basic patient needs

8/2/2019 Basic Patient Needs

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THE PERIOPERATIVE PATIENT

1. Basic Patient Needs

Following Maslows Hierarchy of Needs, the basic needs should be

met first before satisfaction of the higher level of needs can be

met. But priorities may be changed according to the situation:

Preoperatively: anxiety and nutrition status are addressed

Intraoperatively: the team concentrates on the patients

physiologic needs for oxygen, circulation, and the prevention of

shock and infection.

Postoperatively: Team members must prevent complications and

encourage patients self actualization.

2. Patient Reaction to Illness and Surgery

All patients have some type of emotional reaction

before any surgical procedure, be it obvious or hidden, normal or

abnormal. For example, preoperative anxiety may be an

anticipatory response to an experience the patient views as a

threat to his or her customary role in life, body integrity, or lifeitself. Psychological distress directly influences body functioning.

Therefore, it is imperative to identify any anxiety the patient is

experiencing.

Undoubtedly, a patient about to undergo surgery is

faced with various fears, including fears of the unknown, of death,

of anesthesia, pain, or cancer. Concerns about loss of work time,

loss of job, increased responsibilities or burden on family

members, and the threat of permanent incapacity further

contribute to the emotional strain created by the prospect of

surgery. Less obvious concerns may occur because of previous

experiences with the health care system and the people patient

has known with the same condition.

Patient express fear in different ways. For example,

one patient may repeatedly ask a lot of questions even thoughanswers were given previously. Another person may withdraw,

deliberately avoiding communication, perhaps by reading or

watching television. Still, other may talk about trivialities.

Consequently, the nurse must be empathetic, listen well, and

provide information that helps alleviate concerns.

3. Family and Significant Others

During surgery, the significant others usually wait in a

designated lounge. If they must leave the facility for any reason

ask them for a phone number where they can be reached. Provide

the phone number of the clients unit.

When discussing surgery with significant others, be

aware of information previously given by the surgeon regardingthe immediate surgical outcome and eventual prognosis. You can

then answer questions confident the information you give agrees

with previous statements.

Prepare significant others for nasogastric tubes, chest

tubes, suction equipment, respiratory equipment, intravenous

infusions, dressings, or monitoring equipment the client may

require. Inform the significant others when the procedure is

completed. Make certain surgeon knows who is waiting for

information on the client.

Reassure significant others that the length of time the

client is gone may not reflect the actual length of surgery. There

are often unpredictable delays that might cause the client to wait

before surgery. Reassure the family if this has happened to the

client so they will not worry.

4. Patients with Special Needs

4.4 Patients with Diabetes Mellitus

Diabetes Mellitus is an endocrine disorder that affects

glucose metabolism and the production of insulin in the beta cells

o f the pancreas.

3 types:

1. Type 1. Insulin Dependent Diabetes Mellitus (IDDM)-the pancreas produces little or no insulin thus regular

administration of insulin injection is required.

2. Type 2. Non Insulin Dependent Diabetes Mellitus(NIDDM) pancreas produces varying amounts of

insulin. Onset may be at any age but usually 40 y.o. at

obese persons. Blood glucose levels are controlled by

diet and the administration of antihyperlipidemics.3. Type 3. Diabetes Mellitus associated with other

conditions or syndromes Impaired glucose tolerance

may be secondary to pancreatic or hormonal dse, drug

or chemical toxicity, abnormal insulin receptors, or

other genetic syndromes.

Special Considerations:

1. Scheduling Elective Surgical ProcedureAssessment of DM patients can minimize the potential risks:

a. Capillary Blood obtained by fingerstick for fasting serumglucose

b. Preop Insulin dose may be reduced or eliminated preventhypoglycemia and insulin shock.

c. Continuous IV Access in case of metabolic problem.i. Patients who are insulin dependent are determined bu

the severity of the disease, preop control regimen and type

of surgical procedures, insulin infusion or administered

depending on the serum glucose levels.

ii. Adequate hydration; electrolytes to maintainmetabolic status

iii. Monitor fluid intake and output to maintain hydrationwithout fluid overload.

d. Monitoring of blood glucose levels during long surgicalprocedures for hyperglycemia and hypoglycemia and

fractional urine specimens for ketones.

e. Nasogastric suctionf. Anti-embolic stockings are worn during the surgical

procedure or pre-op to prevent thrombophlebitis and

thromboembolism.

g. Guarded skin integrity to prevent sepsisi. Strict aseptic and sterile technique

ii. Foam padding and gel mattress in bony prominencesfor procedure will take 2 or more hrs to prevent pressure

sores

iii. Hyposensitive tape to affix dressings.


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4.5 Obese Patients

2 origins:

1. Endocrine Origin. Usually associated with biliary,hepatic and endocrine disorder

2. Non Endocrine Origin. Associated with excessivecaloric intake

Physiologic Dysfunctions:

Special Considerations:

GOAL: Safety precautions against injury, falls and burns.

1. Transporting and lifting the patienta. Stretchers or Operating Beds

- In moving the ppatient from the stretcher topoperating bed, wheels should be locked.

- Safety belts should be long enough to providesecure limitation of unwanted mobility.

2. Keeping exposure to minimum3. Induction, intubation and maintenance of anesthesia

-

Venous cutdown if peripheral veins are hard toaccess

- Mobility of the cervical spine to hyperextend theneck for intubation may be limited.

- Inefficient respiratory muscles, poor lung or chestwall compliance. intraabdominal muscles in the

supine position.

- Inefficient ventilation4. Positioning in the operating bed5. Increased operating time because of mechanics of the

surgical procedure.

4.6 Patient with Chronic Cardiopulmonary Illness

The goal in preparing patient for surgery is to ensure a

well- functioning cardiovascular system to meet the oxygen, fluid,

and nutritional needs of the preoperative period. If the patienthas uncontrolled hypertension, surgery may be postponed until

the blood pressure is under control.

Because cardiovascular disease increases the risk for

complications, patients with these conditions require greater-

than-usual diligence during all phases of nursing management and

care. Depending on the severity of the symptoms, surgery may be

deferred until medical treatment can be instituted to improve the

patients condition. At times, surgical treatment can be modified

to meet the cardiac tolerance of the patient. For example, in a

patient with obstruction of the descending colon and coronary

artery disease, a temporary simple colostomy may be performed

rather than a more extensive colon resection that would require a

prolonged period of anesthesia.

4.7 Pregnant Surgical Patients

Non-obstetric disease requiring surgery may

complicate pregnancy and jeopardize maternal and fetal well-

being. Surgery may be safely done if the physician is aware of

anatomic and physiologic alterations during gestation that

necessitate an altered approach to diagnosis and management.

Fetal exposure to all diagnostic and therapeutic agents should be

minimized, particularly during organogenesis. However, the risk to

the fetus of diagnostic irradiation is justifiable when information

essential to maternal health is likely to be obtained. Furthermore,

the broad range of available antibiotic, analgesic, and anesthetic

agents provide the physician with options for treatment that have

an acceptable degree of risk to fetal health. Anesthesia and

surgery are tolerated considerably better by the fetus than is

maternal hypotension, hypoxia, or sepsis. When an operative

procedure is urgently or emergently indicated, pregnancy should

not delay timely intervention.

