Study Guide Questions Flashcards
What must occur in a room prior to the first case cart entering the room or the first case taking place?
- Damp dust all horizontal surfaces at beginning of day
- Surgical lights
- Booms
- Equipment
- Furniture
- Counters
- Computer/key boards
- Cleaning must be done before bringing case carts or supplies in room
ASA 2
A patient with mild systemic dz
ASA 3
Patient with severe systemic dz
ASA 4
A patient with severe systemic dz that is a constant threat to life
ASA 5
A moribund pt who is not expected to survive without the operation
ASA 6
A declared brain-dead pt whose organs are being removed for donor purposes
Fasting with clear liquids
2 hrs
Fasting with breast milk
Fasting with infant formula
Fasting with Nonhuman milk
6 hrs
Fasting with light meals
Cricoid pressure
- Located below thyroid cartilage
- Firm pressure with thumb/index finger to occlude esophagus
- Do not release until cuff for ET tube is inflated and position is confirmed
Phase 1 induction
- Anesthetic agents given to put patient to sleep
Phase II Maintenance
- anesthetics are continually through IV or inhalants to maintain anesthetized state
Phase III Emergence
- End of procedure, anesthetic agents d/c or reversed.
Tx of MH
- Stop Sx if possible and d/c inhalants (anesthesia) and succinylcholine. If Sx cannot be stopped then continue with non-triggering agents
- Grab MH cart and Dantrolene
- Call for help
- Hyperventilate with 100% O2 at 10L/min
- Give 2.5mg/kg Dantrolene rapidly by IV. Repeat as needed until pt responds. If > 10mg/kg given without response, consider another Dx.
- Obtain blood gasses
- If core temp > 39C or 102F cool pt
- Stop cooling measures once temp reaches 38C or 100F
- Tx dysrhythmias and electrolytes
- Call MHAUS hotline to consult
Why must cricoid pressure be applied?
- to occlude esophagus and move cricoid cartilage
When do you release cricoid pressure?
cricoid pressure should not be released until the cuff on the ET tube is inflated and the position is confirmed
What is the most specific sign of MH?
- Increase in end-tital CO2
Definition of Hypothermia
core body temperature of < 36C (96.8F)
Factors that contribute to hypothermia in the OR
- OR is cold
- Large areas of skin exposed to air
- Prep is wet and applied to skin
- Irrigation fluids are cooler than body temp
- Long surgeries
- General and regional anesthesia can dysregulate body’s thermoregulation mechanisms
- Vasodilation shifts blood from the body to cooler peripheral tissues
Role of RN when a pt is scheduled to receive local-only anesthesia during sx.
- continously monitored during procedure
- BP
- ECG
- O2
- HR
Role of RN in moderate sedation during Sx
- No other competing responsibilities
- competent in cardiac monitoring
- ability to administer reversal medications and provide advanced cardiac life support measures
Patient’s rights
- considerate/respectful care
- relevant, current, and understandable information concerning their dx, tx, and prognosis
- Self-determination concerning tx and refusal of tx
- Respect wishes written in AD
- Privacy
- Confidentiality
- Access to their medical records
- Health care in a facility and a transfer to another facility when indicated or requested
- Information regarding hospital business relationships
- Consent to or decline involvement in research studies
- Continuity of care when possible and to be informed when hospital care is no longer an option
- Be informed of hospital charges and available payment methods; including hospital P&P for dispute resolutions, grievances, ethical concerns/conflicts
Elements of SODH
- economic stability
- education
- social/community context
- access to health care
- neighborhood/built environment
What is the purpose of a preoperative interview?
Determine that we have the correct patient, correct sx. correct site, and that the patient understands what is being done, their NPO status, medical hx, sx hx , questions or concerns
Describe how a pt’s use or abuse of cannabis can affect them during sx?
- Cannabis can affect the tolerance to induction agents
- unknown tolerance of anesthesia agents
- hyperreactive airway
- bispectral index elevation (BIS) - Uses state-of-the-art technology to process EEG information to provide a direct measurement of the patient’s level of consciousness and insight into the effects of anesthesia on the brain.
