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why must the skin be cleansed with an antiseptic solution before surgery?
to reduce the number of transient and normal microorganisms to an absolute minimum
after skin prep, what is the patient is covered with?
sterile drapes that expose only the surgical site and create the center of the sterile field
why is urinary catheterization performed?
before surgery to empty the bladder and provide continuous urinary drainage throughout the procedure
for what types of procedures is urinary catheterization necessary?
- continuous drainage prevents distention of the bladder during lengthy procedures
- surgery of the lower abdominal and pelvic cavity requires decompression of the bladder to protect it from injury during procedures
- catheterization allows easy measurement of urine and assessment of renal output
most common method of continuous drainage?
what type of catheter is a Foley?
retention catheter - has small, inflatable balloon at the tip of the catheter which is inflated after being inserted into the bladder
used when continuous urinary drainage is unnecessary
what is the choice of the correct catheter based upon?
- patient's age
- patient's size
- patient's gender
appropriate catheter for female
14 to 16 French
appropriate catheter for male
16 to 18 French
what must be verified before catheterization?
allergy status to latex
standard amount of fluid to inflate catheter balloon tip?
what type of syringe is used to inflate catheter balloon?
where is the catheter collection bag placed after insertion?
below the level of the patient
supplies necessary for catheterization
- containers for antiseptic or saline
- Foley catheter
- gauze prep sponges
- antiseptic solution
- sterile lubricant
- sterile gloves
- 10-mL syringe prefilled with water
- perineal drape
- cotton balls
- drainage tubing and urine collection unit
when is catheterization performed?
only after anesthesia care provider has indicated that it is safe
insertion hand for catheterization
- the hand used to insert the catheter and perform the skin prep
- becomes the sterile hand
assisting hand for catheterization
- stabilizes the genitalia and exposes the urethral meatus
- does not come in contact with sterile supplies
what must happen if the insertion hand becomes contaminated?
the procedure must be stopped and the contaminated glove changed
most common cause of hospital-acquired infections in the US
two primary risks associated with catheterization
- infection to the GU tract
- trauma to the GU tract
what is a risk associated with the proximity to the rectum?
urinary meatus can be easily contaminated with E. coli, which may be introduced into the urinary system during catheterization
what can repeated attempts at catheterization produce?
mucosal abrasions that cause pain and increase the risk of infection
what can urethra and sphincter muscle damage cause?
prolonged urinary retention and inability to urinate
what can contribute to difficulty in catheterization in elderly males?
what can happen when normal or transient flora are introduced into the surgical wound?
they can cause a surgical site infection (SSI)
when is the surgical skin prep performed?
immediately before the start of surgery, after the patient has been positioned and anesthetized
what is required for hair removal from the surgical site?
hair removal guidelines
- requires physician order
- should be removed as close to the time of surgery as possible
- removed with razor, electric clippers or chemical depilatory
- shave in direction of hair growth no more than 30 min before surgery
- remove in an area away from the location where surgery is performed
- shaving equipment that comes in contact with the patient is discarded in biohazard container
- if depilatory is used, patient must be tested for sensitivity to the agent - minimum of 12 hours
- when removal of a lot of hair necessary, hair can be returned to the patient after surgery
- eyebrows are never shaved
supplies for skin prep
- sterile gloves
- gauze or foam prep sponges
- sponge forceps
- antiseptic pain prep
- antiseptic scrub soap
- sterile water
- several small basins
- cotton-tipped applicators as needed (abdominal prep)
antiseptics commonly used for surgical skin prep
- chlorhexidine gluconate
what does alcohol solution contain?
at 70% concentration, it is 95% effective against both gram-negative and gram-positive bacteria, mycobacteria, fungi, and viruses
what is alcohol prep not completely effective against?
how does alcohol destroy microorganisms?
through desiccation (drying out) of the cell proteins
what body parts is alcohol never used on?
