CHHS17/311

Canberra Hospital and Health ServicesClinical GuidelinePeri Operative Skin Preparation-AdultsContents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Equipment..............................................................................................................2

Section 2 – Procedure...............................................................................................................3

Section 3 – Preoperative Preparation Sites and Special Instructions........................................3

Related Policies, Procedures, Guidelines and legislation..........................................................4

Definition of Term.....................................................................................................................5

References................................................................................................................................ 5

Attachments..............................................................................................................................5

Attachment 1: Preoperative Skin Preparation.......................................................................6

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Guideline Statement

PurposeThe purpose of this document is to provide guidance for health care professionals to prepare the skin prior to surgery in order to: Minimise the number of microorganisms thereby reducing the risk of infection. To provide a suitable operating field.

In the preparation of an operative site, the preferred method of hair removal is by clipping with an electric clipper. Preoperative clipping is to be performed as close to the theatre time as possible.

AlertA new blade for the clean electric clipper is used for each operative site preparation and for each new patient.

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Scope

Clipping of operative sites will only be carried out if specifically requested by the medical officer. The patient may, in certain circumstances, perform their own preoperative clip. Dependent upon the Medical Officer’s preference, the preoperative clip can be attended in the preoperative ward, Day of Surgery Admissions Unit or within the Operating Theatre. The registered nurse of the area is ultimately responsible for ensuring the surgical site is prepared according to this guideline.

The preoperative clipping can be attended by the following staff: Medical Officers, Registered nurses and registered midwives, Enrolled nurses, Wards person, Medical and nursing students under direct supervision.

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Section 1 – Equipment

Scissors Electric clipper with disposable blade Disposable touch dry ‘Kylie’ Light source Elastoplast Personal Protective Equipment (PPE)

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Section 2 – Procedure

1. Check patient ID and gain consent for proposed preoperative skin preparation and hair clipping as per Section 3 Preoperative Preparation Sites and Special Instructions. Referring to the following policies CHHS Clinical Procedure – Patient Identification and Procedure Matching CHHS Policy: Consent and Treatment

2. Ascertain the area to be clipped3. Explain procedure to patient1. Ensure privacy2. Position patient and cover with a sheet3. Provide adequate lighting4. Attend to hand hygiene and don PPE (gloves) as per CHHS Clinical Procedure: Healthcare

Associated Infections Clinical Procedure5. Clip long hair with scissors6. Using cleaned electric clippers, clip in the direction of the hair growth, holding the skin

with the other hand.

Note: Special care is to be taken over keloid tissues and bone prominences.

7. In the ward areas and Day of Surgery Admissions, the patient should shower post clipping to remove loose hair. Within theatres, remove loose hair with sticky surgical tape such as Elastoplast, post clipping

8. Remove PPE and attend to hand hygiene9. Ensure that a registered nurse inspects the clipping prior to surgery10. Document in the patient clinical record the completion and site of the clipping. If clipping

has been completed in theatre, documentation on the Intra-Operative Nursing Care Plan must be completed.

11. Report and record any abrasions or skin blemishes on the preoperative checklist and in the patient's clinical record

12. Sign the preoperative checklist.

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Section 3 – Preoperative Preparation Sites and Special Instructions

The preoperative preparation sites and special instructions are represented in Attachment 1 and are to be followed unless a medical officer has given specific instructions. The sites have been alphabetically categorised and placed under the headings listed below:

Cardiac Surgery Ear, Nose, Throat, and Eye General Gynaecology

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Neurology Orthopaedic Plastic Thoracic Thoracic-abdominal Urology/Nephrology Vascular

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Related Policies, Procedures, Guidelines and legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy CHHS Policy: Consent and Treatment Administration of Hospital Admissions and Discharges Policy CHHS Clinical Policy: Patient Identification and Procedure Matching Policy

Procedures CHHS Clinical Procedure: Admission Discharge-Adults, Pregnant Women and Neonates CHHS Clinical Procedure: Healthcare Associated Infections Clinical Procedure CHHS Clinical Procedure: Falls Prevention and Management CHHS Clinical Procedure: Clinical Handover Procedure CHHS Clinical procedure- Pressure Injury Prevention and Management: Adults, Children

and Neonates CHHS Clinical Procedure – Patient Identification and Procedure Matching

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011 Health Practitioner Regulation National Law (ACT) Act 2010 Health Records (Privacy and Access) Act 1997 Health Regulation (Maternal Health Information) Act 1998 Human Rights Act 2004 Privacy Act 1988 Children and Young Peoples Act 2008 Guardianship and Management of Property Act 1991 Medical Treatment (Health Directions) Act 2006

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Definition of TermsThrough clip: includes the removal of pubic hair from the symphysis pubis area, the external genitalia, the perineum, including the area around the anus, and the buttocks.