4.8 Immuno-compromised Patients

Immuno-compromised clients are those highly

susceptible to infection, are often infected by their own

microorganisms, by microorganisms on the inadequately cleansed

hands of health care personnel, and by non-sterile items (food,

water, air and client-care equipment). Clients who are severely

compromised include those who

Have diseases, such as leukemia, that depress theclients resistance to infectious organisms.

Have extensive skin impairments, such as severedermatitis or major burns, which cannot be

effectively covered with dressings.

4.9 Patients with Severe Traumatic Disabilities

Perioperative management of the head-injured patient

focuses on aggressive stabilization of the patient and avoidance of

systemic and intracranial insults that cause secondary neuronal

injury. Secondary brain injury complicates the course of the

majority of head-injured patients, adversely influencing outcome.

The need to improve care of these patients in the field and ED has

been recognized with the development of guidelines,

improvement of emergency response services, and better training

of providers. The goals of emergency therapy in the field and ED

are to prevent and treat all secondary insults and, ultimately, to

improve outcome in patients with TBI.

THE SURGICAL ENVIRONMENT

1. Special Procedure Rooms

Operating room management is the science of how to

run an Operating Room Suite. Operational operating room

management focuses on maximizing

operational efficiency at the facility, i.e. to maximize the

number of surgical cases that can be done on a given day

while minimizing the required resources and related costs.

The act of coordinating and running all parts of a

surgical suite to accomplish a defined set of goals. An

emerging field, operating room management is increasingly

studied as how to best:

1) Ensure patient safety and optimal patient outcome

2) Provide surgeons with appropriate access to the OR

so that patients can have operations in a timely

manner

3) Maximize the efficiency ofoperating room

utilization, staff, and materials

4) Decrease patient delays, and
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5) Enhance satisfaction among patients, staff, and

physicians.

This management science as applied to the surgical

suite is gaining more attention because of increasing market

pressures on hospitals from competitors (e.g., other surgical

suites including office based surgery) and from payers seeking

lower prices. The surgical suite is often considered a profitable

hospital unit. As such, surgical suites also comprise an importantfraction of hospital budget spending. Holding patient

safety constant, the opportunity to increase financial gain through

modifying the use of already existing resources is a prime target

for managerial analysis. Incremental improvements in operating

room utilization and operating room efficiency can have major

impacts on hospital staff and finances. Some hospital

administrators perceive efficiency in the operating room as

throughput, completing the most surgical cases within budget.

2. Potential Sources of Injury to the Caregiver and the

Patient

3.1 Physical Hazards and Safeguards

The equipment in areas used for aseptic surgery should

be easy to clean and portable to simplify sanitization of the area.

The operating table should be constructed with a durable surface

material impervious to moisture which can be readily cleaned.

Plastic or stainless steel is frequently used for this purpose. Other

useful table design features which assist patient positioning

include height and tilt adjustments, V-trough configuration and

restraint strap cleats. A disadvantage of stainless steel

construction is that it predisposes animals to hypothermia. This

can be corrected by the routine use of a heating pad placed under

the surgical patient. Reusable, easy to clean vinyl heating pads

which recirculate hot water are frequently used for this purpose.

Inexpensive short-term alternatives include hot water bottles or

heat lamps. Any heat source should be used with caution to

prevent patient burns.

Instrument tables provide the surgeon ready access to

the surgical instruments and minimize the risk of sterilized

instrument contamination by contact with non-sterile fields.

Commercially available instrument tables, such as Mayo stands,

consist of a stainless steel tray supported by a pedestal base with

a foot-operated height adjustment device, but any tray

arrangement may be used for this purpose. The unit should be

easy to clean and simple to operate. The drapes in an instrument

pack frequently include impervious table covers which can

minimize instrument contamination and allow the surgeon to

reposition the table without breaking aseptic technique during

the procedure. Surgical buckets on wheels (kick buckets), which

can be readily positioned with the feet, are another

recommended piece of equipment. They should be easy to clean

and lined with a plastic bag which should be changed at the end

of the procedure.

Adequate lighting is essential for performing surgical

procedures. A variety of fixtures can be used to provide sufficient

light. The commercially available surgical light fixtures may be

ceiling or wall-mounted or free standing. Surgical lights are often

positioned above the operative area and should be regularly

wiped with a moist towel prior to use to minimize potential

contamination of the sterile field below.

3.2 Chemical Hazards and Safeguards

Exposure to various anesthetic drugs, medication or

sterilizing fluids can cause poisoning and is considered a chemical

hazard. Skin irritation or dermatosis, or irritation of the eyes,

nose, and throat can result from a latex allergy, frequent use of

soap or disinfecting liquid, or airborne aerosols. Wear proper

protective equipment to minimize exposure, utilize eye wash

fountains if needed, follow appropriate infection control, makesure your work area is well ventilated and avoid latex in case of

allergies.

3.3 Biologic Hazards and Safeguards

Infectious Waste. A waste that is capable of causing

infectious dses. It contains pathogens with enough virulence

and quantity that exposure to them could result in an

infectious dse in a susceptible host.

Factors that should be considered in deciding if something is

infectious include the following:

- The presence of pathogenic organisms insufficient numbers to be capable of causinginfection in living beings. Many microorganisms

are incapable of causing infection.

- The presence of a portal of entry into asusceptible host. A cut, needle, stick puncture

wound, or skin lesion provides portal of entry but

not living beings are susceptible hosts to

infectious dses.

Infectious waste is places in leask proof containers or bags strong

enough to maintain integrity during transport, and these bags

should be closed and either labeled or color coded.

Biohazards. OSHA defines occupational Infections as reasonably

anticipated skin, eye, mucous membrane, or parenteral contact

with blood, or other potentially infectious materials during the

course of duty. This contact includes blood, tissues, and organs,and all body fluids.

- Handwashing is a must after every patient orglove removal

- Careful Handling and adequate protection frompotentially contaminated equipment.

- Every health care facility must develop a writtenexposure control plan that includes procedures

for evaluating an incident and for determining

when exposure has occurred.

BloodBorne Disease. A penetrating injury or a splash with fluid

contaminated with body fluids.

Surgical Plume. Plume (Surgical Smoke) is generated by the

thermal destruction of tissue, or bone.

3.4 Risk Management

1. Administrationa. Regulations, recommendations, guidelines,

and laws should be enforced to prevent

disastrous consequences of occupational

hazards.

b. Policies and procedures should be written,reviewed periodically, and updated as
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the bathroom in the middle of an operation, inform the

surgeons of the situation and step out (preferably not during a

crucial part of the surgery). Be sure to scrub back in!

Prior to handwashing a mask should be worn. It should

be tied secure ensuring that it covers both the nose and

mouth. It is important that the mask is neither too loose nor

too tight and comfortable to wear, as it will be worn

throughout the procedure. A sterile gown pack should then belaid out ensuring not to touch the gown as it is sterile. A pair of

sterile gloves of the correct size should also be laid out. When

opening the packet it is essential not to touch and contaminate

the gloves.

The next step is handwashing. A comfortable water

temperature should be selected with correct flow and avoiding

splashing. One antiseptic solution should be used throughout

the procedure. There are several antibacterial skin cleansers.

The most commonly used are Providone - Iodine 2% and

Chlorhexidine Gluconate 1.5 %. If sensitivities occur these

should be reported to the senior nurse and to Occupational

Health.