- mucous membranes
- open wound
forms of alcohol prep solutions
- combined with other antiseptics
broad-spectrum antiseptic that has better microbial action than pvoidone-iodine
advantages of chlorhexidine gluconate?
- provides residual activity (continues to kill microorganisms after application)
- not absorbed by the skin
disadvantages of chlorhexidine gluconate?
not effective in the presence of soap and organic debris such as skin oils, blood and body fluids
how is chlorhexidine gluconate used as preoperative bathing?
patient first must bathe normally and chlorhexidine solution is then used as a final wash after all traces of soap have been removed from skin and hair
is chlorhexidine gluconate used for ears or face, or large, open wounds?
no - linked to hearing loss
- iodine combined with povidone
- effective against gram-positive bacteria, but weaker against gram-negative organisms
absorbed through the skin and may cause toxicity - must be rinsed from the skin
antiseptic commonly found in deodorants, antibacterial soaps and other proprietary cosmetics
why is triclosan use limited in surgery?
its full microbial effect occurs with only repeated application
which prep solution is safe for the face and ophthalmic uses?
- limited use in surgery
which prep solution is safe for use in eyes and ears?
is skin prep a sterile or nonsterile procedure?
two-stage skin prep
antiseptic soap solution followed by a coating of antiseptic
one-stage skin prep
antiseptic solution alone
procedure for skin prep
- assess prep site for any lesion or disruption in skin
- clean site if grossly contaminated before prep
- prepare prep supplies on a small table near the patient
- don sterile gloves (open glove)
- place 2 or more sterile towels on either side of patient to catch any prep solution that might pool
- dip prep sponge in solution and squeeze out excess
- start prep at incision site and move outward in circular motion
- any area highly colonized with microorganisms is prepped after surrounding area has been prepped
- blot soap from skin with towel
- for 2-stage prep, antiseptic pain solution is applied to the surgical site
- allow to air-dry
- document skin prep in patient's chart
what type of burns result when prep solutions are allowed to pool under the patient?
what can pressure and contact with the chemical over time result in?
severe blistering and skin loss
how do we prevent burns?
prep area should be framed with sterile surgery towels that can absorb the excess solution at the periphery of prep area
where are towels tucked to prevent burns?
towels must be tucked between the operating table and the pateint to catch any runoff solution and are removed after the prep
what can cause a fire on or inside a patient?
- when alcohol solution or volatile fumes come in contact with heat sources
- risk is greater when in the presence of concentrated oxygen or in an oxygen-enriched environment
- ignition can occur during electrosurgery or laser surgery
what cavities are particularly at risk for fire?
closed cavities, such as the throat, that are small, contained areas
what can we do to prevent a fire arising from a prep solution?
make sure the prep area, towels, linens, and operating bed are dry before applying sterile drapes
should prep solutions be warmed in a microwave or autoclave?
no - heating in this manner is uncontrolled and the exact temp is unknown
what happens when iodine is heated in a closed container?
it combines with free oxygen, causing the iodine to be lost from the solution, which reduces its concentration
supplies for prepping the eye
- adhesive barrier drape
- lint-free cotton balls
- small basins with warm saline solution and prep solution
- bulb syringe
- start at the eyelid
- prep in a circular pattern around the eye to within 1 inch of the hairline, including nose, cheek, jaw on affected side
- prevent prep solutions from entering the patient's ear by placing a cotton ball at the ear canal opening or an adhesive barrier drape along the side of the face
- repeat prep at least 3 times, using fresh sponges each time
- rinse the prepped area using warm saline and cotton balls at least twice
- pull the conjunctival sac slightly downward while flushing with normal saline solution with a bulb syringe
supplies for prepping the ear
- mild prep solution (triclosan or PCMX)
- normal saline
- small plastic drape with adhesive edge
- cotton-tipped applicators
- use sterile drape to exclude eye on affected side
- cleanse and rinse folds of the pinna with cotton-tipped applicators with appropriate prep solution
- extend the prep area with sponges to the edge of the hairline, face, jaw
face prep solution
supplies for prepping face
- nonalcohol prep solution
- warm saline solution
- cotton swabs
- cotton-tipped applicators
- comb and water-soluble hair gel (nonsterile)
- apply gel to hair and comb back, clipping back as necessary
- place towel on each side of the neck
- prep the face from the neck or chin upward to the hairline - ears may be included
- cleanse the folds of the pinna with cotton-tipped applicators
- rinse skin with cotton sabs dipped in warm normal saline solution
for what types of procedures would the neck and throat area be prepped?
