INTRODUCTION

Nature and Scope

 Deals with the principles and techniques of nursing
care management of clients across lifespan undergoing
surgery.
 Covers the scope of nursing practice and
responsibilities on preoperative, intraoperative and
postoperative phases.
 Learn the principles and application of sterile
techniques.
 Utilizing nursing processes and evidenced-based
practices on the provision of perioperative care.
Objectives
 Appreciate the history of perioperative education and
the art and science of surgery.
 Describe perioperative nursing and the three phases of
the surgical experience.
 Utilize the nursing process in providing care for clients
during the three phases of perioperative nursing.
 Perform perioperative nursing practice and sterile
techniques through the proper application of
theoretically-acquired learning.
 Understand the importance pain and pain
management.
I. Fundamentals of Theory and
Practice
 Historical Background
 Egyptian papyri chronicle the progress of medical-
surgical practice up to 1600 B.C.
 Other influences of surgery came from the Babylonian
under the law “Code of Hammurabi” (1955-1913 B.C.)
 Persians had to perform 3 successful procedure before
they are pronounced as competent to perform surgery.
 19th century authors describe the process of Operating
Room education as an element for the success of surgical
team.
 Art and Science of Surgery
 Surgery – branch of Medicine that comprises
perioperative patient care; an invasive medical
procedure performed to diagnose or treat
illness, injury, or deformity.
 1930’s English physician Lord Berkeley George
Moynihan (1865-1936) said “Surgery has been
made safe for the patient; We must now make
the patient safe for surgery”
 More individuals are now considered better
candidates for surgery; however, each patient
and each procedure are unique.
 Collaborative care and independent nursing
care together prevent complications and
promote the surgical client’s optimal recovery.
Perioperative Learner and Educator
 Perioperative Learner
 Learner may be enrolled in a formal educational
program.
 Nursing schools offer basic exposure to perioperative
nursing care and procedures and after graduation they
may need further education before functioning as a
perioperative professional
 Learning styles vary among individuals and are
influenced by internal and external factors.
Understanding the differences is the first step to
imparting knowledge and skills.
 Learning Style Influences
 Intelligence
 Cultural and ethnic background
 Educational Preparation
 Motivation to learn
 Concentration and distractibility
 Personality characteristics
 Psychologic strength and deficiencies
 Social skills and communication skills
 Manual dexterity
 Physical health and physical senses
 Perceptual preferences and sensory partiality
 Environment
 Learning skills identified by Howard Gardner at
Harvard University
 Visual-spatial
 Bodily kinesthetic
 Musical
 Interpersonal
 Intrapersonal
 Linguistic
 Logical-mathematical
 Perioperative Educator
 Experience in the clinical setting should be planned and
supervised. Responsible person is the perioperative
educator.
 Should consider the effect on the learner since exposure
to clinical setting for the first time is overwhelming.
 Positive reinforcement helps learner while punishment,
degradation and damage to self-esteem are barriers to
learning.
 Expected Behaviors of Perioperative Caregivers
 Personal attributes
 Empathy, Conscientiousness, Efficiency, Sensitivity, Open-
mindedness, Supportive, Communicative, Listens,
Versatile, Even-tempered, Analytic, Creative, Sense of
humour, Manual dexterity, Stamina, Hygiene, Ethics,
Curiosity
 Communications
 Teamwork
 Clinical Competence
II. Foundations of Perioperative
Patient Care Standards
 Glimpse of History
 Practitioner of healing arts have been both revered and
feared. They have been depicted as magicians, holy men
and deities, while some were accused of witchcraft or
demonic influence.
 Greek physician Hippocrates (460-377 BC) “Father of
Medicine” instituted training for men who would
administer the treatments and therapies prescribed by
the physician.
 He wrote the “Golden Cabinet of Secrets” a collection of
herbal remedies.
 Traveling health care started in the 9th and 10th centuries
by military and religious groups.
 In 1050, a hospital for the ill was dedicated in Jerusalem
by the Knight Hospitallers of Saint John. Intended to be
a religious order, they learned military skills to protect
civilians on pilgrimage to the Holy Land.
 Churches ceased control of hospitals during the
reformation of the 18th century, from then on, the
standard of care declined as free care associated with
religious personnel was replaced by low-paid,
uneducated workers.
 Early 19th century, patient care gave rise to the clear
separation of medicine and nursing. Nursing profession
was validated by Florence Nightingale (1820-1910) .
 Credited in developing the Environmental Theory of
patient care. According to her, caregivers are
accountable in creating and maintaining the best
possible environmental conditions to assist in the
healing process.