The procedure for handwashing should be practicedreligiously. Hands and nails should be socially clean at the

beginning of the procedure. Hands should be kept above elbow

level so that water washes form the fingertips down to the

elbow throughout the procedure. Open the brush packet and

use the nail pick to clean under the nails. The pick should be

discarded after use. The hands and forearms are then wet and

the sponge side of the brush is used to wash from fingertips to

just above the elbow for 30 seconds per arm. The brush is used

to clean the fingernails for 30 seconds each hand. The brush

should be detached from the sponge and discarded. With the

remaining solution on the sponge the hands and arms should

be rinsed ensuring to wash form the fingertips to mid forearm

for a total of 2 minutes for each hand. Scrub between the

fingers and scrub the palms with the nails.

To finish off the hands and arms should be rinsed. Thetaps should be turned off using the elbows and allow the arms

to drip dry for a short time. Ensure that hands are kept higher

than the elbows.

The first scrub of the day should last for 5 minutes and

all subsequent scrubs should last for 3 minutes.

Once the hands are washed, use the towel provided

with the gown pack to dry the hands and forearm. Hold the

hands above the elbows and dry from the fingertips down.

When the hands are dry discard the towel. Holding the gown

from the inside open it up ensuring the gown does not make

contact with anything. Place the hands through the sleeves of

the gown but do not push the fingers through the cuffs. Using

the cuffs pick up one glove ensuring not to touch the glove with

the skin and put it on. Pull the cuff of the glove over the cuff of

the gown. Repeat the same procedure for the other hand.

Finally, ask a colleague to assist you in fastening the

gown at the back. Keep hands up at all times and do not touch

anything that is not sterile.

If you start to feel ill or faint during an operation,

immediately inform the surgeons and then step away from the

table. Do not try to hold out, since it would be a disaster if

you fainted and fell into the sterile field.

REMEMBER:

The use of gloves does not replace hand washing

Stay a safe distance away from obstacles to preventcontamination of the gown

In general, just remember: if you are sterile, do not touch

anything that's not sterile and vice versa.

Sterile areas are marked by green or blue colored drapes.

These generally include the operative field (i.e. the patient),

the scrub table (where are the instruments are kept), and the

front and sleeves of your gown.

The back of your gown and anything below the waist is

considered not sterile or contaminated. Your mask, protective

eyewear, and hat are also non-sterile.

Always wash your hands after removing your gloves.

Change your gloves between clean and dirty procedures -

even on the same patient

All disposable garbs must be removed and disposed of

into the designated garbage basket after leaving the operating

room. Non-disposable surgical gowns and scrubs must be put

into the laundry basket, usually next to the entrance.

1.3 Gowning and gloving

The purpose of gowning and gloving is to protect the health

care workers and clients from transmission of potentially

infective materials.

TECHNIQUES

Preparation

1. Check for:Which activities will be required while you are in the clients room

to determine which personal protective equipment is

required.

Arranging for the care of your other clients, if necessary.

If special handing is indicated for removal of any specimens or

other materials from the room.

Which supplies are present within the clients room and which

must be brought with you.

2. Assemble equipment and supplies:Gown; Mask; Eyewear; Clean gloves; Proper Disposable Container

Donning Procedure

3. Remove or secure all loose items, such as nametags orjewellery.

4. Perform hand hygiene.5. Apply cap to head, being sure to tuck hair under the

cap.

6. Don Facemask. Locate the top edge of the mask. The


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mask usually has a narrow metal strip along the edge.

7. Hold the mask by the top two strings or loops. Placethe upper edge of the mask over the bridge of the

nose, and tie the upper ties at the back of the head or

secure the loops around the ears. Secure the lower

edge of the mask under the chin, and tie the lower ties

at the nape of the neck.

8. Don protective eyewear9. Pick up a clean gown, and allow it to unfold in front of

you without allowing it to touch any area soiled with

body substances.

10. Slide the arms and the hands through the sleeves.11. Fasten the ties at the neck to keep the gown in place.

Have a co-worker hold or tie the waist tie of your

gown.

12. Put the hands inside the shoulders of the gown, andwork the arms partway into the sleeves without

touching the outside of the gown.

13. Open the sterile glove inside the sterile wrapper whilethe hands are still covered by the sleeves.

14. With the dominant hand, pick up the opposite glovewith the thumb and index finger, handling it through

the sleeve.

15. Lay the glove on the opposite gown cuff, thumb sidedown, with the glove opening pointed toward the

fingers. Position the dominant hand palm upward

inside the sleeve.

16. Use the nondominant hand to grasp the cuff of theglove through the gown cuff, and firmly anchor it. With

the dominant hand working through its sleeve, grasp

the upper side of the gloves cuff, and stretch it over

the cuff of the gown.

17. Place the fingers of the gloved hand under the cuff ofthe remaining glove. Extend the fingers into the glove

as you pull the glove up over the cuff.

Removing Procedure

18. Remove the first glove by grasping it on its palmarsurface just below the cuff, taking care to touch only

glove to glove. Pull the first glove completely off byinverting or rolling the glove inside out.

19. Continue to hold the inverted removed glove by thefingers of the remaining gloved hand. Place the first

two fingers of the hand inside the cuff of the second

glove while the hands are covered under the sleeves.

20. Pull the second glove off to the fingers by turning itinside out. This pulls the first glove inside the second

glove. Continue to remove the gloves, which are now

inside-out, and dispose of them in the refuse

container.

21. Have a co-worker hold or tie the waist tie of yourgown, remove the gown, making sure not touching the

contained part. Fold and roll gown down in front into a

ball, so contaminated area is rolled into the center of

gown.

22. Remove the mask, Untie the top strings, and whileholding the ties securely, remove the mask from the

face orIf side loops are present, lift the side loops up

and away from the ears and face. Discard disposable

mask in the waste container.

23. Remove Cap and Eyewear, Discard disposable cap inthe waste container.

24. Don Handwashing

2. Application of Principles of Asepsis and Sterile

Techniques

2.1 Infection

Four major categories of microorganisms cause

infection in humans: bacteria, viruses, fungi, and parasites.

Bacteria are by far the most common infection causing

microorganisms. Viruses consist primarily of nucleic acid and

therefore must enter the living cells in order to reproduce. Fungi

include yeasts and molds. Parasites live on other living

organismas. They include protozoa, such as the one that causes

malaria, helminths (worms), and arthropods (mites, fleas, ticks).

Types of Infection

Colonization is the process by which strains of microorganisms

become resident flora. In this state, the microorganisms may grow

and multiply but do not cause disease. Infection occurs when

newly introduced or resident microorganisms succeed in invading

a part of the body where the hosts defense mechanisms are

ineffective and the pathogen cause tissue damage. The infection

becomes a disease when the signs and symptoms of the infection

are unique and can be differentiated from other conditions.

Local Infection limited to a specific part of the bodywhere the microorganisms remain.

Systemic infection if the microorganisms spread anddamage different parts of the body.

Bacteremiawhen the culture of the persons bloodreveals microorganisms.

Septicemia when bacteremia results in systemicinfection.

Nosocomial Infections are classified as infectionsthat are associated with the delivery of health care

services in a health care facility (hospital- acquired

infections).

2.2 Sources of Contamination

Endogenous Source if the microorganisms that causenosocomial infections originate from the clients

themselves.

Exogenous Source if the microorganisms that causeinfection originate from the hospital environment and

the hospital personnel.

Contaminating bacteria are commonly present on thehands of anesthesia providers and found high rates of

transmission to the surgical field during operations.