- Increased myocardial infarction risk within 1 hr after use
How can Hx of ETOH abuse affect a patient during Sx?
- lowered immunity
- prolonged bleeding times
- increased stress response
- cardiac complications
Insufflation
The act of blowing gas into a body cavity for visual examination
What is the most common gas used for insufflation?
CO2
Potential complications of CO2 insufflation
- elevated BP
- elevated CO2 in blood
- acidosis
- decreased C/O
- decreased renal blood flow
- decreased U/O
- Cardiac arrythmias
- Gas embolism
- Peritoneal irritation
- Gas embolism
Clinical signs of gas embolism
- systemic hypotension
- dyspnea
- cyanosis
- cardiac anomalies
- tachycardia
- bradycardia
- arrhythmias
- asystole
- elevated pulmonary arterial pressure
- elevated central venous pressure
- hypoxemia
- end-tidal CO2 changes
Borescope
An inspection tool that is placed through an instrument’s lumen and is used to inspect the internal element of the instrument
No Fly Zone
- hybrid OR
- Designating a collision-free or “no-fly” zone in which personnel, monitors, and other ceiling-mounted equipment cannot be present while the C-arm is in motion limits opportunities for damage or injury.
- Restricted area reserved for imaging equipment
- Other necessary equipment is positioned outside of this area or moved to allow for imaging equipment use
Pneumoperitoneum
Presence of air or gas within the peritoneal cavity
Practices to reduce the risk for patient injuries and complications associated with gas insufflation are ______
- Placing the insufflator above the level of the surgical cavity
- Checking that the alarms are on and audible
- Ensuring that a hydrophobic filter is between the insufflator and the insufflation tubing
- Flushing the insufflator tubing with the gas that will be used for the surgery before the tubing is connected to the cannula
- Setting the flow rate according to the manufacturer’s instructions for use and surgeon’s preference
- Maintain the pneumoperitoneum at a pressure less that 15mm Hg
- Maintaining insufflation pressure at the lowest level necessary for the pneumoperitoneum and surgical site visualization
What pressure must the gas be sustained at to reduce injury rt gas insufflatio n
Maintain the pneumoperitoneum at a pressure less that 15mm Hg
Fiber Optic Cable safety
- Check that all cable connections are secure before turning on the light source
- Ensure that the sterile cable end does not contact the patient’s skin or any flammable material or liquids
- Ensure that the cable end does not rest on sterile drape
- Turn off the light source or place it on standby when the cable is disconnected from the endoscope
Gas cylinder safety
Irrigation and distension media - Low viscosity non-electrolyte fluids
- Is used for procedures performed using monopolar instruments
- Is used for gynecological and urological procedures
- Is hypotonic
- Can cause TUR syndrome if absorbed in large quantities
- Examples:
- 1.5% glycine
- 5% mannitol
- 3% sorbitol
Irrigation and distention media - NS
Is often selected for use with bipolar instruments
Is isotonic
Contains electrolytes
safer than nonelectrolyte fluids if large amounts are absorbed
Irrigation and distention media - High viscosity fluids
- Is a plasma volume expander provides good visibility when bleeding occurs
- Can draw six times its own volume into the bloodstream
- Can cause significant complications (eg, fluid overload, heart failures, pulmonary edema)
- Contains a high glucose content
- Example
-
Dextran
- Note: rinse surgical instruments with sterile water for irrigation after use
-
Dextran
SSI
an infection that develops at or near the surgical site within 30 days of the procedure or within a year when the prosthesis is implanted.
Reservoir
Reservoir: the environment in which an organism grows, lives, and multiplies (source of infection). Dirty surfaces and equipment, people, water, animals/insects
Vehicle
Vehicle: infectious organism leaves reservoir via portal of exit
Mode of Transmission
Mode of Transmission: organism transmitted to a susceptible host via contact, ingestion, and inhalation.