 Both perioperative and scrub technologist work toward a
common goal – provide safest possible care so that
patients achieve favorable surgical outcomes.
 PATIENT RIGHTS
 As a consumer, patient purchases services to fulfill
health care needs and is entitled to certain rights. Access
to health care is recognized as a right and not a privilege.
 1. Establish rapport with the patient, family or significant
others in a manner that conveys genuine concern and sincere
caring
 2. Encourage patient and family to express feelings and ask
questions
 3. Help relieve anxiety and apprehension by providing factual
information
 4. Helps patients make informed decisions throughout the
perioperative experience
 5. Acts as a patient representative by communicating
pertinent information to other members
 6. Oversees all activities throughout the perioperative
experience to ensure safety and welfare
 7. Keeps the family informed of significant events throughout
the perioperative experience
 8. Protects the patients’ rights by compliance with advance
directives for care (living will, durable power of attorney, or
both)
 Importance of Standardization
 Perioperative personnel should be able to cope with all
situations and to give patients the best of their skills.
Each hospital establishes policies and procedures for all
personnel to follow based on standards, recommended
practices and guidelines.
 These written policies foster coordination of all activities
and prevents confusion between and among the surgical
team members.
 Uniformity and standardization of procedures help
personnel develop skill and efficiency for the following
reasons:
 Ensure safety and welfare of patient
 Easier to teach learners consistent methods of care
 Learning is easier if everyone performs in the same way
 Evaluation of the procedure and revision if needed
 Uniform procedure provide efficient check during preparation
of any procedure
 One person can take over in the absence of another
 Routine procedures establish habits that increase speed
 Standards allow intelligent decision making on modification
of a routine
 Sources of Standardization
 Each facility uses several sources from which to derive
standardization data with efficient use of time and
resources as the end result.
 Establishing protocols and performance expectations
that are specific to the needs of the facility benefits the
patient, the caregiver, and the facility
 Facility-specific patient care standards
 Hospital policy and procedure manual
 Safety plan manual
 Material safety data sheets (MSDS)
 Disaster plan manual
 Infection control manual
 Perioperative policy and procedure manual
 Orientation manual
 Instrument book
 Surgeon’s preference card
 Directories
III. Legal and Ethical Issues
 INTRODUCTION
 Competent patient care is the best way to avoid a
malpractice or negligence claim. Unfortunately, even
under the best circumstances a patient may be injured
and recover monetary damages as compensation.
 Understanding how a liability action starts and how it
proceeds is important in the effort to avoid the many
pitfalls that can lead to being named and successfully
sued in a lawsuit.
 LEGAL ISSUES
 Any caregiver can be named in a lawsuit. Regardless of
who is in charge of the team, each team member is
responsible for his or her own actions.
 Honest mistakes can result in patient injury. If a suit is
brought to court, a jury can evaluate a reasonable set of
circumstances, facts, and testimony to render a verdict
in favor of the caregiver.
 LEGAL ISSUES
 Along with the development of consumerism, a well-
informed public has developed an increasingly litigious
attitude, demanding compensation for bodily injuries or
damages.
 Causes for litigation lie in patients’ and their families
belief that physicians and/or health organizations have
not provided appropriate diagnosis, treatment, or
results.
 LIABILITY
 Legally binding and responsible for personal actions
that adversely affect another person. Care should be in
accordance with the standard and practice guidelines.
Deviation from these standards and practices that
causes injury or damage to patient can result in liability
for negligence or malpractice.
 Negligence is the failure to use the care or skills that any
caregiver in the same or a similar situation would be
expected to use. These acts of omission or commission
that cause damage to patient may give rise to tort action,
which is a civil lawsuit.
 Malpractice is any professional misconduct,
unreasonable lack of skill or judgment, or illegal or
immoral conduct.
 Factors contributing to a successful lawsuit on behalf of
the plaintiff have been called the Four D’s of
Malpractice:
 Duty to deliver a standard of care directly proportional to
the degree of specialty training received
 Deviation from that duty by omission or commission
 Direct causation of a personal injury or damage because of
deviation of duty
 Damages to a patient or personal property caused by the
deviation from the standard of care
 LIABILITY PREVENTION (FACILITY & TEAM)
 Complex technologies, acuity of hospitalized patients’
conditions, short-stay procedures, diverse roles of providers,
inadequacy of staffing numbers, and other factors present
challenges in managing risks of liability.
 Many surgeons restrict their practices to avoid patients who
have complex diseases or who are at high risk of uncertain
outcomes.
