Beth Kalkman, BSN, RNC-OB • Skeletal • Gastrointestinal • Reproductive • Respiratory • Circulatory • Nervous • Genitourinary • Thromboembolism • Anemia • Aspiration • Hypoxia • Hemorrhage • Two Patients Cesarean Section Education Video Skin incision is made, then the subcutaneous (sub-q) tissue down to the fascia is incised. Cutting through rectus fascia (in this case, with cautery) Separating Abdominal muscles with fingers Opening the peritoneum Stretching the Abdominal Wall Uterine incision is made Amniotic membranes are ruptured Uterine incision is stretched laterally Surgeon reaches in to identify and lift the presenting part out of uterus through the abdominal incision Head is delivered by hand or, by vacuum assistance The trunk and lower extremities follow. After the cord is clamped, the baby is suctioned and handed to the newborn team. Collection of the cord blood sample follows. Removal of placenta and amniotic membranes Exploration of uterus to insure complete Removal of tissue Uterine incision is closed in one or two layers Fascia is closed Skin is closed with suture, staples, or glue Class I: Clean wound: Gastrointestinal (GI), genitourinary(GU), or respiratory track is not entered. Class II: Clean contaminated: The GI, GU, or respiratory track is entered under planned, controlled means. Class III: Contaminated Wound: Gross contamination is present but obvious infection is not present. Class IV: Dirty or infected: old traumatic wound with dead tissue or an infection process is present Nunny, R. (2008) Providing perioperative care for pregnant women. Nursing Standard, 22(47), 40-44. To provide a safe, clean environment for obstetric surgical patients and hospital personnel Origin of Governing Documents • Holland Hospital Policies • Association of periOperative Registered Nurses (AORN) • Association of Women’s Health, Obstetric, and Neonatal Nursing (AWHONN) • Association of Surgical Technologists (AST) Culture of Safety Operating Room Suite Divided into three designated areas. Determined by the activities that take place in each area • Unrestricted • Semi-restricted • Restricted Unrestricted • All areas where street clothes may be worn. • Area where surgical and nonsurgical personnel interface Semi-restricted: • Scrub attire and caps are required. • Storage of clean and sterile supplies and instruments • Corridors leading to restricted area Restricted • Surgical procedures are performed and sterile items are stored. • All areas where scrub attire, caps, and masks are required and traffic is limited. Semi-restricted Semi-restricted Semi-restricted Unrestricted Restricted Preparation and Maintenance of BBC Operating Room 220.127.116.11 Preparation and Maintenance of the Operating room Environment 18.104.22.168 Holland Hospital Policies and Procedures Recommended Practices for Traffic Patterns in the Perioperative Practice Setting. AORN Perioperative Standards and Recommended Practices • Sterile Team Members(Scrubbed) • Primary Surgeon • Assistant Surgeon • Scrub Technician • Non-Sterile Team Members • • • • Circulator Anesthesiologist Infant Nurse Infant Provider • Preparing the Sterile Field • Selecting appropriate instruments and supplies • Scrubbing, donning gown and gloves • Maintaining integrity and sterility of the sterile field • Knowledge of the procedure and anticipation of the surgeon’s needs • Providing instruments, sutures, and supplies to the surgeon • Preparing sterile dressings • Implementing procedures that contribute to patient safety • Cleaning and preparing instruments for sterilization (Spry, 2009, p.7) • Managing and implementing activities outside the sterile field • Emotional support to patient prior to and during induction of anesthesia • Performing ongoing patient assessment • Documenting patient care • Obtaining appropriate surgical supplies and equipment • Creating and maintaining a safe environment • Administering medications • Implementing and enforcing policies and procedures that contribute to patient safety • Preparing and disposing of specimens • Communicating relevant information (Spry, 2009, p. 7) Culture of Safety: What is it? • Reporting • Flexible • Learning • Wary • Just It’s about Caring, It’s about the Patient. Surgical Conscience: “An inner commitment to adhere strictly to aseptic practice, and to correct any violation, whether or not anyone else is present or observes the violation“ (Spry, 2009, p.101) You are a team!!!! Responsibilities of the Circulating Nurse 22.214.171.124 Surgical Assistants in the Operative Room/ Boven Birth Center Guidance Statement: Creating a Patient Safety Culture 126.96.36.199 Holland Hospital Policies AORN Perioperative Standards and Recommended Practices Microorganisms that cause disease Can you name a few? • MRSA • E-Coli • Pseudomonas • Strep Sources of Infection • Endogenous: From the patient’s own body • Exogenous: Outside the body Nosocomial Infections: Hospital Acquired Infections (HAI) • 1 in 20 patients Surgical Site Infections (SSI) • 1-3 in 100 patients The Patient-Internal Factors • Lifestyle Choices • Nutritional Status • Age • Existing Disease • Acute Illness External Factors-presence of others • Movement • Talking • Attendance • Security Surgical attire • Laundered by facility-approved laundry service • Replaced daily or when soiled • Loose fitting tops are tucked in • Non-scrubbed personnel – long jackets buttoned or closed. **Personal clothing that extends beyond the neck or sleeves of the scrub attire are not worn.