All items used in the wound and on the sterile setup. Dust

2.3 Environmental Control of Microorganisms

Aseptic technique is most strictly applied in

the operating room because of the direct and often extensive

disruption of skin and underlying tissue. Aseptic technique helps

to prevent or minimize postoperative infection.

PREOPERATIVE PRACTICES AND PROCEDURES. The most

common source of pathogens that cause surgical site infections is

the patient. While microorganisms normally colonize parts in or

on the human body without causing disease, infection may result

when this endogenous flora is introduced to tissues exposed
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during surgical procedures. In order to reduce this risk, the patient

is prepared or prepped by shaving hair from the surgical site;

cleansing with a disinfectant containing such chemicals as iodine,

alcohol, or chlorhexidine gluconate; and applying sterile drapes

around the surgical site.

In all clinical settings, handwashing is an important

step in asepsis. The "2002 Standards, Recommended Practices,and Guidelines" of the Association of Perioperative Registered

Nurses (AORN) states that proper handwashing can be "the single

most important measure to reduce the spread of

microorganisms." In general settings, hands are to be washed

when visibly soiled, before and after contact with the patient,

after contact with other potential sources of microorganisms,

before invasive procedures, and after removal of gloves. Proper

handwashing for most clinical settings involves removal of

jewelry, avoidance of clothing contact with the sink, and a

minimum of 1015 seconds of hand scrubbing with soap, warm

water, and vigorous friction.

A surgical scrub is performed by members of

the surgical team who will come into contact with the sterile field

or sterile instruments and equipment. This procedure requires use

of a long-acting, powerful, antimicrobial soap on the hands and

forearms for a longer period of time than used for typical

handwashing. Institutional policy usually designates an acceptable

minimum length of time required; the CDC recommends at least

two to five minutes of scrubbing. Thorough drying is essential, as

moist surfaces invite the presence of pathogens. Contact with the

faucet or other potential contaminants should be avoided. The

faucet can be turned off with a dry paper towel, or, in many cases,

through use of a foot pedal. An important principle of aseptic

technique is that fluid (a potential mode of pathogen

transmission) flows in the direction of gravity. With this in mind,

hands are held below elbows during the surgical scrub and above

elbows following the surgical scrub. Despite this careful scrub,

bare hands are always considered potential sources of infection.

Sterile surgical clothing or protective devices such asgloves, face masks, goggles, and transparent eye/face shields

serve as barriers against microorganisms and are donned to

maintain asepsis in the operating room. This practice includes

covering facial hair, tucking hair out of sight, and removing

jewelry or other dangling objects that may harbor unwanted

organisms. This garb must be put on with deliberate care to avoid

touching external, sterile surfaces with nonsterile objects

including the skin. This ensures that potentially contaminated

items such as hands and clothing remain behind protective

barriers, thus prohibiting inadvertent entry of microorganisms

into sterile areas. Personnel assist the surgeon to don gloves and

garb and arrange equipment to minimize the risk of

contamination.

Donning sterile gloves requires specific technique sothat the outer glove is not touched by the hand. A large cuff

exposing the inner glove is created so that the glove may be

grasped during donning. It is essential to avoid touching

nonsterile items once sterile gloves are applied; the hands may be

kept interlaced to avoid inadvertent contamination. Any break in

the glove or touching the glove to a nonsterile surface requires

immediate removal and application of new gloves.

Asepsis in the operating room or for other invasive

procedures is also maintained by creating sterile surgical fields

with drapes. Sterile drapes are sterilized linens placed on the

patient or around the field to delineate sterile areas. Drapes or

wrapped kits of equipment are opened in such a way that the

contents do not touch non-sterile items or surfaces. Aspects of

this method include opening the furthest areas of a package first,

avoiding leaning over the contents, and preventing opened flaps

from falling back onto contents.

Equipment and supplies also need careful attention.

Medical equipment such as surgical instruments can be sterilized

by chemical treatment, radiation, gas, or heat. Personnel can take

steps to ensure sterility by assessing that sterile packages are dry

and intact and checking sterility indicators such as dates or

colored tape that changes color when sterile.

INTRAOPERATIVE PRACTICES AND PROCEDURES. In the operating

room, staff have assignments so that those who have undergone

surgical scrub and donning of sterile garb are positioned closer to

the patient. Only scrubbed personnel are allowed into the sterile

field. Arms of scrubbed staff are to remain within the field at all

times, and reaching below the level of the patient or turning away

from the sterile field are considered breaches in asepsis.

Other "unscrubbed" staff members are assigned to the

perimeter and remain on hand to obtain supplies, acquire

assistance, and facilitate communication with outside personnel.

Unscrubbed personnel may relay equipment to scrubbed

personnel only in a way that preserves the sterile field. For

example, an unscrubbed nurse may open a package of forceps in

a sterile fashion so that he or she never touches the sterilized

inside portion, the scrubbed staff, or the sterile field. The

uncontaminated item may either be picked up by a scrubbed staff

member or carefully placed on to the sterile field.

The environment contains potential hazards that may

spread pathogens through movement, touch, or proximity.

Interventions such as restricting traffic in the operating room,

maintaining positive-pressure airflow (to prevent air fromcontaminated areas from entering the operating room), or using

low-particle generating garb help to minimize environmental

hazards.

Other principles that are applied to maintain asepsis in the

operating room include:

All items in a sterile field must be sterile. Sterile packages or fields are opened or created as

close as possible to time of actual use.

Moist areas are not considered sterile. Contaminated items must be removed immediately

from the sterile field.

Only areas that can be seen by the clinician areconsidered sterile (i.e., the back of the clinician is not

sterile).

Gowns are considered sterile only in the front, fromchest to waist and from the hands to slightly above the

elbow.

Tables are considered sterile only at or above the levelof the table.

Nonsterile items should not cross above a sterile field.
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There should be no talking, laughing, coughing, orsneezing across a sterile field.

Personnel with colds should avoid working while ill orapply a double mask.

Edges of sterile areas or fields (generally the outerinch) are not considered sterile.

When in doubt about sterility, discard the potentiallycontaminated item and begin again.

A safe space or margin of safety is maintained betweensterile and nonsterile objects and areas.

When pouring fluids, only the lip and inner cap of thepouring container is considered sterile; the pouring

container should not touch the receiving container,

and splashing should be avoided.

Tears in barriers and expired sterilization dates areconsidered breaks in sterility.

2.4 Universal Precautions

Universal precautions refers to the practice, in medicine, of

avoiding contact with patients' bodily fluids, by means of the

wearing of nonporous articles such as medical gloves, goggles,and face shields. The practice was introduced in 198588. In 1987,

the practice of universal precautions was adjusted by a set of

rules known as body substance isolation. In 1996, both practices

were replaced by the latest approach known as standard

precautions (health care). Nowadays and in isolation, practice of

universal precautions has historical significance.

Under universal precautions all patients were

considered to be possible carriers of blood-borne pathogens. The

guideline recommended wearing gloves when collecting or

handling blood and body fluids contaminated with blood, wearing

face shields when there was danger of blood splashing on mucous

membranes and disposing of all needles and sharp objects in

puncture-resistant containers.

Universal precautions were designed for doctors, nurses, patients,

and health care support workers who were required to come into

contact with patients or bodily fluids. This included staff and

others who might not come into direct contact with patients.

Pathogens fall into two broad categories, bloodborne

(carried in the body fluids) and airborne.