 As lawyers have become increasingly sophisticated in
representing injured patients, all health care providers need to
take measures to protect themselves from litigation
 PREVENTIVE STRATEGIES
 Remain current with continuing education
(certification and credentials).
 Establish positive rapport with patients.
 Active participation within the professional
organizations associated with setting the standards for
practice.
 Document assessments, interventions, and evaluation
and patient care outcomes.
 PREVENTIVE STRATEGIES
 MAintain good communications with other team
members.
 Legal statutes and standard compliance of accrediting
agencies, professional associations, and the health
care facility policies.
 If injury occurs, control further injury or damage by
reporting problems and take corrective actions.
 Prevent injuries by adhering to policies and
procedures.
 LIABILITY INSURANCE

 BORROWED SERVANT RULE

 INDEPENDENT CONTRACTOR

 DOCTRINE OF REASONABLE MAN

 DOCTRINE OF “RES IPSA LOQUITOR”

 DOCTRINE OF RESPONDEAT SUPERIOR

 DOCTRINE OF CORPORATE NEGLIGENCE

 EXTENSION DOCTRINE
 ASSAULT AND BATTERY

 INVASION OF PRIVACY

 ABANDONMENT
 CONSENT
 GENERAL CONSENT
 Facilities require the patient or legal guardian to sign a general
consent form upon admission.
 Authorizes physician and staff to perform standard day-to-day
treatment or routine care.
 INFORMED CONSENT
 A process and not merely a document.
 Patients are informed of the risks, benefits, and alternatives of
a procedure and to obtain a consent before any procedure.
 Informed Consent for a Surgical Procedure
 A reasonable approach to consent should involve
answering the following questions:
 What do you plan to do with me?
 Why do you want to do this procedure?
 Are there any alternatives?
 What things should I worry about?
 What are the greatest risks or the worst thing that could
happen?
 Responsibility for Informed Consent before a Surgical
Procedure
 The surgeon is responsible in securing consent
 The patient or guardian may be required to sign the
consent in the presence of a witness.
 When checking the patient’s identity and chart on
arrival in the OR, it is the duty of the circulator and
anesthesia provider to be certain of the following:
 Appropriate consents are on the chart and properly completed
and signed
 The information on the form is correct
 DOCUMENTATION
 Verbal communication between patients and health care
providers does not constitute legal documentation of
care.
 The broad assumption is that “if something is not
documented, it was done” the record serves as a
communication among providers for continuity of care.
 Policies and procedures should be in place for
documentation.
 Each patient and care facility is responsible for the
following:
 Establishing, evaluating and enforcing policies and
procedures for patient care documentation.
 Interpreting and outlining standards for care documentation.
 Protecting the privacy of patients by preventing unauthorized
access and use of documented patient care data and reports.
 Creating forms and charting formats for personnel to use in
hard copy documentation.
 Selecting protocol for computerized archives of records.
 Timely mechanism for retrieval of archived patient care
records and reports for reference in timely manner.
 All interactions with patients should be documented
regardless of the format or media used for the patient
record. All entries should be:
 Documented on the appropriate forms
 Written legibly in ink without erasures
 Stated factually. Observations and actions should be stated
definitively, objectively, and concisely.
 Stated in understandable terminology.
 Dated and timed.
 Signed with full legal signature, title, and status of the writer,
either in permanent ink or electronically.
  Corrected if an error is made. Single line should be drawn
through the incorrect entry with date, time and initials of the
person making the correction should be noted next to the
correction.
 Additional documentation
 Execution of the physicians order
 Any teaching of the patient or family including their
understanding
 Any unusual event
 All visitors especially physicians
 Any notification of physicians or supervisors
 SURGICAL CONSCIENCE
 Key elements of perioperative nursing practice are:
 CARING, CONSCIENCE, DISCIPLINE AND TECHNIQUE
 The concept of a surgical conscience: Do unto the
patient as you would have others do unto you
 Florence Nightingale summarized what is, in essence, its
meaning when she said, “The nurse should keep a
high sense of duty in her own mind, must aim at
perfection in her care, and must be consistent
always in herself”
 A surgical conscience involves self-inspection coupled
with moral obligation. Involving both scientific and
intellectual honesty, it is self regulation in practice
according to a deep personal commitment to the highest
values.
 Correct practice of asepsis provides a foundation for
development of a mature conscience – mastery of
personal integrity and discipline. Development of this
conscience incorporates knowledge of aseptic principles,
perpetual attention to details, and experience.