Chain of infection
Infectious agent → Reservoir → Portal of Exit → Mode of Transmission → Portal of entry → Susceptible Host
* vehicle is the pathogen’s transport to portal of entry. Mod of transmissionion describes the orgin of vehicle?
Disrupting the chain of infection - Infectious agents
Hand hygiene antimicrobial stewardship to reduce abx resistance. Dx and Tx
Disrupting the chain of infection - Reservoir
Infection prevention policies, cleaning , disinfection, sterilization, pest control.
Disrupting the chain of infection - Portal of exit
PPE, Hand hygiene, control of aerosols, respiratory etiquette, proper waste disposal
Disrupting the chain of infection - mode of transmission
Hand hygiene, PPE, cleaning, disinfection, sterilization, isolation, food safety
Disrupting the chain of infection - Portal of entry
Hand hygiene, first aid, PPE, personal hygiene, safe removal of catheters and tubes.
Disrupting the chain of infection - Susceptible host
Hand hygiene, immunization, treatment of underlying dz, patient education
IFU for cleaning products includes _____
microorganisms killed, contact time required, ingredients, cleaning instructions, removing gross materials, cleaning the surface with clean water and allowing time to air dry.
How is cleaning performed in the OR?
Clean from top to bottom
Clean from less-soiled areas to dirty areas
Why are standardized method of cleaning a room employed?
to avoid missing areas
Zone cleaning method
room is divided into zones/areas. One person focuses on their assigned area. The team cleans their respective zones until the whole room is clean.
Perimeter cleaning method
Contaminated items moved to center of room and perimeter is cleaned and disinfected. Contaminated equipment is then cleaned and moved to the perimeter. Center of the room is cleaned after contaminated equipment is cleaned and moved to the perimeter.
Divide in half cleaning method
Contaminated equipment moved to one side of the room. Empty side is cleaned and disinfected, and then the equipment is cleaned and moved to the clean side. Repeat with the second side.
Adjunct cleaning technologies
Room decontamination can be done via UV light or hydrogen peroxide in addition to manual cleaning. Technologies are approved by multiple departments.
Turnover cleaning
Terminal cleaning
Terminal cleaning occurs at end of each day, should be cleaned x1 q 24 hrs. Through cleaning performed by special trained EVS.
Universal cleaning conditions
Equipment, trash, contaminated laundry are removed after patient leaves the OR
Methodical cleaning process is followed to limit microorganism transmission.
Equipment is cleaned and disinfected before it enters OR or returned to storage
Clean and disinfect high touch objects and surfaces
Floor is always considered contaminated
Reusable mop heads and cleaning cloths are soaked in cleaning solution and then put in laundry.
How can RNs reduce the amount of wasted supplies in the OR?
Review preference cards at least yearly
Open only what is needed
Hold items that are labeled as “hold items” on the preference card
Ask the surgeon before opening
Create spreadsheet comparing costs and show to surgeons → make surgeon aware of cost
Describe the process of turnover cleaning
Hand hygiene
Don PPE → check type of precautions
Check supplies, cleaning cloths, bed linens, mop buckets
Remove large debris from floor
Remove trash and linen
Clean and disinfect all items used in patient care → remember transfer devices
Mop floor → move bed
Spot clean walls
Place used cloths in trash or linen
Remove PPE
Hand hygiene
Don appropriate PPE
Take trash and linen out
Describe the process of terminal cleaning
Similar to turn over cleaning except
- All exposed surfaces of items in OR are cleaned and disinfected including wheels and casters
- Entire floor is mopped or wet vacuumed, including under bed/equipment
What are the rooms/areas of SPD?
Areas of the sterile processing department (SPD) include the decontamination area, assembly area, sterilization of equipment area, and sterile storage areas.
What area of SPD is cleaned last?
When cleaning SPD the Deon room is cleaned last → most contaminated area of SPD
How often are the floors of SPD cleaned?
Clean the floors in all SPD areas every day the areas have been used.
Define scheduled cleaning and give examples of what items should have scheduled cleaning.