Universal precautions were typically practiced in any

environment where workers were exposed to bodily fluids, such

as:

Blood Semen Vaginal secretions Synovial fluid Amniotic fluid Cerebrospinal fluid Pleural fluid Peritoneal fluid Pericardial fluidBodily fluids that did not require such precautions included:

Feces Nasal secretions Urine Vomitus Perspiration Sputum Saliva

Universal precautions were the infection control techniques

that were recommended following the AIDS outbreak in the

1980s. Every patient was treated as if infected and therefore

precautions were taken to minimize risk.

Essentially, universal precautions were good hygiene habits,

such as hand washing and the use of gloves and other barriers,

correct handling of hypodermic needles and scalpels, and aseptic

techniques.

2.5 Sterile Technique and Their Applications

Principles of Sterility

Principle Number 1: Only sterile items are used within the sterile

field.

Drapes, basins, sponges are obtained from a stock room with

sterile packages. The instruments used are sterilized and are

placed in a sterile table. Any person who holds the sterile

equipments should be very cautious to maintain sterility. One

important consideration in implementing sterility is this: IF YOU

ARE IN DOUBT ABOUT THE STERILITY OF A CERTAIN OBJECT,

CONSIDER IT UNSTERILE. Any suspected or known unsterile items

should not be placed the sterile field.

Any sterile package found in an unsterile or contaminated area is

considered unsterile.

If the actual timing or sterilization procedure is undetermined and

the nurse is unsure about the sterilization process, the

equipments sterilized with the suspected procedure are

considered contaminated.

A sterile table which has been touch or rubbed accidentally by an

unsterile person or vice versa is no longer considered sterile.

If the packaging material is broken or has missing pieces it is no

longer sterile.

Microorganisms can enter a packed sterile package when it is

damp or wet. Thus, damp packages are unsterile.

A sterile package dropped on a floor is considered contaminated.

Principle Number 2: Sterile persons are gown and gloved.

When wearing a gown, the considered sterile area is the part

where you can see in front down to the level of the sterile field.

Thus, gowns are only considered sterile in front of the chest,

sleeves above the elbow to the cuffs down to the level of the

sterile field. Certain methods should be employed in the OR:

Gowning is not done on the sterile table to avoid dripping water

onto the sterile equipments. Gloving and self-gowning should be

done in a distinct sterile surface.
http://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Medical_gloveshttp://en.wikipedia.org/wiki/Goggleshttp://en.wikipedia.org/wiki/Face_shieldhttp://en.wikipedia.org/wiki/Body_substance_isolationhttp://en.wikipedia.org/wiki/Pathogenshttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Semenhttp://en.wikipedia.org/wiki/Vaginal_secretionhttp://en.wikipedia.org/wiki/Synovial_fluidhttp://en.wikipedia.org/wiki/Amniotic_fluidhttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Pleural_fluidhttp://en.wikipedia.org/wiki/Peritoneal_fluidhttp://en.wikipedia.org/wiki/Pericardial_fluidhttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Nasal_secretionhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Vomitushttp://en.wikipedia.org/wiki/Perspirationhttp://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Salivahttp://en.wikipedia.org/wiki/Hypodermic_needlehttp://en.wikipedia.org/wiki/Scalpelhttp://en.wikipedia.org/wiki/Scalpelhttp://en.wikipedia.org/wiki/Hypodermic_needlehttp://en.wikipedia.org/wiki/Salivahttp://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Perspirationhttp://en.wikipedia.org/wiki/Vomitushttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Nasal_secretionhttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Pericardial_fluidhttp://en.wikipedia.org/wiki/Peritoneal_fluidhttp://en.wikipedia.org/wiki/Pleural_fluidhttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Amniotic_fluidhttp://en.wikipedia.org/wiki/Synovial_fluidhttp://en.wikipedia.org/wiki/Vaginal_secretionhttp://en.wikipedia.org/wiki/Semenhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Pathogenshttp://en.wikipedia.org/wiki/Body_substance_isolationhttp://en.wikipedia.org/wiki/Face_shieldhttp://en.wikipedia.org/wiki/Goggleshttp://en.wikipedia.org/wiki/Medical_gloveshttp://en.wikipedia.org/wiki/Medicine


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Stockinette cuffs of the gowns are absorbent and may retain

moisture, thus making it a suitable area for bacteria or

microorganisms to thrive in. because of the said principle,

stockinette cuffs should be inserted beneath the sterile gloves.

Principle Number 3: Tables are only sterile at Table Level

Edges and sides of the table drape are considered contaminated.

Below the table level is also considered unsterile.

Any sterile person who touches a part of the drape hanging below

the table level is considered unsterile. Any object or equipment

that drops below the table surface is considered contaminated.

In unfolding and placing a sterile drape any portion of that falls

below the table surface is unsterile and should not be moved or

touched or brought back up to the level of the table.

To prevent cords and tubing from sliding to the edge of the table,

it should be fastened with a non-sharp device or object.

Principle Number 4: Sterile Persons Touch ONLY Sterile Items

while Unsterile OR Personnel Touch Only Unsterile Items

Sterile OR personnel comes in direct contact with persons who

wears gowns and gloves only. The items that they will touch are

the sterile equipments. Any supply brought by an unsterile staff

should transfer the item in a sterile manner.

Unsterile OR personnel (circulator), should not directly come in

contact with a gowned and gloved person.

Principle Number 5: Unsterile persons avoid reaching over sterile

field and sterile persons avoid touching or leaning over an

unsterile area.

In cases where a solution has to be poured into a sterile basin, the

unsterile OR personnel should only hold the lip of the bottle over

the basin to prevent any contact with the sterile area.

To prevent the circulator from reaching over a sterile area when

pouring solutions, the scrub person places the basin and glasses

or any container for solutions near the edge of the table. This

prevents the circulator from reaching over the sterile area by just

standing near the edge of the table to fill the container with the

liquid solution.

When surgeons perspire on their brows, he or she should to turn

away from the sterile field and have the sweat removed by the

circulator.

In draping or covering an unsterile table the scrub person drops

the sterile drape at the center of the table while holding the fan-

folded drape high and standing back from the table to protect the

sterile gown.

Sterile gloves are protected by cuffing a drape. The sterile OR

personnel should place the gloved hands inside the sterile part of

the drape.

The scrub person unfolds the drape towards him or herself first to

allow him or her to move closer to the table when working on the

opposite side of the table since the first part of the unfolded

drape now protects the sterile gown.

Principle Number 6: Edges of anything that encloses sterile

contents are considered unsterile

Sterile supplies are packed. In opening sterile packages, the area

within 1 inch from the edges is considered unsterile. Supplies are

handled by the circulator. The upper portion of the package is

flapped away from the self and turns the side under. In doing so,

the end of the flaps is secured by the band of the circulator to

prevent it from dangling loosely. The other flap is pulled towardsthe circulator; hence, the contents are exposed yet away from the

unsterile hands.

To open a sterile package, the flaps on peel-open packages should

be pulled not torn. The sterile contents should be flipped and

lifted upward. The circulator should prevent the sterile contents

to slide over the unsterile edges.

When lifting contents from packages, sterile personnel should lift

the object straight up while holding their elbows high.

In cases where a sterile wrapper is used as a table cover instead of

a drape, it should cover the entire table surface. Only the interior

surface of the wrapper is considered sterile.

Sterile bottles when opened cannot be recap without

contaminating the pouring edges. Thus, all contents must be used

or in cases where there is still a solution left, it should be

discarded.