Classification of Surgical Procedure
 Purpose
 Diagnostic – determine or confirm diagnosis
 Exploratory – confirms the type and extent of disease
 Ablative – remove diseased tissue, organ, or extremity
 Constructive – build tissue/organs that are absent
 Reconstructive – rebuild tissue/organ that has been
damaged
 Palliative – alleviate symptoms of a disease
 Transplant – replace organ or tissue to restore function
Classification of Surgical Procedure
 Risk Factor
 Major – extensive physical assault and/or serious risks
 Minor – minimal physical assault with minimal risks
 Urgency
 Emergency – must performed immediately
 Urgent – necessary to be performed within 1 -2 days
 Elective – suggested, no foreseen ill effects if postponed
Optional – decision rests with the patient or the
preference of the patient
Common Surgical Terms
 Surgical Prefixes
 angio- : related to blood vessel
 arthr- : related to a joint
 bi- : two
 colono- : related to large intestine colon
 colpo- : related to the vagina
 cysto- : related to the bladder
 encephal- : related to the brain
 gastr- : related to stomach
 hepat- : related to the liver
 hyster- : related to the uterus
Common Surgical Terms
 lamino- : related to the lamina (posterior aspect of
vertebra)
 lapar- : related to the abdominal cavity
 lobo- : related to a lobe (of the brain or lungs)
 mammo- and masto-: related to the breast
 myo- : related to muscle tissue
 nephro- : related to the kidney
 oophor- : related to the ovary
 orchid- : related to the testicle
 rhino- : related to the nose
 thoraco- : related to the chest
 vas- : related to a duct, usually the vas deferens
Common Surgical Terms
 Surgical Suffixes
 -centesis : surgical puncture
 -clasia : crushing or breaking up
 -desis : fusion of two parts into one, stabilization
 -ectomy : surgical removal.
 -opsy : looking at
 -oscopy : viewing of, normally with a scope
 -ostomy or -stomy : surgically creating a hole (a new
"mouth" or "stoma")
Common Surgical Terms
 -otomy or -tomy : surgical incision
 -pexy : to fix or secure
 -plasty : to modify or reshape (sometimes entails
replacement with a prosthesis)
 -rrhaphy : to strengthen, usually with suture
SURGICAL RISK FACTORS
 Advanced age
 Age affects physiologic, cognitive and psychosocial
responses to stress of surgery. Decrease tolerance of
general anesthesia and post operative medications, and
decrease wound healing.
 Obesity
 Increased risk of wound healing, wound dehiscence,
infection, pneumonia, atelectasis, thrombophlebitis,
arrhythmias and heart failure
 Malnutrition
 Reserves may not be sufficient to allow the body to
respond satisfactorily to the physical assault of surgery.
Increased metabolic demands may result in poor wound
healing and infection.
 Dehydration/Electrolyte Imbalance
 Depending on the imbalance, dysrhythmia or heart
failure may occur. Renal and liver failure may also result.
 Cardiovascular disorders
 Presence of CV diseases increases risk for hemorrhage
and shock, hypotension, thrombophlebitis, pulmonary
embolism, stroke, and fluid volume overload.
 Respiratory disorders
 Bronchitis, atelectasis and pneumonia are the most
common post operative complications. Clients with
pulmonary disease are at more risk for developing these
complications.
 Diabetes mellitus
 Increased risk of fluctuating blood glucose levels which can
lead to life-threatening hypoglycemia or ketoacidosis.
Increased risk for cardiovascular disease, delayed wound
healing, and infection.
 Renal and liver dysfunction
 May poorly tolerate , may have electrolyte imbalances,
decreased metabolism and excretion of drugs.
 Alcoholism
 More anesthesia may be required. Poor wound healing and
hemorrhage can occur because of damaged liver and poor
nutritional status.
Perioperative Nursing
 Perioperative nursing is a specialized areas
of practice. It incorporates three phases of
the surgical experience
 Preoperative phase
 Intraoperative phase
 Postoperative phase
 Preoperative Phase
 Begins when the decision is made to proceed with surgical
intervention and ends with the transfer of patient to the
Operating Room.
