 2. All possible head and facial hair, including sideburns and neckline, should be covered when in the surgical suite. 3. All persons entering an operating room or centerwell area should wear a mask. 4. All personnel entering the suite should have all jewelry confined or removed. Watches and plain wedding bands are acceptable. Earrings must be covered by the scrub cap. 5. Nail polish and artificial nails should not be worn within the suite. 6. Protective barriers (gloves, masks, protective eyewear, and face shields) are provided by the hospital and should be utilized to reduce the risk of exposure to potentially infective agents. 7. Shoes should be dedicated to the OR and shoe covers are not required. If shoe covers are necessary, the wearer should remove them before leaving the operating room to avoid tracking blood and debris through the department. SURGICAL HAND SCRUB 1. A five (5) minute anatomical timed scrub will be used for all surgical hand scrubs. 2. Fingernails must be free of polish/enamel and of medium length. No jewelry is permitted on the hands and arms while performing as a member of the surgical team. 3. **Remember to put your mask on prior to starting you scrub.** 4. Wash hands and arms with solution to 2 inches above the elbow. 5. Clean fingernails with file. Take sterile brush in right hand. Wet brush with water and soap. Scrub fingernails of left hand. 6. Start scrubbing fingers of left hand, one at a time, treating each finger as four-sided; palm, knuckles, and back of hand. Repeat with right hand. 7. Scrub right wrist and continue up arm to 2 inches above elbow. Repeat with left arm. Discard brush. Rinse both hands and arms under running water keeping hands above level of elbow so that water runs off the elbows and not the hands. Gloving Procedure - Open 1. Avoid contact of sterile gloves with ungloved hands during closed-glove procedure. 2. For closed-glove method, never let the fingers extend beyond the stockinette cuff during the procedure. Contact with ungloved fingers constitutes contamination of the glove. 3. For open-glove method, touch only the cuff of the glove with ungloved hand, and then only glove to glove for other hand. 4. If contamination occurs during either procedure, both gown and gloves must be discarded and new gown and gloves must be added. 5. When removing gloves after a procedure is finished, the gloves are removed after the gown is removed inside out, using glove-to-glove, then skin-to-skin technique. Gloving Procedure - Closed Points to Remember about Aseptic Technique Adherence to the Principles of Aseptic Technique Reflects One's Surgical Conscience. 1. The patient is the center of the sterile field. 2. Only sterile items are used within the sterile field. A. Examples of items used. B. How do we know they are sterile? (Wrapping, label, storage) 3. Sterile persons are gowned and gloved. A. Keep hands at waist level and in sight at all times. B. Keep hands away from the face. C. Never fold hands under arms. D. Gowns are considered sterile in front from chest to level of sterile field, and the sleeves from above the elbow to cuffs. Gloves are sterile. E. Sit only if sitting for entire procedure. 4. Tables are sterile only at table level. A. Anything over the edge is considered unsterile, such as a suture or the table drape. B. Use non-perforating device to secure tubing and cords to prevent them from sliding to the floor. 5. Sterile persons touch only sterile items or areas; unsterile persons touch only unsterile items or areas. A. Sterile team members maintain contact with sterile field by wearing gloves and gowns. B. Supplies are brought to sterile team members by the circulator, who opens wrappers on sterile packages. The circulator ensures a sterile transfer to the sterile field. Only sterile items touch sterile surfaces. 6. Unsterile persons avoid reaching over sterile field; sterile persons avoid leaning over unsterile area. A. Scrub person sets basins to be filled at edge of table to fill them. B. Circulator pours with lip only over basin edge. C. Scrub person drapes an unsterile table toward self first to avoid leaning over an unsterile area. Cuff drapes over gloved hands. D. Scrub person stands back from the unsterile table when draping it to avoid leaning over an unsterile area. 7. Edges of anything that encloses sterile contents are considered unsterile. A. When opening sterile packages, open away from you first. Secure flaps so they do not dangle. B. The wrapper is considered sterile to within one inch of the wrapper. C. In peel-open packages, the edges where glued, are not considered sterile. 