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Search Terms

Peri operative, peri op, skin, prep, preparation.Back to Table of Contents

References

1. Wenzel R, Prevention and Control of Nosocomial Infections (1997) 3rd EditionWilliams and Wilkins Baltimore, London: pg.527

2. The Joanna Briggs Institute, Preoperative Skin Preparation: Hair Removal, Best Practice (27/11/2015) (JB1197)

3. 5 moments of Hand Washing- Hand Hygiene Australiahttp://www.hha.org.au/

4. World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare5. http://www.nursingmidwiferyboard.gov.au/Codes-and-Guidelines.aspx 6. Zimmerman B, Pre-Operative Clipping: Identifying the best tools and practices for infection

prevention (17/6/2016)7. Spencer M, Pre-Operative Surgical Clipping: New Advances in Efficiency and Infection Prevention

(5/4/2016)8. http://www.free-ed.net/sweethaven/MedTech/Surgery02/Default.asp?iNum=0102 (1/1/18)

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Attachments

Attachment 1: Preoperative Skin Preparation

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 02 January 2018 Full Revision Executive Director, SOH CHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS12/187 Skin Preparation Standard Operating Procedure

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Attachment 1: Preoperative Skin Preparation

SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONCARDIAC SURGERYCoronary Artery Bypass

Mitral Valve Replacement

Atrial Valve Replacement

Clip hair from mid axilla, arms, both legs (for Coronary Artery Bypass only), pubic, full chest and abdomen shave. Shower with skin wash (Microshield) (after hair clipping has been performed) evening and morning prior to surgery

EAR, NOSE, THROAT, EYEEar SurgeryTympanoplastyStapedectomyMastoidectomyMyringoplastyOssicular repositioning

Wash hairWash hairWash hairWash hairWash hair

No preparationNo preparationNo preparationNo preparationNo preparation

Nasal Surgery No preparationThroat Surgery No preparationMouth SurgeryTonsillectomy

Dental Procedures

Major Jaw Reconstruction

Wiring Fractured Jaw

Clean teeth with toothpaste and brush and give patient a mouthwash.

Clean teeth with toothpaste and brush.

Give patient mouthwash. Wash hair. Shave male patients, face and neck.

If possible give the patient a mouthwash.

No preparation

No preparation

No preparation for female

No preparation Eye Surgery No preparation unless

ordered, eg: eye drops No preparation

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATION

Alert: Cutting of eyelashes is not performed.

GENERALAppendicectomy

Removal of Axillary GlandsGynaecomastiaExcision of Breast LumpSimple Mastectomy

Prepare area from umbilicus to top of thighs. No visible hair when legs are together. No through clip required.

Prepare area from the neck to below the breast from midline to bed-line on the affected side. The upper arm from shoulder to elbow including the axilla is also clipped.

RADICAL MASTECTOMYBreast Lump (frozen section)

Mastectomy

Prepare area from neck to umbilicus and laterally from 2/3 of front around to midline back.

Include clipping the underarm and axilla to the elbow on the affected side.

HERNIAInguinal HerniaFemoral Hernia

Prepare area from the umbilicus to the mid-thigh of the affected side, as well as a through clip.

OPERATIONS OF THE NECK

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONRemoval of Parotid Gland or Calculus.Scalene Node Biopsy.Brachial Cyst Removal.Cervical Rib Excision.Total Laryngectomy.Radical Excision of Glands of Neck.Removal of Thyroid Adenoma.Scalenotomy.Thyroidectomy.Excision Pharyngeal Diverticulum.Carotid EndarterectomyMediastinoscopy

Clip area from bottom lip, throat and down to the nipple line. From shoulder to shoulder and including the back of the neck.

Alert: A shave is not required for women.