- thyroid surgery
- carotid artery surgery
- lymph node biopsy
- radical dissection of the mandible, shoulder plexus, and mediastinum
neck/throat prep area
extends from the chin to the nipple line or waist and around the side of the body to the operating table on each side
prep area for radical breast or thoracic surgery
extends from the chin to the umbilicus and includes the lateral thorax on each side
prep area for removal of breast mass
- from the clavicle to the midthorax and from the midline, including the sides of the thorax to the operating table on the affected side
- extended to the axilla for leasions in the upper lateral quadrant of the breast
prep area for radical mastectomy
encompasses the neck, shoulder of the affected side, thorax to the operating table surface, and midpelvic region
prep area for shoulder procedure
includes neck, shoulder, upper arm, and scapula on the affected side
prep area for arm procedures
- if nerve block will be performed, the entire arm is usually prepped with the hand prepped but excluded from the operative site by a occlusive drape (stockinet)
- if site is on upper arm, prep extends several inches above the elbow
prep area for hand procedures
- upper boundary is a few inches above the elbow
- if Bier block used, prep required to the level of the tourniquet
prep area for abdominal procedures
extends from the nipple line to midthigh and both sides of the body to the operating table
prep area for back procedures
extends from the neck to the sacrum
how is the vaginal prep performed?
- patient is put in lithotomy position
- lower table break is flexed downward
- place kick bucket at the foot of the table to receive used sponges
- impervious drape placed under the buttocks with the tail of the sheet in the kick bucket to drain excess prep solution
in how many stages is the vaginal prep performed?
two-step vaginal prep procedure
- pelvis, labia, perineum, anus and thighs are prepped first
- vagina is prepped separately
why is a two-step vaginal prep procedure used?
to ensure that bacteria from the external genitalia and perineum are not introduced into the vagina
how is the perianal prep performed?
- patient is in the prone position
- midpelvis break in the operating table
- surrounding area of anus is prepped first and anus last
- similar to that of the arm
- prep extends from the ankle to the groin
- entire leg is prepped and the foot is wrapped in a separate drape
- prevent prep solutions from seeping under the tourniquet cuff if used
circumferential prep from the midcalf to the iliac crest, excluding the groin
who preps a trauma patient with protruding objects from wound?
remove all foreign material and trim away devitalized tissue from wound
where does preliminary debridement take place?
- emergency department
- in some cases, in a separate treatment room to prevent gross contamination of the surgical environment
graft that is removed from one site on the patient and grafted to another site
when is draping performed?
immediately after the skin prep
what is the purpose of draping?
- to provide a wide sterile area around the surgical site
- act as a barrier surface between nonsterile objects and the sterile field
what are drapes made of?