8. Sterile field is created as close as possible to time of use. A. Covering sterile tables is not recommended. 9. Sterile areas are continuously kept in view. A. Sterility cannot be ensured without direct observation. An unguarded sterile field should be considered contaminated. 10. Sterile persons keep well within sterile area. A. Sterile persons pass each other back to back or front to front. B. Sterile person faces a sterile area to pass it. C. Sterile persons stay within the sterile field. They do not walk around or go outside the room. D. Movement is kept to a minimum to avoid contamination of sterile items or persons. 11. Unsterile persons avoid sterile areas. A. Unsterile persons maintain a distance of at least 1 foot from the sterile field. B. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it. C. Unsterile persons never walk between two sterile fields. D. Circulator restricts to a minimum all activity near the sterile field. 12. Destruction of integrity of microbial barriers results in contamination. A. Strike through is the soaking through of barrier from sterile to non-sterile or vice versa. B. Sterility is event related. 13. Microorganisms must be kept to irreducible minimum. A. Perfect asepsis is an idea. All microorganisms cannot be eliminated. Skin cannot be sterilized. Air is contaminated by droplets. HAZARDS IN THE SURGICAL SUITE Electrical Cautery Units, Defibrillators, OR Beds, numerous pieces of equipment All equipment must be checked for electrical safety before use!! Anesthetic Waste Radiation Leaded aprons and shields available for use during procedures. Laser Safety Protective eyewear for patient and operating team. Doors remain closed with sign - "Danger, Laser in Use." Sterile water available in the room and on sterile field. Smoke evacuation system is to be employed when applicable. Surgery high filtration masks should be worn during procedures that produce a plume. General Safety Apply good body mechanics at all times when transferring patients. Operating room beds and gurneys will be locked before patient transfer. Operating safety belts will be used for all patients. Never disconnect or connect electrical equipment with wet or moist hands. Discard all needles, razors, scalpel blades and broken glass into special identified containers. UNIVERSAL PRECAUTIONS SUMMARY Although the risk of contracting HIV in the healthcare setting is extremely low, there are other bloodborne pathogens which pose a much more significant risk. Precautions should be followed to reduce the risk of exposure to bloodborne pathogens. Each healthcare worker should assess their possible risks and take precautions to reduce these risks. Universal Precautions are designed to protect healthcare workers from occupational exposure and should be followed when potential for exposure might occur. Universal blood and/or body fluid precautions should be consistently used for ALL patients. Fundamental to the concept of Universal Precautions is treating all blood and/or body fluids as if they were infected with bloodborne pathogens and taking appropriate protective measures, including the following: 1) Gloves should be worn for touching blood and/or body fluids, mucous membranes, non-intact skin, or items/surfaces soiled with blood and/or body fluids. Gloves should be changed after contact with each patient and hands washed after glove removal. Though gloves reduce the incidence of contamination, they cannot prevent penetrating injuries from needles and other sharp instruments. 2) Gowns or aprons should be worn during procedures that are likely to generate splashes of blood and/or body fluids onto clothing or exposed skin. 3) Masks and protective eyewear should be worn during procedures that are likely to generate droplets of blood and/or body fluids into the mucous membranes of the mouth, nose, or eyes. 4) Needles and sharps should be placed directly into a puncture-resistant leakproof container which should be as close as possible to the point of use. Needles should not be recapped, bent, broken, or manipulated by hand. 5) Hands and skin surfaces should be washed after contact with blood and/or body fluids, after removing gloves, and between patient contact. 6) Gloves should be worn to cleanup blood spills. Blood spills should be wiped up and then an EPA registered tuberculocidal disinfectant applied to the area. The disinfectant should have a one minute contact time and the area rinsed with tap water. If glass is involved, wear double gloves or heavy gloves. Pick up the glass with broom and dust pan, tongs, or a mechanical device. 