 Establish baseline evaluation of the patient before surgery
 Ensure necessary tests have been or will be performed
 Educate on what to expect after surgery and exercises that will
benefit the patient post-operatively
 Day of surgery: Verify patient’s identity, surgical procedure
and site, confirm informed consent, diagnostics, pre-
medications and IV infusion
 Intraoperative Phase
 Begins when the client is transferred to the OR bed,
administration of anesthesia, surgical procedure is
performed and ends with the admittance to PACU
 Activities include: provide safety of client, ensure proper
functioning of equipment, maintain aseptic
environment, assists surgeon in providing instruments
and supplies, proper documentation
 Postoperative Phase
 Begins when the client in admitted to PACU and ends
with transfer to surgical unit/discharge from hospital
 Alleviate pain and discomfort, ensure safe recovery from
anesthesia
 Prevent post operative complications
 Ensure adequate discharge plan and teaching
Operating Room Decorum
 Applicable to the entire surgical team. Its
purpose is to centralize, organize and deliver
patient care during surgical intervention.
Every member must know their
responsibilities and understand the
consequences of their actions.
PERIOPERATIVE TEAM
 NONSTERILE TEAM MEMBERS
 Anaesthesiologist and Nurse Anaesthetist
 Circulating Nurse
 STERILE TEAM MEMBERS
 Surgeon
 First Assist
 Scrub Nurse
SPONGE, SHARP, and INSTRUMENT
COUNT
 CLASSIFICATION OF INSTRUMENTS
 CUTTING AND DISSECTING
 SCALPELS – the type of scalpel most commonly used has a
reusable handle with a disposable blade. Handles are made of
brass; blades may be made of carbon steel.
 No. 10 most often used. Rounded cutting edge along one side
and fits on Nos. 3, 7, and 9 handles. Nos. 20, 21, and 22 are of
the same shape but are larger and fits No. 4 handles.
 No. 11 has straight edge with sharp point. Fits Nos. 3,7,9
handles
 No. 12 blade is shaped like a hook with a cutting edge on the
inside curvature. Fits Nos. 3,7,9 handles
  No. 15 blade has a smaller and shorter curved cutting edge than a No.
10 blade and fits Nos. 3,7,9 handle.
 No 15C blade has the same shape but is smaller for tiny incisions
(pediatric procedures).
 No. 23 has curved cutting edge that comes to more of a point than
Nos. 20, 21, 22 blades. Fits a No. 4 handle
 SCISSORS
 Maybe straight, angled, or curved, as well as either pointed or blunt
at the tips.
 Tissue/Dissecting Scissors
 Suture scissors
 Wire scissors
 Dressing/Bandage Scissors
  Bone Cutters or Debulking Tools
 Osteotomes and Rasps
 Other Sharp Dissectors
 Biopsy forceps
 Curettes
 Snares
 Blunt dissectors
 GRASPING AND HOLDING
 Tissue Forceps
 Smooth forceps / Thumb forceps / Pickups
  Toothed forceps / Rat toothed forceps
 Allis forceps
 Babcock forceps
 Stone forceps
 Tenaculums
 Bone holders
 CLAMPING AND OCCLUDING
 Hemostatic forceps
 Hemostat
 Crushing clamps
 Noncrushing vascular clamps
 EXPOSING AND RETRACTING
 Handheld Retractors
 Malleable retractors
 Hooks
 Self-Retaining Retractors
 SUTURING AND STAPLING
 Needle holders
 Staplers
 VIEWING
 Speculums
  Endoscopes
 SUCTIONING AND ASPIRATING
 Suction
 Poole Abdominal Tip
 Frazier Tip
 Yankauer Tip
 Aspiration
 Trocar
 Cannula
 DILATING AND PROBING
 MEASURING
 ACCESSORY INSTRUMENTS
 MICROINSTRUMENTATION
HANDLING INSTRUMENTS
 SETTING UP THE INSTRUMENT TABLE
 Handle loose instruments separately prevent
interlocking
 Never piled up and laid side by side
 Microsurgical instruments are delicate
 Metal to metal contact is avoided or minimized
 Inspect instruments for alignment, imperfections,
cleanliness and working condition
 Scalpel should be properly set on handles
 Teeth and serrations should be aligned
 Scissors should be snug and sharp in action
  Cannulas should be clear and without obstruction
 Sort instruments neatly by classifications
 Keep ring-handled instruments together with the
curvatures and angles pointed in the same direction
 Hang ring handles over a rolled towel or over the edge of the
instrument tray
 Remove instrument stringers or holders if used to keep box
locks open during procedures
 Close box locks on the first ratchet
 Leave retractors and other heavy instruments in a tray or
container, or lay them out on a flat surface or table.
 Protect sharp blades, edges, and tips. They should not
touch anything. Take care not to perforate the sterile
table cover.
 Sets of instruments may be in sterilization racks so that the
blades and tips are suspended and can remain in the rack
during the initial table setup and until they are needed.