** What Else? • Doors kept closed • Personnel kept to a minimum • Room is Cleaned before, during, and after cases Personal Protective Equipment Traffic Patterns in the Operating Room 188.8.131.52 Cesarean section, Personnel in Attendance 184.108.40.206 Holland Hospital Policies Recommended Practices (RP) for Traffic Patterns in the Perioperative Practice Setting RP for prevention of Transmissible Infections in the Perioperative Practice Setting AORN Perioperative Standards and Recommended Practices The single most important step in the prevention of infection The Targets: Microorganisms Transient : Accumulate during activities of the day. Found on the surface of hands Resident : More permanent dwellers. Found in the deeper layers. Methods: • Hand Washing Washing with soap and water for at least 15 seconds • Antiseptic Hand Wash Hand wash performed with a product Intended to decrease the resident and transient flora • Antiseptic Hand Rub An alcohol containing agent which is applied to the hands to decrease the resident and transient flora • Surgical Hand Antisepsis Wash or rub performed before surgery to eliminate transient microorganisms and significantly reduce resident organisms. Condition and cleanliness: • Natural fingernails: < ¼ inch long • No rings, watches, or other jewelry up to elbows. • Free of damage Performing the Surgical Hand Scrub Surgical Scrub Attire and Hand Hygiene 10.1.181 Holland Hospital Policies RP for Hand Hygiene in the Perioperative Setting AORN Perioperative Standards and Recommended Practices The practices by which contamination from microorganisms is prevented ( Spry, 2009, p. 95) Aseptic: The absence of all disease causing microorganisms. Synonym: Sterile Modes of Contamination: • Airborne: Transmitted through the air small particles • Droplet: Sneezing, Talking, Coughing slightly larger particles • Contact: Touching • Direct: Touching infected patient • Indirect: Touching something in contact with Patient Methods to Prevent Contamination • Surgical Attire • Personal Protective Equipment (PPE) Principles of Asepsis 1. Scrubbed persons function within a sterile field 2. Sterile drapes are used to create a sterile field 3. All items used within a sterile field must be sterile 4. All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity. Continued. . . 5. A sterile field should be maintained and monitored constantly 6. All personnel moving within or around a sterile field should do so in a manner to maintain the sterile field 7. Policies and procedures for maintaining a sterile field should be written, reviewed annually, and readily available within the practice setting. Maintaining the Sterile Field Surgical Scrub Attire and Hand Hygiene 10.1.181 Holland Hospital Policies Recommended Practices for Surgical Attire AORN Perioperative Standards and Recommended Practices The use of specific actions and activities to prevent contamination and maintain sterility of identified areas during operative or other invasive procedures “First, do no harm” Basic: • Clean scrub attire • Surgical Head Covers • Personal Protective Equipment More Advanced: • Sterile Gowns • Sterile Gloves • Creating and Maintaining a Sterile Field Sterile drapes, gowns, and gloves are intended to create a barrier Are your gowns, gloves, and supplies free from damage??? Sterile Gowning and Gloving Sleeve cuffs Are Unsterile once Hands have passed through Gown is considered sterile from the chest to the level of the sterile field Gown sleeves are sterile from two inches above the elbow to the cuff Neckline Axillary regions Shoulders Are ALL Unsterile Gloving yourself or Gloving another. . . It’s all going to take some time I recommend Practice, Practice, Practice!!! Sterile Field: : The area . . . surrounding a body site that has been prepared for an invasive procedure covered by sterile drapes or sterile attire. • working areas • Furniture • Personnel Preparing the Sterile Field Surgical Draping 220.127.116.11 Holland Hospital Policies Recommended Practices for Sterile Technique AORN Perioperative Standards and Recommended Practices Goal: Reduce the risk of post operative surgical site infection • Removing debris, soil, and transient microorganisms • Reduce resident microbial count • Inhibit rapid rebound growth of microorganisms Hair Removal Research indicates that preoperative shaving increases the risk of surgical site infections **Patients should be instructed NOT to shave surgical site the day before or day of surgery** So, what are our options? • With Clippers • Only at the operative site • Outside of the OR • Only if necessary Antisepsis: The prevention of sepsis by preventing or inhibiting the growth of resident and transient microbes Basics of Skin Preparation For our patients: Umbilicus is cleaned with cotton-tipped applicator Skin Preparation of Patients 18.104.22.168 Holland Hospital Policies Recommended Practices for Preoperative patient skin antisepsis AORN Perioperative Standards and Recommended Practices PREPROCEDURE SIGN-IN TIME-OUT SIGN-OUT CHECK-IN In Holding Area Before Induction of Anesthesia Before Skin Incision Before the Patient Leaves the Operating