UPPER ABDOMINAL All general Laparoscopic procedures.Cholecystectomy.Colectomy.Splenectomy.Gastrectomy.Oversew of Ruptured Gastric Ulcer.Ileo-jejunal By-pass.Laparotomy.Pyloplasty.Vagotomy.Hiatus Hernia - Abdominal Approach.Celestin Tube Insertion.Ivor Lewis Procedure.

Prepare area from the level of the nipple to the upper thighs including external genitalia. Laterally it extends around the body to the bed-line on either side.

LOWER ABDOMINALHemicolectomyAbdominal - Perineal Resection of ColonPull through operation of Colon

Prepare area from nipple line to mid-thigh, bed-line to bed-line including external genitalia and through clip to posterior mid-thigh.

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONHaemorrhoidectomy.Pilonidal Sinus.Peri-anal Procedures

Sigmoidoscopy

Lords Procedure

Prepare area for the buttocks from the level of the iliac crest to the upper third of the thigh, including the anal region

No preparation

No preparation

GYNAECOLOGYLaparoscopy

Laparoscopic Sterilisation

Cautery of Cervix

Dilation and Curettage

Cone Biopsy of Cervix

Shirodkar Suture of Cervix

Hysterosalpingogram

Termination of Pregnancy

Inter-uterine Device Insertion

Bartholin’s Cyst-MarsupilisationBartholin's Abscess

Vaginal repair - Anterior and Posterior

Clip pubic hair only.

Check medical officer's preference.

Check medical officer's preference

Prepare area from umbilicus to the upper level of the thighs include genitalia and perineal region

No preparation

No preparation

No preparation

No preparation

No preparation

No preparation

No preparationNo preparationNo preparation

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATION

Vaginal Hysterectomy

Marshall Marchetti

Prepare area from umbilicus to the upper level of the thighs include genitalia and perineal region

Prepare area from umbilicus to the upper level of the thighs include genitalia and perineal region

As above

As above

Abdominal HysterectomyAbdominal Tubal LigationCaesarean SectionEctopic GestationOophorectomyOvarian CystectomyOvarian Cyst RuptureSalpingectomyTubal Re-anastomosisVentrosuspension

Prepare area from level just below the breasts, bed-line to bed-line, to the upper thigh. No visible hair when legs are together.

NEUROSURGERYAnterior Cervical Procedures

Craniotomy/Posterior Cervical Procedures

Cloward's Cervical Fusion

Check medical officer's preference.

Preparation attended in the Operating Room.

Prepare area from the lobes of both ears to the shoulders including both axillae.

Alert: Female patients - do not prepare neck.The graft site is

No preparation

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONprepared from the waist to mid-thigh and laterally from the bed-line to bed-line. (The immediate pubic area is excluded). The medical officer may indicate which iliac crest is to be used. Prepare from midline to bed-line on that side.

ORTHOPAEDICS

Spinal Fusion

Lumbar Laminectomy

Prepare area from the level of the axillae downward to upper thigh, bed-line to bed-line. No through clip required.

Hand and Wrist Operations

Finger Injuries

Release of Carpal Tunnel

Clean fingernails. The clipped area extends from fingers (if hairy) to elbow, round the whole circumference of the arm.

Alert: Do not clip female patient’s hand or arm

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONElbow Operations

Tennis Elbow Correction

Open Reduction of Olecranon Process.

Prepare area from the wrist to the top of the upper arm (not axilla) around the whole circumference of the arm.

Knee Operations

Meniscectomy

Total Knee Replacement

Knee Reconstruction

Patellectomy

Prepare area from mid-thigh to mid-calf around the whole circumference of the leg.

Foot Operations

Keller's Operation

Silastic Implant to Toes

Total Ankle Replacement

Prepare area from the toes to the mid-calf around the whole circumference of the calf and foot.Clean toe nails

Hip Surgery (Unilateral)

Austin Moore Prosthesis

Total Hip Replacement

Innominate Osteotomy

Internal Fixation of # Neck of Femur

Prepare area from waist to ankle including the whole circumference of the leg on the affected side. A through clip including peri-anal is required

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONShoulder Operations

Putti Platt

Total Shoulder Replacement

Prepare area from neck to waist and to the midline both anteriorly and posteriorly. The affected shoulder, axilla and circumference of the arm to the wrist are included.