Scheduled cleaning is cleaning of equipment (eg, appliances, air-handling systems, closets, cupboards) that occurs on a periodic, routine basis (eg, daily, weekly, monthly).
Includes ice machines, fridge, sinks, vents (ducts/grilles), air filters
When is enhanced cleaning employed and why?
Enhanced cleaning when pts with MDROS or Spores occupy OR → these pathogens are hard to kill and need special measures.
ex.
C.diff → bleach
Aspergillus found in air systems thus systems need to be cleaned and filters replaced as well as air handling testing
If the patient has TB, measles, chicken pox, or COVID which measures should be employed and what PPE is used?
N95, PAPR,CPAR with aerosolizing procedures (Airborne transmission; TB, measles, chicken pox, COVID.
How does an N95 mask work?
N95 creates negative pressure inside mask dt inhalation → must be fitted or else negative pressure will draw pathogens into mask.
How does a PAPR/CAPR work?
PAPR/CAPR provide positive pressure, HEPA filter in blower filters germs and provides clean air.
Once a patient with airborne precautions leaves the OR what must occur?
After Pt leaves room it must remain unoccupied for designated amount of time → depends on how many air exchanges in OR
What are some sources of environmental contamination in the OR, and how must they be dealt with?
Construction
Flooding
Condensation on surfaces
Mold
Pests
Terminal cleaning must occur following correction of source of contamination
How must potential contamination from construction be dealt with?
Temporary barriers and access paths created to decrease contamination
All areas under construction are cleaned before barriers are removed and terminally cleaned before returning to service.
How can cleanliness of rooms be measured?
Rooms can be tested for cleanliness via visual inspection, fluorescent gel, markers, microbio tests, ATP testing
What is the difference between cleaning and disinfecting?
Cleaning: the removal of dust, debris, blood, and other infectious materials
Disinfecting: the removal of pathogenic and other microorganisms from surfaces by using chemical or physical means
What information should you communicate to the cleaning personnel when a patient is suspected or diagnosed with tuberculosis and the OR needs to be cleaned? When should this information be communicated?
Prior to EVS entering OR contaminated with TB the RN should alert EVS and communicate that the OR must be unoccupied for the recommended amount of time based on the number of air exchanges in the facility. RN may encourage use of airborne PPE (N95 etc.) when entering room after waiting for recommended amount of time.
Visual inspection
Room is checked for clean appearance. Used to assess cleaning routine and provide immediate feed back.
Fluorescent gel markers
A gel is applied before cleaning. Blacklight illumination applied following cleaning. Presence of fluorescent gel shows that cleaning was not done per protocol or cleaning was performed with dirty cloth
Microbiology tests
ATP found in saliva, blood, etc. ATP monitoring shows residual organic material following cleaning. Surface is swabbed and swab is inserted into luminometer. Test results available within seconds.
ATP testing
ATP measured in RLUs (relative light units) as numeric value. Numeric value correlates with amount of ATP swabbed from service.
What are the goals of documentation?
Support RN workflow
Data capture
Eliminate redundancy in data entry
Reflecting patient focused care
Contain infor for transitional care
Perioperative Nursing Data Set (PNDS)
Standardized nursing language focused on perioperative nursing and supports EBP practice → helps to standardize nursing care
PNDS is inclusive of nursing process workflow and represents each phase (preadmission, preop, intraop, postop)
Recognized by ANA and registered in National Library of Medicine
Benefits of Structured Vocabulary
Helps develop computer databases
Helps to shape policy
Quality indicators for research
Compare cost and performance
Downtime procedures
Process in place for alternate data entry during system downtime
Be prepared → paper forms for documentation, how will new orders be documented?, potential loss of data, how will downtime data be reincorporated into EHR?
When should verbal orders be used?
Verbal orders should be used only when required by clinical necessity
Orders should be _____
Enter/document as close to the time they were given as possible
Verify by reading back orders
Record the names and roles of all individuals involved in perioperative care
Avoid abbreviations → write out name or unit of measurement
Avoid trailing zeros → 2.0g should be 2g
Use standardized names
Preprinted and standing orders should be reviewed by physician according to facility policies/procedures
How can a nurse make corrections to a paper chart?