 Tip-protecting covers or instrument-protecting plastic sleeves
should be removed and discarded before the instrument is
used since they are not radiopaque.
 If they are not in a rack, handles should be supported on a
rolled towel or gauze sponge.
 HANDLING INSTRUMENTS DURING SURGERY
 Know the name and appropriate use of each instrument
 Handle instruments individually
 If several instruments are needed, three or four may be picked
up at one time, but they are passed individually.
 Instruments with sharp edge and fine tips are more to
damage. Prevent catching the tips on any object that could
bend them.
 Hand surgeon or assistant the correct instruments for
each particular tasks. “Use for intended purpose”
 Avoid placing fingers in the rings as the instrument is passed.
 Surgeons use hand signals to indicate the type of instrument
needed.
 Select instruments appropriate to the location of the surgical
site. Experience will facilitate instrument selection according
to the surgeons’ preference and need.
 Many instruments are used in pair or in sequence.
 Hand instruments around the incisional area, not directly
over it, to prevent possible injury.
 A knowledge of anatomy is useful for determining which
instrument in needed.
 Pass instruments decisively and firmly. When the
surgeon extends his/her hand, the instrument should be
slapped or placed firmly into his/her palm in the proper
position for use.
 If the surgeon is in the opposite side of the OR bed, pass
instruments in a right-to-right or left-to-left hand technique.
 If on the same side of the bed to your right, pass with the left
hand. And if on the left, pass with your right.
 Hemostatic forceps are held near the box lock by the scrub
person and passed by rotating the wrist clockwise.
 Sharps and delicate instruments are placed on flat surface for
the surgeon to pick up to avoid potential contact.
 Watch the sterile field for loose instruments
 With moist sponge, wipe blood and organic debris from
instruments
 Demineralized, sterile distilled water should be used
 Blood and debris that are allowed to dry on surfaces, in the
box locks, and in crevices increase the bioburden that could
be carried into the surgical site.
 A nonfibrous sponge should be used to wipe off micro-
surgical, ophthalmic, and other delicate tips.
 Flush suction tip and tubing with sterile distilled water
periodically to keep the lumens patent
 Remove debris from electrosurgical tips to ensure
electrical contact.
 Place used instruments that will not be needed again in
a tray or basin during or at the end of a surgical
procedure
 Blood and debris are removed prior to actual cleaning
 Instruments that have been wiped can be immersed in a basin
with demineralized distilled water
 Heavy instruments are placed on a different tray
 Keep instruments accessible for final counts
INFECTION PREVENTION
 ASEPTIC TECHNIQUE
 Methods by which contamination with microorganisms
is prevented
 STERILE TECHNIQUE
 Methods by which contamination with microorganisms
is prevented to maintain sterility throughout the
surgical procedure.
 SOURCE OF CONTAMINATION AND INFECTION
 People remain the major source of contamination in the
environment followed by contaminated instruments.
 Transmission Based Precautions should be
implemented in the in the perioperative environment.
 AIRBORNE
 DROPLET
 CONTACT
 HUMAN-BORNE SOURCES OF CONTAMINATION
 SKIN
 HAIR
 NASOPHARYNX
 HUMAN ERROR
 CROSS-INFECTION
 NONHUMAN FACTORS
 FOMITES
 AIR
 SOURCES OF INFECTION
 Community-Acquired Infection
 Communicable Infection
 Spontaneous Infection
 Nosocomial Infection
 Exogenous
 Endogenous
Standard Precautions
 Formerly referred to as Universal Precaution – protects
health workers from contact with blood and body
fluids. SP include considerations for the following:
 All body fluids
 Handwashing
 Barrier clothing
 Handling of equipment and linen
 Occupational exposure to bloodborne pathogens
 Patient placement
 1. Protective barriers and PPE
 Prevent contact of the skin and mucous membrane with
blood and body fluids. PPE include Gloves, Mask,
Eyewear, Gowns/Aprons, and Shoe Cover.
 2. Prevention of puncture injuries
 Needles, knife blades, and sharp instruments present a
potential hazard for the handler and user
 Do not manipulate sharp by hand
 Do not recap or remove needles by hand
 Place all sharps in puncture resistant container
 3. Management of Puncture Injuries
 4. Care of specimens
 5. Decontamination
 6. Waste
 7. Handwashing
 8. Prophylaxis
Principles of Sterile Technique
 1. Only sterile items are used within the
sterile field.
 2. Sterile persons are gowned and gloved.
 3. Tables are sterile only at table level.
 4. Sterile persons touch only sterile items or
areas. Unsterile persons touch only unsterile
items or areas.