Iliac Crest OperationsDonor Site for Bone Graft

Prepare area from the waist to the top of the thighs both anteriorly and posteriorly excluding the immediate pubic area.

PLASTICS

Skin Graft Donor Sites:

Thigh

Upper or Lower Limb

Alert: Obtain specific orders from medical officer before commencing site preparation.

General guidelines only included here:Circumferential clip from groin to knee. No pubic clip required.

Clean finger or toe nails. Do not clip unless

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONFace and Scalp

Bat Ears

specifically ordered. Alert: NEVER clip or shave eyebrows. Long hair to be plaited and centred on crown of head.

THORACICThoracotomyLobectomyPneumonectomy

Bronchoscopy

Oesophagoscopy

Prepare area from 2/3 of back around affected side to 2/3 of front.Neck to umbilicus; include underarm and axilla to mid-forearm clip on affected side.

No preparation

No preparation

Pacemaker ImplantationThe prepared area includes a 18cm x 18cm square over the area. Check with the medical officer. Female patients may not require

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONclipping

MediastinoscopyPrepare area from mid-neck, bed-line to bed-line, under chin and downward in an arc from shoulder tip to shoulder tip. Prep down to nipple line.

THORACIC-ABDOMINALExcision Hydatid Cyst.Thoraco-Abdominal Gastrectomy.Hepatectomy.Oesophagectomy.Ruptured Diaphragm.Ruptured Liver.Hiatus Hernia - Thoracic approach.

Prepare area from neck to mid-thigh at the front, 2/3 of affected side including the affected axilla and arm to the elbow. The back area extends from neck to upper third of buttocks, 2/3 of affected side including the arm to the elbow.

No through clip required. Clip visible pubic hair only

UROLOGY / NEPHROLOGY

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONUreters

Re-implantation of Ureter.Partial or Total Cystectomy

Prepare area from the nipple. A through shave is not required. Clip visible pubic hair only.

Kidneys

NephrectomyNephropexyNephro-ureterectomyPercutaneous Nephrolithotomy (PCNL)

Prepare area from nipple to groin. Laterally it covers the circumference of the torso excluding the buttocks.

Scrotum, Testes & Prostate

Trans Urethral Resection of Prostrate

Prostatectomy (Open)

Orchidopexy

Prepare area from umbilicus to mid-thigh, bed-line to bed-line, including through clip.

Peri-anal clip not required.

Prepare area from umbilicus to mid-thigh, bed-line to bed-line, including through clip.

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONVaricocele

Hydrocele

Ligation of Spermatic VeinUltrasonic Lithotomy

Prepare area from umbilicus to mid-thigh, bed-line to bed-line, including through clip.

Prepare area from umbilicus to mid-thigh, bed-line to bed-line, including through clip.

Prepare area from umbilicus to mid-thigh, bed-line to bed-line, including through clip.

As above

As above

As above

Bladder and Prostate

Includes all bladder or prostate operations except Trans Urethral Resection of Prostate

Prepare area from waist to symphysis pubis, bed-line to bed-line. No through clip required.

Urethroplasty Clip hair to 1/4 on scrotum and penis, shorter on pubic area. The area extends from umbilicus to upper thigh, bed-line to bed-line.

Alert: Check with the medical officer regarding full or half presentation

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONLoin Lesion Prepare area from

midline of back to bed-line, from below axilla to mid-buttocks.

VASCULARLeg AmputationBelow Knee Amputation

Prepare area from mid-thigh to ankle on affected leg, front and back.

Above Knee Amputation Prepare area anteriorly from the iliac crest to mid-calf on the affected side. Posteriorly clip from below buttock to mid-calf on the affected side. A full pubic clip is required.

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SURGICAL PROCEDURE SPECIAL INSTRUCTIONS PREOPERATIVE SITE PREPARATIONAortic and Iliac Endarterectomy

Prepare area from the nipples to the ankles, bed-line to bed-line. No visible hair when legs together.

Aortic Aneurysm

Oesophagectomy

Pulmonary Embolectomy

Prepare area from the chin to the groin and laterally from bed-line to bed-line including the axilla and top of upper arms.

Popliteal Endarterectomy Obtain specific orders from the medical officer

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