Single line through inaccurate info
Write “error,” “mistaken entry,” “omit” next to incorrect text
Provide rationale for correction above statement or in margin
Sign and date entry
Enter correct info next to inaccurate info
How can a nurse make a correction in an EHR?
Versioning or “track corrections” function; electronic strike through with time stamp
Automatic date, time, and author stamp feature
EHR should feature a symbol or notation to identify when an alteration has been made and a new version of document was created
Retain and link original to new version
Reflect corrections in EHR in paper chart
What acronym is used when documenting?
FACT
Factual
Accurate
Complete
Timely
U/O
An occurrence can be an actual event or near miss; RSI (retained surgical item), patient injury or med error
How to reduce risk of a lawsuit.
Maintain open, honest, respectful communication with others
Maintain patient confidentiality
Maintain competence in your practice
Attend nursing continuing professional development programs
Know your job description and scope
Know your strengths and weaknesses
Discuss assignments with preceptor or manager
Only accept duties that you can perform competently
Nurse practice act
provides legally binding rules and regulations that collectively describe the scope of nursing practice in that state or territory.
Causes of lawsuits
Failure to:
- Communicate
- Document
- Assess and monitor
- Follow standards of care
- Act as patient advocate use equipment in a reasonable manner
- Top 10 Safety Issues of Concern
- wrong site/procedure/patient
- RSI
- Med errors
- Instrument reprocessing failures
- Pressure Injuries
- Specimen management errors
- Surgical Fires
- Perioperative hypothermia
- Burns from energy devices
These rights are protected via informed consent for medical procedures
For procedure itself
Any research interventions
Patient’s wishes listed in advanced directive
If a nurse wanted to know when informed consent is required where would they look?
P&P
In addition to informed decision making a patient or a patient representative is entitled to ____
Requesting or refusing treatment
Items to Include in Informed Consent
- Facility name
- Name of intervention
- Indication for intervention
- Name of health care professional performing intervention
- Risks and benefits of intervention
- Discussion of risks vs. benefits with pt or pt representative
- Patient or Pt rep. Signature along with date and time
- Signature of witness along with date and time
Am I Responsible for Obtaining Informed Consent?
No. The surgeon or anesthesiologist is
You may be asked to witness the patient’s or patient rep’s signature on informed consent
Review informed consent forms during preoperative interview
What should be taken into account with visitors in the OR?
HIPAA
ORs should have policies to limit product reps or other visitors in the OR → policies must have revisions for pt consent
How can an RN protect an anesthetized patient’s privacy?
Protect patient from unnecessary exposure
Comments about pt appearance, lifestyle, or social status are never appropriate unless necessary to provide safe care.
What are the phases of care and what do they entail?
- Preoperative → decision for Sx is made
- Informed consent obtained
- See documentation elements for specific documentation guidelines
- Handover → ends when patient is transferred to OR bed
- See documentation elements for specific documentation guidelines
- Intraoperative → Starts when pt on OR bed and end at PACU
- See documentation elements for specific documentation guidelines
- Handover
- Postoperative → return home or be admitted to hospital
What patient information shared between the preoperative and intraoperative nurses during the hand off?
Patient identifiers
Planned procedure
Operative side/site
NPO status
Allergies
Diagnostic test results
Current medications
Blood products available
Patient mobility issues
Family contact information
What patient information shared between the intraoperative and postoperative nurses during the hand off?