woven (cotton or cotton-synthetic blend) or nonwoven material (bonded synthetics)
sterile body sheet with a hole that exposes the surgical site:
drape with adhesive on one side and may be impregnated with antiseptic:
last drape to be applied:
procedure or specialty drape
guidelines for aseptic draping
- handle drapes with as little movement as possible
- do not touch the patient's body (or any nonsterile surface) when draping
- do not move the drape after it is placed
- use only nonpenetrating towel clamps for securing drapes
- any portion of the drape that falls below the edge of the table is contaminated
- after drape is placed, edges are nonsterile
- do not reach over prepped surgical site to place drape
- use only impervious drapes to avoid strike-through contamination
- use drapes fitted with pocket reservoir and drainage system for procedures with risk of excessive fluids or blood
- aluminum-coated drapes used when laser surgery is planned
- plan for draping
- place plain sheet over legs
- place four towels in a square to frame surgical site
- plastic incise drape may be applied over the towels (2 people)
- smooth the plastic drape over the contours of patient's skin
- center fenestrated drape over teh incision site and unfold to provide sterile field
for what type of procedures is lithotomy/perineal draping used?
- gynecological surgery
- transperineal surgery of prostate
- combined abdominal-perineal resection of colon
- for GYN surgery, place barrier between anus and vulva
- apply adhesive towel across perineum midway between vulva and anus
- cover legs with leggings in stirrups
- center fenestrated sheet over perineal area and extend it upward over patient's abdomen and upper body
- wrap towel around pneumatic tourniquet
- place stockinet over foot and unroll
- secure split drape around proximal part of the limb
- apply fenestrated drape to complete surgical field
hand or arm draping
- suspend hand and forearm while first drape is placed on surgical arm board
- wrap proximal arm with a towel and cover pneumatic tourniquet
- cover arm with stockinet
- position split sheet with tails draped toward hand
- place arm through fenestrated sheet and complete sterile field
- place patient in Fowler position
- suspend arm away from body
- place impervious drape between upper torso, shoulder and operating table
- position sheet over torso
- use towels to frame the shoulder and cover them with incise drape
- apply split drape
- place arm and shoulder through fenestrated sheet
why is head drape performed?
occasionally used for nose and throat procedures to maintain a sterile barrier between the face and head
how should you remove drapes?
- pull them away from the patient, starting at the patient's head and proceeding to the feet
- remove one layer at a time
all patients are identified in how many ways?
at least 3
where is the patient's chart?
must accompany patient whenever the individual is transported from the unit
- patient's identification band - compare with chart
- ask the patient to state full name
- ask the patient to tell what procedure is planned and point to the side on which the surgery will take place
transferring patient from bed to wheelchair
- help patient to a sitting position
- help patient to a standing position
- back to a sitting position in the wheelchair
- free any tubes or lines
assisting patient from standing position to wheelchair and transporting
- rotate entire body as the patient does the same until the patient's back is lined up with the wheelchair
- slowly lower the patient into the wheelchair, spreading your feet shoulder width apart
- bend knees
- place patient's feet on footrests and cover patient with blanket
- make sure you have patient's chart
- pull wheelchair backwards into elevators/doorways
transferring patient from wheelchair to bed or OR table
- place table/bed at lowest height
- place wheelchair in line with bed and lock wheels
- lift patient by placing your arms under patient's arms
- place bracing foot back and rotated slightly outward
- lift patient up, rocking back on bracing foot, rotating your body with patient's until positioned to sit on edge of bed/table
- ease patient to lying position and place blanket
assisting ambulatory patient
- position yourself behind patient's shoulder while helping patient walk
- when patient is falling, ease patient to the floor while protecting the person's head
- follow patient's movements with your own body
- immediately call out for assistance
- do not abandon patient
elements of safe positioning of patients
- knowledge of anatomy, physiology, and patient's specific medical condition
stainless steel or Plexiglas attachment that slides under the patient and holds the arm at the patient's side
toboggan (also called a sled)
skin and deep tissue injury causing pressure in areas caused by improperly placed padding
nonblanchable erythema of intact skin
stage-I pressure ulcer
partial-thickness skin loss involving epidermis and/or dermis
full-thickness skin loss involving damage to or necrosis of subcutaneous tissue - may extend down to underlying fascia - deep crater without undermining of tissue
full-thickness skin loss with extensive destruction, tissue necrosis or damage to bone, muscle, or supporting structure