Principle Number 7: Sterile field is set-up just before a surgical

procedure

The longer a sterile item is exposed to air and environment, the

higher the possibility of contamination.

The practice of covering a sterile set-up does is not in the best

interest of the patient. Sterility cannot be guaranteed by just

covering a sterile set-up, unless it is under a constant

surveillance.

Covering and uncovering a table may contaminate the sterile

items.

Principle Number 8: Sterile areas are continuously kept in view.

Sterility cannot be guaranteed by just covering a sterile set-up,

unless it is under a constant surveillance.

Sterile persons should face the sterile area.

While waiting for the patient to come inside the OR, someone

must stay in the sterile area to maintain vigilance on the sterile

set-up.

Direct observation ensures sterility.

Principle Number 9: Sterile persons keep well within sterile area.

In draping the patient, sterile persons stay at a safe distance from

the operating table to maintain sterility.

Movements in a sterile area are done by passing with each other

back to back at a 360 degree turn.


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When a sterile person passes by an unsterile person or area, he or

she should turn back to maintain sterility.

When sterile persons pass by a sterile field or area, they face

towards it.

To prevent contamination during movements in an area, the

sterile person asks the unsterile personnel to step aside.

Movement inside the sterile area is kept at a minimum to avoid

contamination.

Sterile persons stay inside the sterile field or area.

Principle Number 10: Sterile persons keep in contact with sterile

areas to minimum.

Inside the operating room or within a sterile field the following

are strictly observed:

Sterile persons avoid leaning over sterile tables or drapes.

Sterile personnel who lean over or sit on an unsterile area is

considered contaminated.

Principle Number 11: Unsterile persons avoid sterile areas

Unsterile personnel should have the knowledge on the proximity

to the sterile field. They must be aware of their distance to the

sterile area or field to prevent contamination. A distance of at

least 1 foot or 30 cm from a sterile field should be maintained and

observed by the unsterile staff.

Unlike the sterile persons who turn their back towards the

unsterile surface, unsterile personnel (circulator) face the sterile

area (within 1 foot) when passing by to observe and maintain the

distance and to avoid touching any sterile objects.

All activity of a circulator should be kept to a minimum.

Principle Number 12: Destruction of integrity of microbial barriers

result in contamination

A sterile packages integrity is destroyed by the following

instances:

Perforation

Puncture

Strike-through soaking of moisture through unsterile or sterile

layers or vice versa.

Before opening a sterile package to be used in a certain procedure

or operation the package should be checked thoroughly beforeopening. The following principles should also be employed in

handling packages:

To prevent strike-through all sterile packages should be placed on

a dry surface.

If any part of the package becomes damp or wet it is considered

unsterile and should be discarded or re-sterilized.

Tables used for operation should be dried before draped.

If the sterile drape is soaked with a solution the wet area should

be covered with an impermeable sterile towels or drape.

Sterile items should be placed not only in clean but also in dry

areas.

In handling sterile packages, the hands should be dried first.

Air can also cause contamination. Thus, undue pressure on sterile

packs should be avoided. This prevents the ejection of sterile air

and the entry of unsterile air into the pack.

Principle Number 13: Microorganisms must be kept to irreducible

minimum

Sterilization is the process of removing ALL microorganisms

including the bacterial spores. However, not all things or area can

be sterilized. The following principles are employed to employ

sterile technique in:

Skin

Skin cannot be sterilized thus, it can be very good source of

contamination in any operation. To prevent entrance ofmicroorganism to the patients wound the following are done:

Surgical hand washing; Chemical antisepsis of the skin around the

surgical site; Gowning and gloving; Application of sterile draping.

Air

Air contains dust, droplets and shedding that may cause

contamination. Environmental control measures include:

Movement around the sterile field is kept to a minimum.; Drapes

are not flipped and fanned to avoid the spread of dusts.; Talking

inside the operating room is kept to a minimum because moisture

droplets are expelled with force into the mask when a person is

talking.

2.6 Methods of Sterilization of Instruments

Sterilization destroys all microorganisms, including bacterial

endospores.

To be effective, sterilization requires time, contact, temperature

and, with steam sterilization, high pressure. The effectiveness of

any method of sterilization is also dependent upon four other

factors:

1. The type of microorganism present. Some microorganisms are

very difficult to kill. Others die easily.

Note: Although rinsing an item with alcohol and then igniting it

with a match (flaming) sometimes is suggested as a method of

sterilization, it is not effective!

2. The number of microorganisms present. It is much easier to kill

one organism than many.

3. The amount and type of organic material that protects the

microorganisms. Blood or tissue remaining on poorly cleaned

instruments acts as a shield to microorganisms during the

sterilization process.

4. The number of cracks and crevices on an instrument that might

harbor microorganisms. Microorganisms collect in, and are


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protected by, scratches, cracks and crevices such as the serrated

jaws of tissue forceps. Finally, without thorough cleaning, which

removes any organic matter remaining on the instruments that

could protect microorganisms during the

2.7 Sterilization Process

Heat Sterilization for Prion Diseases

STERILIZATION BY STEAMGeneral Principles Steam is an effective sterilant for two reasons.

First, saturated steam is an extremely effective carrier of

thermal energy. It is many times more effective in conveying this

type of energy to the item than is hot (dry) air. In a kitchen,

potatoes can be cooked in a few minutes in a steam pressure

cooker while cooking may take an hour or more in a hot-air oven,

even though the oven is operated at a much higher temperature.

Steam, especially under pressure, carries thermal energy to the

potatoes very quickly, while hot air does so very slowly. Second,

steam is an effective sterilant because any resistant, protective

outer layer of the microorganisms can be softened by the steam,

allowing coagulation (similar to cooking an egg white) of the

sensitive inner portions of the microorganism. Certain types of

contaminants, however, especially greasy or oily materials, can

protect microorganisms against the effects of steam, thushindering the process of sterilization. This reemphasizes the need

for thorough cleaning of objects before sterilization.

CHEMICAL STERILIZATION

An alternative to high-pressure steam or dry-heat sterilization is

chemical sterilization (often called cold sterilization). If objects

need to be sterilized, but using high-pressure steam or dry-heat

sterilization would damage them or equipment is not available (or

operational), they can be chemically sterilized.

OTHER STERILIZATION METHODS

Gas Sterilization The use of formaldehyde gas for killing

microorganisms was practiced before the turn of the century. One

of the first uses of formaldehyde gas was to fumigate rooms, a

practice long since shown to be ineffective and unnecessary

(Schmidt 1899). There are, however, automatic, low temperaturesteam formaldehyde sterilizers that are effective and can be used

to process heat-sensitive instruments and plastic items. As

mentioned previously, because formaldehyde vapors are irritating

to the skin, eyes and respiratory tract, the use of formaldehyde in

this form should be limited.

Other Chemicals:

Paracetic acid (peroxyacetic acid). The acid is rapidly effective

against all microorganisms, organic matter does not diminish its

activity and it decomposes into safe products. When diluted, it is

very unstable and must be used with a specially designed

automatic sterilizer (APIC 2002). It is usually used for sterilizing

different types of endoscopes and other heat-sensitive

instruments.

Paraformaldehyde. This solid polymer of formaldehyde may be

vaporized by dry heat in an enclosed area to sterilize objects

(Taylor, Barbeito and Gremillion 1969). This technique, called

self-sterilization (Tulis 1973), may be well suited for sterilizing

endoscopes and other heat-sensitive instruments.