Current condition on airway, breathing, and circulation
Type of anesthesia administered
Procedure performed
Any surgical issues/complications and corrective actions taken
Skin condition
Pressure injury risk
Hypothermia status
Estimated blood loss
Input and output
Presence and location of drains, wound packing
Complications of surgical bleeding
Surgeon’s view is obstructed → longer Sx times
Blood replacement therapy and associated risks →multiple organ failure, SIRS, TRALI, increased risk for infection and mortality
Hypothermia and associated coagulopathies → as temp nears 34C (93.2F) platelets do not stick to each other as well
Altering pharmacodynamics of anesthesia
Hypothermia and acidosis reduces thrombin generation due to altered function of enzymes. Low O2 levels and Cl- in fluids contribute to acidosis
Aggressive fluid resuscitation can cause hemodilution decreasing O2 carrying capacity and diluted coagulation factors/ platelets
Progressive coagulopathy leads to further hemorrhage and shock
Thrombocytopenia can occur to massive blood loss
Hypovolemic shock may occur → reduces cardiac output and affects pulmonary gas exchange
What are the 7 goals of hemostasis?
- Decrease and control bleeding
- Minimize the need for blood replacement
- Optimize the surgical field view
- Avoid major organ damage
- Shorten the length of surgery and length of facility stay
- Decrease the risk of infection
- Decrease health care costs for patients and facilities
How can EBL be determined?
Inspect surgical drapes, suction canisters, sponges
Weigh surgical sponges
Monitor lab values
Circulator and scrub can help by:
Communicating amount of irrigation solution used during Sx for accurate I&O
Place used sponges in visible location
Traditional Methods to Achieve Surgical Hemostasis
Hold pressure
Electrosurgery or energy generating devices
Suturing and ligating
Trad methods are usually mechanical, chemical (pharmaceutical), or Thermal (energy)
Mechanical methods of achieving hemostasis
Direct pressure → applied with surgical sponges
Sutures, staples, clips → Pressure or ligation will stop bleeding
Dressings → Placed once Sx is complete
Ligating Clips
Small V-shaped devices placed around lumen of vessel
Countable item
Thermal based energy sources
- used to promote hemostasis
- ignition source
- include:
- Lasers
- Monopolar Electrosurgery device
- Ultrasonic Devices
- Bipolar electrosurgery devices
- Vessel sealing devices
Chemical methods of achieving hemostasis
Epinephrine → A hormone that causes direct vasoconstriction and increases HR
Vitamin K → administered preop to reverse warfarin
Protamine → Heparin reversal agent
Vasopressors → (Desmopressin) Administered preop to patients with hemophilia A
Topical hemostatic agents and surgical sealants
Used when Trad methods fail or are impractical
Requires physician’s order
Not medications and not intended for IV use
Adjunct methods to obtain hemostasis
Topicals can be divided into 4 categories:
- Mechanicals (Passive hemostatic agents) → collagen, cellulose, gelatin, polysaccharides
- Actives → Thrombin products
- Flowables → Thrombin + Gelatin
- Fibrin Sealants → Thrombin + Fibrinogen
Tissue sealants
Aka Adhesives (glues tissue together):
- Cyanoacrylates
- Synthetic Skin sealants
- Tissue sealants
- Glutaraldehydes
- PEG polymers
What are some considerations that must be taken with tissue sealants?
Some patients may have allergies to sealants
Cultural beliefs may limit use of some products
Some products may be limited in use of some pt populations
Topical products may have requirements for transport, storage, handling, and disposal
Product may only be good for specific amount of time
What questions should a nurse ask a patient in preop regarding hemostasis?
Allergies to hemostatic agents, bovine, porcine products
Active prescriptions
Is patient taking anticoagulants, antiplatelets, aspirin, NSAIDS?
Taking vitamin E, bilberry, ginkgo biloba, garlic, ginseng, fish oil, grape seed extract, dandelion root, saw palmetto, and quinine → increased bleeding time
Results of coag profile
Hx bleeding gums, easy bruising, excessive superficial bleeding, severe nosebleeds
Anemia?
Hx of renal/hepatic dz
Proposed Sx procedure
Blood products ordered?
Has pt expressed cultural, ethical, or religious beliefs against blood or blood product use?
What is the principal enzyme for hemostasis?
⭐ Thrombin is the principal enzyme for hemostasis ⭐
Surgical Sponges
Only sponges with radiopaque indicator should be used during Sx
Different sponges have different uses during Sx, (ex. Packing, removing blood from field)
All sponges must be accounted for before procedure, during procedure, and before closing wound
What are the types of surgical sponges?