7) Healthcare workers with exudative lesions or weeping dermatitis should not perform direct patient care until the condition resolves. 8) Disposable resuscitation devices should be used in an emergency. 9) Occupational Exposures: Definition - Puncture wounds - Needlesticks/Cuts - Splashes into the eyes, mouth, or nose - Contamination of an open wound 10) Occupational Exposures: - Wash the area immediately with soap and water - If splashed in the eyes mouth or nose have them properly flooded or irrigated with water - Notify supervisor as soon as possible - Call Employee Health Center at (409) 772-5582 for information regarding blood and/or body fluid exposure management SAMPLE EVALUATION FORM COMPARATIVE DIVISION OF DUTIES Scrub Nurse/Technician A. Preoperative 1. Checks the card file for surgeon's special needs/requests. 2. Opens sterile supplies. 3. Scrubs, gowns, and gloves and sets up sterile field. Obtains instruments from flash autoclave if necessary. Checks for proper functioning of instruments/equipment. 4. Performs counts with circulator. B. Preincisional 1. Completes the final preparation of sterile field. 2. Assists surgeon with gowning/gloving. 3. Assists surgeon with draping and passes off suct C. During the Procedure 1. Maintains orderly sterile field. 2. Anticipates the surgeon's needs (supplies/ equipment). 3. Maintains internal count of sponges, needles and instruments. 4. Verifies tissue specimen with surgeon, and passes off to circulator. D. Closing Phase 1. Counts with circulator at proper intervals. 2. Organizes closing suture and dressings. 3. Begins clean-up of used instruments. 4. Applies sterile dressings. 5. Prepares for terminal cleaning of instruments and nondisposable supplies. 6. Reports to charge nurse for next assignment. Circulating Nurse A. Preoperative 1. Assists in assembling needed supplies. 2. Opens sterile supplies. 3. Assists scrub in gowning. 4. Performs and records counts. 5. Admits patient to surgical suite. B. Preincisional 1. Transports patient to procedure room. 2. Assists with the positioning of the patient. 3. Assists anesthesia during induction. 4. Performs skin prep. 5. Assists with drapes; connects suction and cautery. C. During the Procedure 1. Maintains orderly procedure room. 2. Anticipates needs of surgical team. 3. Maintains record of supplies added. 4. Receives specimen and labels it correctly. 5. Maintains charges and O.R. records. 6. Continually monitors aseptic technique and patients needs. D. Closing Phase 1. Counts with scrub at proper intervals. 2. Finalizes records and charges. 3. Begins clean-up of procedure room. 4. Applies tape. 5. Assists anesthesia in preparing patient for transfer to PACU. 6. Takes patient to PACU with anesthesia and reports significant information to PACU nurse. 7. Disposes of specimen and records. 8. Reports to charge nurse for next assignment. Medical Student A. Preoperative * Introduce self to nursing personnel. ** If "scrubbing in" on case, informs scrub person of glove and gown size. B. Preincisional * Assists with transfer of patient to OR bed. * Brings patient a warm blanket. * Performs patient catheterization if necessary. * Performs skin prep. ** If "scrubbing in" on case, begin scrub early. ** If "scrubbing in" on case, assists surgeon and/or scrub person with draping when appropriate. C. During the Procedure * Answers physician pagers. * Runs specimen to lab, when appropriate. D. Closing Phase * Assists with undraping of patient. * Assists in preparing patient for transfer to PACU: - Brings patient a warm blanket. - Brings patient bed/stretcher into room. - Assists with transfer of patient from OR bed to stretcher/bed. Hospital Negligence and the Law · Misdiagnosis, which can lead to inappropriate treatment, medications, and procedures · Surgical errors such as wrong site surgery, wrong patient, and wrong procedure · Mismanagement, including failure to act on available information in a timely manner · Emergency room errors · Inadequate or unqualified staff, which can lead to errors in judgment or incorrect use of medical equipment · Laboratory mistakes, including confusing patient test results or misinterpreting tests · Failure to properly maintain medical equipment, records, update records · Prescriptions errors · Hospital sanitation · Deviation from standards of care for doctors, nurses, and medical support staff |