Gas plasma sterilization (hydrogen peroxide based). This method

can sterilize items in less than 1 hour and has no harmful by

products. It does not penetrate well, however, and cannot be

used on paper or linen. A specialized sterilizer is required for

performing gas plasma sterilization (Taurasi 1997).

3. Surgical Instrumentation

2.4 Inspecting and Testing of Instruments

Surgical instruments and devices must be properly

decontaminated and inspected to ensure their quality, and verify

their integrity. Damaged instruments may fail during a procedure

and injure the patient; and inadequately cleaned instrumentscannot be properly sterilized, which increases the risk of infection.

Central Processing technicians must learn how to properly

identify, inspect and test surgical instruments for cleanliness and

function.

Instrument inspection is a vital process that ensures that the

many instruments and medical devices that are used every day

function properly and are thoroughly cleaned so they be sterilized

effectively.

Scissor Sharpness - Using scissor test material, make several

complete cuts through the material, cutting all the way through to

the distal tip (where scissors most often dull). Red material is used

for scissors measuring 4.5" to 12" in length, while yellow material

is used for scissors measuring 3" to 4" in length. The test willindicate satisfactory sharpness. Be sure scissors cut all the way to

the tip. Scissor test material is available from Spectrum.

Needle holder Jaw Wear - Visual examinations best. Jaw wear at

the distal tips will be noticeable, needle holder jaw "tread" always

wears out and always wears out at the tip.

Kerrison Rongeur - Sharpness of a rongeur can be tested by using

a 3" x 5" index card. The rongeur should take a clean bite out of

the card.

Bone Cutter - Bone cutting rongeurs should be able to cut through

a 3" x 5" index card.

Laparoscopic Scissor - To test the sharpness, cut through a single

layer of tissue paper. The scissor should cut through cleanly.

3.5 INSTRUMENT SET ASSEMBLY

a. Instrument trays should be assembled using a

detailed photo p rocedure. Ringhandled instruments should be

placed on a stringer, instrument rack, or other means that allows

the instruments to remain in an open or unlocked position. This

will allow the sterilant contact to all surfaces. Instruments with

multi parts, such as a Balfour retractor or tonsil snare, should be

disassembled to allow all parts exposure to the sterilant.

b. Instruments placed on a stringer or rack will require

placement in such a manner to prevent damage to the

instruments and easy, orderly access by the operating room scrubnurse. The illustration below shows the proper alignment of string

instruments. The scissors can be turned in, toward the center of

the stringer, as long as the tips do not touch another instrument.

In many cases, the tips of the curved scissors will face away from

the center of the stringer to prevent damage to the curved tips.

The shorter instruments are at the end of the stringer, with the

longer toward the center. This order aids the operating room

nurse since the instruments at either end of the stringer will be

used first during the procedure, with progression to the longer

instruments as the case proceeds.


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13/15

Packaging Chapter. Double peel packs may be preferred by some

O.R.s for items packaged for use.

j. If the instrument has sharp points, tip guards can be

utilized for protection of the instrument. Commercially available

tip guards or foam sleeves can be purchased for this purpose. Tip

guards or foam sleeves should be permeable to the sterilant used

and the manufacturer's instructions followed for use. Latex tubing

should never be used for this purpose because the sterilant will

not contact the surface of the instrument.

3.6 Handling and Cleaning of Powered Instruments

The first "rule" is to always obtain and follow the

instrument/device manufacturer's written instructions for

cleaning, packaging and sterilization. This information should be

verified each time a new device is received. Without this

information, device/instrument can be damaged or not properly

cleaned. Exposure of metals to incompatible solutions can cause a

chemical and electrochemical attack called corrosion which may

be irreversible. Liquids, especially chlorides (e.g. bleach) are of

concern for stainless steel therefore, surgical instruments should

never be exposed to bleach. If exposure to saline cannot be

avoided, then the instrument should immediately be rinsed off

with sterile water.

Damage to Instruments - The life of an instrument should last

about twenty years if cared for properly. There are many causes

of damage which include:

Misuse- not used as intended by design

Abuse- (e.g.) dumping instruments, stacking

Improper cleaning, sterilization

Exposure to chemicals/detergents (e.g. saline - chlorine bleach,

blood even water).

Stainless steel will corrode and when it does, the corrosion usually

appears as surface blemishes (roughness / rust). This creates

difficulties for cleaning, disinfection and sterilization. Corrosion

can also indicate locations where future device failure can occur.

Stainless steel can corrode by pitting, crevice corrosion and stresscorrosion cracking (SCC) (also known as hydrogen cracking). This is

usually caused by exposure to blood, chloride or bromide

containing solutions. The effect is deep "pockets" or pits which

look like black holes on the surface. When pitting occurs, this

cannot be repaired, the instrument must be replaced.

Corrosion is often found in box locks and other joints of

instruments. Sometimes this appears as red rust. The cause is

usually blood and/or other soils in the joint and box lock. Any type

of corrosion interferes with proper cleaning and can inhibit the

disinfection/sterilization process. Therefore, it is important to

carefully inspect instruments for corrosion. A major factor in

corrosion is improper cleaning.

Water Quality- The quality of water can have great impact on

instrument life. It is recommended to have your water analyzed.

This should be done by your detergent manufacturer at no

charge. Mot water supplies have minerals such as sodium,

magnesium and iron present. All of these can adversely affect

cleaning as well as detergent action impacting on the life of

instrument.

How to Protect Instruments - Instruments should only be used as

intended. For example, only use dissecting scissors on tissue only

use suture scissors to cut suture, never use tubing clamps to

clamp tubings, never "dump" instruments from tray. Always keep

instruments as clean as possible while in use. At end of the

procedure, place the instruments in their specific container. If this

is a protective container, place the items in the designated

location to protect instruments from damage in transport.

Instruments should not be stacked unless they are in a rigid

container.

Protect delicate items and items with fine/sharp tips by using tip

protectors. Before using a tip protector, get the manufacturer'stechnical data verifying the tip protectors will permit penetration

of the sterilant (steam, ETO, gas plasma, etc.). Always place

heavier items on the bottom of the set and lighter items on top. It

is important to separate scopes from instruments to avoid

damage to scopes.

The use of specialty containers helps to keep delicate items in

place before and after use. Purchase of delicate instruments

should always include a specialty container to avoid unnecessary

damage.

Competencies - All individuals handling surgical instruments and

devices need to be knowledgeable in the care, handling and

processing of surgical instruments. Surgical instruments are the

extension of the surgeon's hands therefore; they must befunctional when used in the OR. Scissors should be tested for

sharpness each time they are processed. Ratchets should be

checked for tension. Finger forceps should be checked to make

sure the tips meet (approximate) and that teeth are present if

indicated.

Quality Control- All instruments should be inspected using a

lighted magnifying lamp. The device should be inspected for

cleanliness, to make sure all components are present that the

instrument works as intended, that there is no damage to the

instrument and that the instrument is the one identified for the

set (correct instrument.)

Scopes -There are two categories of scopes; rigid and flexible. The

flexible scopes are mainly used in GI/Endo (e.g. gastroscopes). The

rigid scopes include arthroscopes, cystoscopes, etc. Thisinstrumentation is very expensive. Cleaning is paramount to the

safety of the device yet by design many of these devices defy

cleaning. Therefore compliance with the device manufacturer's

written instructions is critical.