Laps
X-ray detectable 4x4
Surgical peanuts
Cottonoids
Tonsil sponges
What are the circulator’s responsibilities in preventing RSIs?
Room survey → check for open countable items from previous Sx before next case
“Reset” count boards and sheets prior to new case
Initiate count
View items while counted
Record count items in a visible area
Record instrument counts on preprinted count sheets
If item is passed or dropped from sterile field put on gloves, show it to scrub, isolate it from field, and include it in final count.
Ask team members if any items will be needed before closing count
Separate and point out items off of sterile field while audibly counting
Participate in count reconciliation
Report discrepancies
Document counts
What is the scrub’s responsibilities in preventing RSIs?
Maintain sterile field according to P&P
Maintain awareness of the location of each countable item on sterile field and in the Pt.
Know function configuration of all medic devices used during procedure
Verify integrity and completeness of items returned from surgical site
Consult with surgeon whether supplies will be needed before closing count
Count audibly and point out items on sterile field (SF) so circulator can see
Speak up when discrepancy occurs
Participate in count reconciliation
What are anesthesia’s responsibilities concerning RSIs?
Plan anesthetic milestones (induction and emergence) to allow for proper counting
Tell team when bite blocks, throat packs, and other devices inserted in oropharynx, nose, or nasopharynx
Verify removal of above listed items and communicate to team when removed
When should the first count be performed?
before the patient enters the room
Standardized sequence of counting countable items
- Sponges on or in the patient
- Mayo stand
- Back table
- Kick bucket
- Pocketed sponge bag
What happens if the count is interrupted?
If count is interrupted, restart count for item type that was being counted
In what way should items be counted?
During the initial count and when adding items to the SF, count packaged items according to the number in which the item is packaged
Verify the package contains # of items on label
What should be done if packages contain an incorrect # of items or the items are defective?
Exclude them from the count
Remove them from the field
Isolate them from the rest of the countable items in OR
How should a count be recorded?
Immediately after each type of item is counted
On a standardized template
In a location that is visible to the surgical team
In agreement with the scrub person
How should items be added to the field after the initial count?
Count items immediately
Record item and number added on the count board in a standardized format as defined by the health care organization
Verify # with scrub
Break/relief counts
account for items in use and perform structured handover communication of accounting procedures
Permanent relief counts
Perform complete count when there is permanent relief of the RN circulator or scrub person
Account for all items → even those not seen
When should counts not be performed?
Do not perform counts or actions requiring counts (breaks) during critical moments (time outs, critical dissections, confirming and opening implants, induction and emergence, care and handling of specimens)
When can counted items be removed from room?
Do not remove counted items from room until counts complete and reconciled
Do not remove linen and waste containers from the room until all counts are completed and reconciled and pt has been transported from room
When is final count considered complete?
Do not consider final count complete before all items removed from patient and returned to scrub
What types of sponges should be used for vaginal antisepsis?
use radiopaque and count them
Inspect vagina for radiopaques following vaginal procedures
Can radiopaques be used as dressings?
Do not use Radiopaques for dressings unless it is left in wound intentionally
Can towels be used in surgical wounds?
Do not use regular towels in surgical wound
When should non-radiopaque sponges be added to field?
Hold non-radiopaque sponges from field until surgical incision is closed and final count complete
When a radiopaque sponge is left as packing in a wound how should it be placed in wound?
Leave portion of radiopaque outside of wound to visualize if possible
What happens if surgical sponges fall on the ground?
Place sponges in kick bucket or pocketed holder, show scrub sponges that fall before placing in holder
What should be done if radiopaques are used as packing?
Document # and type if possible
Compare items removed to items that were charted as packing in prior case
Isolate removed sponges and do not include in counts for procedure
Surgeon should thoroughly explore wound and order X-ray
Remove packing before final closure
When should sutures be counted?
Count all sutures regardless of size or procedure
In item is returned to scrub broken what should they do?