 5. Unsterile persons avoid sterile areas.
Principles of Sterile Technique
 6. Unsterile persons avoid reaching over
sterile fields. Sterile persons avoid leaning
over unsterile areas.
 7. Edges of anything that encloses sterile
content are considered unsterile.
 8. Sterile field is created as close as possible
to the time of use.
 9. Sterile areas are continuously kept in
view.
Principles of Sterile Technique
 10. Sterile persons keep well within sterile
areas.
 11. Sterile persons keep contact with sterile
areas to a minimum.
 12. Microorganisms must be kept to
irreducible minimum.
 13. Destruction of integrity of microbial
barriers results in contamination.
Application of Sterile Technique
 Sterile technique prevents the transfer of
microorganisms into body tissues during invasive
procedure. Intact skin and mucous membrane is the
body’s first line of defense against infection, but a
portal for microorganisms is created once it is
interrupted.
 LEVELS OF STERILITY AND DISINFECTION
 Critical
 Semicritical
 Noncritical
Operating Room Attire
 Provides effective barriers that prevent the
dissemination of microorganisms to patients and
protect personnel from blood and body substances of
the patients, and prevent contamination of the
surgical wound and sterile field by direct contact.
Surgical Scrub
 Process of removing as many organisms as possible
from the hands and arms by mechanical washing and
chemical antisepsis before participating in a surgical
procedure. Done just before gowning and gloving for
each procedure.
 Microbiology of the skin
 Transient organisms acquired by direct contact. Loosely
attached to the skin surface.
 Resident microorganisms below the skin surface in hair
and follicles and in sebaceous and sweat glands.
 Scrubbing removes/cleanses as many microorganisms
as possible through:
 Mechanical – the process removes soil and transient
organisms with friction
 Chemical – the process reduces resident florae and
inactivates microorganisms with antimicrobial or
antiseptic agent.
 Purpose of scrubbing is to remove or deactivate soil,
debris, natural skin oils, hand lotions, and transient
microorganisms from the hands and forearms
 Antimicrobial Skin-cleansing Agents should have the
following desirable characteristics of anti-microbial
agents:
 Broad-spectrum
 Fast-acting and effective
 Nonirritating
 Prolonged action
Skin Preparation & Draping
 SKIN PREPARATION
 Purpose of which is to render the surgical site free of as
possible from transient and resident microorganisms,
dirt, and skin oil so that the incision site can be made
through the skin with minimal danger of infection from
this source.
 PRELIMINARY SKIN PREP
 Hair removal is carried out per surgeon’s order, either on
the preoperative unit or in the OR as close to the
scheduled time of the procedure as possible.
 ANTISEPTIC SOLUTION – should have the following
qualities:
 Broad spectrum antimicrobial action and rapidly
decreases microbial count.
 Can be quickly applied and remains effective
 Can be safely used without skin irritation or
sensitization. Should be nontoxic
 Effectively remains active in alcohol, organic matter,
soap, or detergent.
 Nonflammable for use with laser or high energy devices.
 CHLORHEXIDINE GLUCONATE
 Discovered in 1950 in England. A solution of 2-4% is
used as antiseptic skin cleansing soap preoperatively. A
tincture of 0.5% in 70% isopropyl alcohol (Hibitane) is
sometimes used.
 Broad spectrum and rapid acting antimicrobial agent
binds to negative charges in microbial cell walls to
produce irreversible damage and death.
 Irritant to the eyes and ototoxic , it is contraindicated
for facial antisepsis.
 IODINE AND IODOPHORS
 Discovered in 1812, first used in wound care in 1839. a
solution of 1-2% iodine in water or 70% isopropyl
alcohol is an excellent antiseptic.
 Broad spectrum antimicrobial agents that have some
virucidal and sporicidal activity. Relatively nontoxic and
nonirritating to the skin or mucous membrane.
 Not to be used to prep skin of patients who are sensitive
to iodine or seafood.
 The concentration of iodine may be altered by
evaporation of the solution is warmed.
 ALCOHOL
 Isopropyl and Ethyl alcohols are broad spectrum agents
that denature protein in cells.
 70% concentration with continuous contact for several
minutes is satisfactory for skin antisepsis if the surgeon
prefers colorless solution that permits observation of
true skin color.
 Coagulates protein, should not be applied to mucous
membrane or used on an open wound.
 Volatile and flammable. Not to be used with ESU or
lasers.
 TRICLOSAN
 1% solution of Triclosan is a broad spectrum
antimicrobial agent. It is incorporated in many OTC
products used by consumers, such as deodorants and
bath soaps.