All personnel processing endoscopic instrumentation should be

trained and competencies verified.

Rigid Scopes are a critical part of the endoscopic surgery

instrument inventory. They are fragile and expensive. They

provide light and image to the surgeon therefore, they must

function as expected. The smaller the diameter of the scope,

usually the more fragile therefore careful handling is essential to

avoid damage to the small glass rods that transmit the light.

Always follow the scope manufacturer's instructions for cleaning.

Usually it is recommended to brush the distal end with soft bristle

brush and then wipe the outer surfaces of the scope and

accessories with gauze or soft cloth moistened with detergent

solution. However, this may vary with the manufacturer.

Ultrasonic cleaning is not usually recommended for scopes; the

vibrations can damage the lens seals and possibly fracture the

optical fibers.

All areas of the scope should be inspected for scratches, dents,

burns, etc. Each time the scope is processed, it should be


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inspected for image clarity. The image should be crisp, clear.

However, if the image is cloudy, discolored or hazy, this may be

caused by improper cleaning, disinfectant residue, cracked or

broken lens, presence of internal moisture or external damage to

the shaft. Rigid scopes should be stored in specialty containers to

prevent damage; there are also protective sleeves to place over

the shaft to prevent damage as well. Verify with the cope

manufacturer if these sleeves can remain on during the

sterilization process.

Today two companies manufacture rigid scope testers to identify

issues with rigid scopes before processing. They are very effective

in identifying scope problems.

Light Cables - Fiber optic light cables also require special handling.

They should be cleaned per the manufacturer's instructions using

only those detergents recommended. When preparing for

sterilization, the cables should be loosely coiled (no less than 8-

inches in diameter) to prevent damage to the glass rods.

Laparoscopic Instrumentation - provides unique challenges for

processing due to the design. This instrumentation can be

extremely difficult to clean due to the design (long shaft) and jaw

assembly. Both areas can trap debris. During surgery, the positivepressure of the insufflated abdomen can cause blood and body

fluids to flow under insulation and into channels making cleaning

difficult/impossible. Disassemble (if recommended by the

manufacturer). The use of enzymatic cleaner Alas soon as possible

after surgery is recommended. Many endoscopic instrument

manufacturers recommend the use of an ultrasonic cleaner

(however, follow the instrument manufacturers

recommendations for cleaning). Pay special attention to jaws and

channels.

For laparoscopic instruments, there are some newer technologies

to help with cleaning. Several manufacturers offer high pressure

water jets for lumens as an alternative to manually brushing and

flushing. It is important to rinse repeatedly to remove all

detergents and residues from the instruments. There are also

table-top ultrasonic lumen cleaners which adapt to the lumens ofendoscopic instruments to enhance cleaning.

Inspection - Insulated instruments require special inspection.

There is a patient safety issue associated with insulated

instruments. Repeated use/sterilization can cause the layer of

insulation covering the shaft to break down. If this occurs, minute

tears can go unnoticed during cleaning/inspection. During surgery

the defective insulation could allow 100% of the electrical current

(700oF) to flow from the defect to the patient's organs, tissue.

What is even more important to note is that the smaller the crack

the more dangerous to the patient because more current can

escape from a small hole because it is more concentrated.

Furthermore, a majority of the instrument is outside the surgeon's

visual field and therefore the defect could go unnoticed. The

patient may suffer peritonitis and even death from septicemia

(infection of the blood stream; also called blood poisoning).

Damage to the insulation will occur due to normal wear and tear,

high voltages, the cleaning and sterilization process (flash

sterilization increases damage) and contact with sharp

instruments (e.g. trocars). Therefore, it is imperative that a

comprehensive system for inspection of insulation be

implemented. This inspection should occur each time the

instrument is processed. The inspection can be done by using an

insulation tester in the processing area (reusable device) or a

single use tester that is sterile and used in the sterile field prior to

surgery.

The insulation can get damaged from dropping the instrument,

repeated sterilizations and/or placing instruments on top of other

instruments, or "dumped" into a table; therefore proper care and

handling of these instruments is essential to patient safety.

Trocars - If reusable trocars are being used, they must be tested

for sharpness each time. Identify the maximum number of uses

that would indicate re-sharpening. Observe for nicks, defects

which would interfere with passage of the scope.

Power equipment utilized by surgery includes a wide

variety utilizing different power sources. Power sources may be

electrical, either line current or battery, compressed medical

gasses, such as carbon dioxide, nitrogen, or compressed air.

Equipment powered by gasses is referred to as pneumatic or air-

powered instruments. Examples of power equipment are:

reamers, drills, screwdrivers, and saws used by orthopedic and

some neurosurgeons. Craniotomes, drills, and perforators are

used by neurosurgeons. Dermatomes are used by plastic and

general surgeons to take skin grafts, and sternal saws are used by

thoracic surgeons to cut the sternum.

Powered equipment should be cleaned and cared for

according to the manufacturer's recommendations, but under no

circumstances should a power instrument be immersed in a

solution of any kind. They should never be processed through an

ultrasonic or washer/sterilizer. The attachments used with the

equipment, however, may be processed in the same manner as

most stainless steel surgical instruments. These attachments can

include chucks, chuck keys, burr guards, hudson and trinkle

adapters, and wrenches. These attachments are all metal and will

retain a great deal of blood and debris. Close attention should be

give to ensure the power equipment and attachments are

thoroughly inspected and cleaned. All attachments must be

removed from the equipment before processing. Saw blades, drill

points, and bits should be discarded in the operating room after

the surgical procedures. These items should not be reusedbecause the sharp cutting edge cannot be guaranteed once they

have been used.

Skull perforators should be checked frequently and

sent for sharpening on a routine basis. Due to their cost and

complexity, a maintenance schedule should be established.

Disposable, single use perforators are being produced by several

vendors but the cost still remains high. Air hoses should be

inspected prior to cleaning for any damage, then washed with a

mild detergent and lukewarm water. Never immerse the cord into

any solution. If the equipment has an electrical cord, the cord may

be washed with a cloth soaked with mild detergent solution.

Other components are also cleaned in this manner, and then

wiped with a disinfectant to assure safe handling prior to

packaging.

Newer powered equipment requires no lubrication

since they are self-lubricating and are enclosed with a sealed

casing. Older equipment will require some lubrication, and this

should be done during the testing process. Pneumatic equipment

should be hooked up to compressed air and tested within the

required PSI (pounds per square inch), and the pressure never

exceeded to prevent damage to the equipment. Battery operated

power equipment may be tested also with a battery pack. If

compressed air is not provided with a wall gauge and a tank is

required to be stored in SPD, measures must be taken to secure


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the tank safely to the wall. A battery pack may also be purchased

and kept in SPD to test the battery operated equipment. Any

equipment that does not function correctly should be sent for

repair. If backup equipment is not available, a loaner piece will be

required to assure surgery cases are not cancelled. Any time

equipment malfunctions the operating room should be notified.

Sterilization by a prevacuum sterilizer is recommended

most frequently for a large majority of equipment. If gravitydisplacement sterilizers are used, the sterilization time must be

lengthened. Electrical equipment should be sterilized by ethylene

oxide to prevent damage to the electrical parts. With the variety

and complexity of power equipment available, it is recommended

that detailed cleaning, testing, and assembly procedures be

provided for the technician's use. Frequent inservices will keep

the SPD staff abreast of current changes and technology.

Remember; always follow the manufacturer's recommendations.

basic patient needs

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