Room Patient/patient representative actively confirms with Registered Nurse (RN): RN and anesthesia care provider confirm: Initiated by designated team member RN confirms: Identity □ Yes Procedure and procedure site □ Yes Consent(s) □ Yes Site marked □ Yes □ N/A by person performing the procedure Confirmation of: identity, procedure, procedure site and consent(s) □ Yes Site marked □ Yes □ N/A by person performing the procedure All other activities to be suspended (unless a lifethreatening emergency) Patient allergies □ Yes □ N/A RN confirms presence of: History and physical □ Yes Preanesthesia assessment □ Yes Diagnostic and radiologic test results □ Yes □ N/A Blood products □ Yes □ N/A Any special equipment, devices, implants □ Yes □ Include in Preprocedure check-in as per institutional custom: Beta blocker medication given (SCIP) □ Yes □ N/A Venous thromboembolism prophylaxis ordered (SCIP) □Yes □ N/A Normothermia measures (SCIP) □ Yes □ N/A N/A Difficult airway or aspiration risk? □ No □ Yes (preparation confirmed) Risk of blood loss (> 500 ml) □ Yes □ N/A # of units available ______ Anesthesia safety check completed □ Yes Briefing: All members of the team have discussed care plan and addressed concerns □ Yes Introduction of team members □ Yes All: Confirmation of the following: identity, procedure, incision site, consent(s) □ Yes Site is marked and visible □ Yes □ N/A Relevant images properly labeled and displayed □ Yes □ N/A Any equipment concerns? Anticipated Critical Events Surgeon: States the following: □ critical or nonroutine steps □ case duration □ anticipated blood loss Anesthesia Provider: □ Antibiotic prophylaxis within one hour before incision □ Yes □ N/A □ Additional concerns? Scrub and circulating nurse: □ Sterilization indicators have been confirmed □ Additional concerns? Name of operative procedure Completion of sponge, sharp, and instrument counts □ Yes □ N/A Specimens identified and labeled □ Yes □ N/A Any equipment problems to be addressed? □ Yes □ N/A To all team members: What are the key concerns for recovery and management of this patient? _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ April 2010 Caution!!!!! Our Prepping agents are flammable until completely dry Place the dispersive pad as close to surgical site as possible to surgical site • Dry, clear (hairless) skin • Well-vascularized • Once placed, do not lift and re-place. Electrosurgery 22.214.171.124 Surgical Fire Prevention and Fire Response Recommended Practices for Electrosurgery 126.96.36.199 Holland Hospital Policies AORN Perioperative Standards and Recommended Practices BBC C-Section Instruments Routine Instruments Stat Instruments 2 4 2 2 4 2 2 4 6 1 1 1 2 2 1 2 4 2 2 1 1 1 1 1 Long Sponge Sticks Short Sponge Sticks Towel Clamps Towel Clips Babcock Forceps Allis Forceps Kocker Forceps Crile Forceps Kelly Forceps Needle Holder Short Needle Holder Straight Scissors Large Richardson Retractors Small Richardson Retractors DeLee Retractor Knife Handles Short Sponge Sticks Kocker Forceps Crile Forceps Needle Holder Straight Scissors Curved Mayo Scissors Curved Metenbaum Scissors Bandage Scissors Forceps 2 Adsons with Teeth 2 Toothed Forceps 1 Russian Forceps 1 Singley Bowel Forceps 1 Smooth Forceps 1 Debakey Forceps 1 Ferris Smith 60 Sponge Sticks ( Also known as Ringed Forceps) 2 - Long 8 - Short Towel Clamps(2) Towel Clips(2) Babcock (4) Allis (2) Kockers (4) Crile and Kelly Hemostats(4 of each) Scissors Bandage Curved Mayo Straight Mayo (2) Curved Metzenbaum Forceps (Also known as Pick-ups) Adson with Teeth (2) Toothed Forceps (2) Russian Forceps Singley Bowel Forceps Smooth Forceps Debakey Forceps Ferris Smith Retractors Richardsons Large (2) Small (2) Delee And Two Knife Handles Purpose: To prevent retained surgical items (RSI) in patients undergoing surgical or other invasive procedures. RSIs are “Never Events” They should NEVER happen! Primary responsibility of the RN circulator and the perioperative team • Prompt • Standardized • Documented • Deliberate What needs to be counted? • Soft Goods • Sharps • Needles • Instruments Radiopaque: Visible upon xray. Lap sponges Raytecs or xrays Blue indicates radiopaque Material (xray detectable) Procedure: Aloud,concurrently, and visually observed Order of location: • Surgical Site • Mayo Stand • Back table • Off the field Order of items: • Sponges (as packaged) -xrays and laps • Sharps -needles, blades, bovie tips • Instruments Soft items that do not contain radiopaque material(white towels, dressings) should never be on the sterile field at any time. Surgical Counts 188.8.131.52 Holland Hospital Policy Recommended Practices for Prevention of Retained Surgical Items AORN Perioperative Standards and Recommended Practices You have the foundational knowledge to start perfecting your hands-on role in providing great care to our patients! Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). (2011). Perioperative care of the pregnant woman. Washington, DC: Author. Association of periOperative Registered Nurses (AORN). (2012). Perioperative standards and recommended practices (2012 ed.). Denver, CO: AORN. Nunney, R. (2008). Providing perioperative care for pregnant women. Nursing Standard, 22(47), 40-44. Spry, C. (2009). Essentials of perioperative nursing (4th ed.). New York, NY: Jones and Bartlett.