 Cumulative suppressive action develops slowly only with
prolonged routine use. Considered nontoxic and safe for
use around eyes and on the face.
 PARACHLOROMETAXYLENOL (PCMX)
 Developed in 1948 in Europe as a hair conditioner. It has
bactericidal properties useful for skin antisepsis.
 It is effective against some fungi, tuberculosis, and
viruses.
 Has residual properties with repeated use and is
nontoxic to the skin, eyes and ears.
 SKIN PREPARATION FOR SPECIFIC ANATOMIC
AREAS
 HEAD AND NECK
 EYE
 Eyebrows are never shaved unless deemed necessary
 Eyelashes may be trimmed if ordered by the surgeon
 Eyelids and periorbital areas are cleansed with a nonirritating
antiseptic agent and rinsed with warm sterile water. Start
centrally and extend to periphery
 The conjunctival sac is flushed with a nontoxic agent, such as
sterile normal saline, with a bulb syringe. Care must be taken
to prevent prep solution from entering the eyes or ears.
 EARS, FACE, OR NOSE
 Usually not easy to define the area with towels. As much as the
surrounding area is included, as is feasible and consistent with
aseptic technique. Skin surfaces should be cleansed at least to
the hairline
 Cotton applicators are used for cleansing the nostrils and
external ear canals
 Protect the eye with a piece of sterile plastic sheeting. If the
patient is awake, ask that the eyes be kept closed during prep.
Cotton balls should be placed in the ears to prevent run-off.
 CHEST AND TRUNK
 LATERAL THORACOABDOMINAL AREA
 Gown is removed, blanket is turned down well below the
lower limit of the area to be prepped. A towel is folded under
the edge of a blanket
 Arm is held up during prep
 Beginning at the site of incision, the area may include the
axilla, chest, and abdomen from the neck to the iliac crest.
 For a surgical procedure in the region of the kidney, it extends
up to the axilla and down to the pubis. The area also extends
beyond midlines, anteriorly and posteriorly, and may include
the arm to the elbow.
 CHEST AND BREAST
 Anesthesia provider turns the patient’s face toward the
unaffected side.
 One towel is folded under the blanket edge, just
 DRAPING
 Procedure of covering the patient and surrounding areas
with a sterile barrier to create and maintain an adequate
sterile field. An effective barrier eliminates or minimizes
passage of microorganisms between nonsterile and
sterile areas. Criteria to be met in establishing an
effective barrier are that the material must be:
 Blood and fluid resistant to keep drapes dry and prevent
migration of microorganisms. Must be impermeable to moist
microbial penetration, resistant to tearing, puncture or
abrasion.
 Lint-free to reduce airborne contaminants and shedding.
 Antistatic to eliminate the risk of a spark from static
electricity.
 Sufficiently porous to eliminate heat build-up so as to
maintain an isothermic environment.
 Drapable to fit around contours of the patient, furniture, and
equipment.
 Dull, nonglaring to minimize color distortion from refelcted
light.
 Free of toxic ingredients, such as laundry residue, and nonfast
dyes
 Flame-resistant to self-extinguish on removal from ignition
source.
 PRINCIPLES OF DRAPING
 Place drapes on dry area. The circulator removes damp
items or covers the area to provide a dry field fro drapes.
 Allow sufficient time to permit to permit careful
application.
 Allow sufficient space to observe sterile technique.
 Handle drapes as little as possible.
 Never reach across the OR bed to drape the opposite
side.
 Take towel and clips, if used, to the side of the operating
bed from which the surgeon is going to apply them.
 Carry folded drapes to the OR bed. Stand well back from
the nonsterile OR bed.
 Hold drapes high enough not to touch the nonsterile areas
 Hold drape until it is directly over the proper area, and lay it
down where it is to remain. Once placed, do not adjust it. Be
careful not to slide the sheet out of place when opening.
 In unfolding the sheet from the prepped area toward the
foot or head, protect gloved by hand by enclosing it in a
turned-back cuff of sheet provided for this purpose.
Keep hands at table level.
 If a drape becomes contaminated, do not handle it
further. Discard it without contaminating gloves.
 If sheet falls below waist level, discard it.
 If in doubt of its sterility, consider it contaminated.
 If incorrectly placed, discard it without contaminating other
drapes or the prepped area.
 If a hole is found in a drape after I has been laid down,
cover the hole with another piece of draping or the
entire drape is discarded.
 A hair found on drape must be removed and the area
must be covered immediately.