Account for sharps and misc. Items used in the surgical wound in their entirety immediately after removal
Notify perioperative team if broken or separated item is returned from surgical site
Immediately attempt to locate and retrieve item
Remove free clips from abd cavity when possible
Precaution regarding prep sticks used in vagina
Account for preparation sticks used in vaginal antisepsis
Keeping track of instruments and device fragments
Count all instruments for open cases (eg, thorax, abd)
Count instruments when sets are assembled for sterilization
Do not consider the final count complete until instruments used to close wound are removed and returned to scrub
Account for individual pieces of instruments
Inspect instruments for all removable parts, breakage, fragmentation immediately on instrument’s removal
Keep all counted instruments in room until all counts complete
Standardize instrument sets
When there is a count discrepancy what is the role of the RN?
Inform team → team should acknowledge type and # missing
Call for assistance
Search room
Recount with scrub
When there is a count discrepancy what is the role of the scrub?
Organize SF
Search SF including drapes and tables
Recount with circ.
When there is a count discrepancy what is the role of the surgeon and first assist?
Suspend closure of wound if possible
Perform a methodical wound exam
Participate in attaining intraop x-rays
Remain in room until item is found or determined not to be in pt
What happens if count discrepancy is not resolved?
No breaks or relief until count is resolved
Do not use empty packages to resolve count discrepancies
When missing item is found recount item type
If missing item is not recovered request x-ray, if unstable then obtain imaging ASAP once stable
Document unresolved counts
Description and location of item if known
All measures taken to recover
Patient notification and consultation
Plan for f/u care
*Inform EVS and next team in room of discrepancy *
Documenting counts
Types of counts items counted
Number of counts
Names and titles of personnel performing counts
Results of counts (eg correct, incorrect)
Verification of removal and integrity of items
Surgeon notification of count results
Explanation for waived counts
Number and location of any instruments/items intentionally remaining with patient as packing
Actions taken for discrepancies
Rationale if counts were not performed or completed as prescribed by P&P
Outcomes of actions taken
RSI are considered _____
Never events
How are chest tube wounds dressed in a patient?
Sutured in place and dressed with gauze 4x4 split dressing and 4x4s
Connections secured with plastic zip ties at end of procedure
What should be documented concerning drains?
Type
Size
Serial #
Location
Description and amount of drainage
Functionality → was it working when pt left OR?
Primary dressing
applied directly over wound; usually nonadherent
Secondary dressing
cover primary dressing (eg 4x4 gauze sponges, abd pads, perineal pads)
How are dressings secured?
Dressings may be secured with soft gauze rolls, elastic bandages, and tape
Iodoform packing
- Sterile single-use wound dressing consisting of a single cotton gauze strip impregnated with formulated Iodoform solution that are packaged in HDPE amber-colored jars. They are primarily used for sterile drainage of open and/or infected wounds.
- Iodoform is the organoiodine compound with the chemical formula CHI₃. A pale yellow, crystalline, volatile substance, it has a penetrating and distinctive odor and, analogous to chloroform, sweetish taste. It is occasionally used as a disinfectant.
Why might splints be chosen over a cast?
Flexible and allows for swelling post op → cast may be applied after swelling subsides
How should dressings be documented?
Type of dressing material and device used to secure it (eg tape, elastic bandage, wrap)
Ointments/meds
Location of dressing or packing
Immobilization devices
Elevation of limb, if applicable and equipment used (eg pillows)
CMS (circulation, motion, and sensation) checks of affected extremity
Functionality of a devices part of dressing
How should specimens be documented?
Specimen name, body location, tissue type, and side of body
Correct spelling of anatomical parts
Requested pathology exam
Date and time specimen collection
Electronic health records may include several of the necessary components that the RN circulator fills out with the specific details
How should specimens be treated on the SF?
- Handle the specimen as little as possible
- Keep the specimen moist
- Cover the specimen or place it into a container
- Label the covered or contained specimen
- Protect the specimen in a secure location on the back table or other sterile field location
Transferring specimens off of SF
