Download General Patient Care and Safety

General Patient
Care and Safety
Objectives
• Describe preoperative routines.
• Identify, describe, and demonstrate the
principles of transportation of the
surgical patient.
• Discuss, demonstrate, and apply the
principles of surgical positioning.
• Understand the methods of preparation
of the operative site for surgery.
Objectives
• Describe the application of
thermoregulatory devices.
• Explain the principles and demonstrate
the taking and recording vital signs.
• Explain the principles of urinary
catheterization and demonstrate the
procedure.
Objectives
• Describe how the principles of the
surgical skin prep and catheterization are
related to patient care and asepsis.
• Discuss methods of hemostasis and blood
replacement, and demonstrate the use of
appropriate agents or devices.
• Discuss methods of documentation in the
OR.
Objectives
• Identify developing emergency situations,
initiate appropriate action, and assist in
treatment of the patient.
• Discuss the relationship between patient
safety and the surgical environment.
Preoperative Patient Routines
• Prior to surgery, the patient must have
certain information and tests performed.
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History and Physical
Lab tests and results
X-rays
Preoperative checklist
Special needs and allergies
Consent
• Surgical, Anesthetic, Blood products,
Sterilization.
Preoperative Education
• Preoperative education is
intended to:
– Alleviate anxiety
– Educate the patient about
expectations before, during,
and after the procedure.
– Teach pre-op and post-op
behaviors that may promote
faster recovery.
Admissions Procedure
• Patient arrives evening before or morning of
surgery.
• Required paperwork completed.
• Identification bracelet.
• Vital signs
• Patient changes clothes
• IV’s are started
• Preoperative medication
• Transported to the Operating Room.
Informed Consent
• Patient must sign before any procedure.
• Signing implies that patient has been
informed of the procedure and any
possible complications.
• Patient may refuse or change their mind
at any time.
Informed Consent
• Includes risks of surgery in general and
risks for specific procedure.
• Usually contains a clause specifying
permission to perform further action, if
during the operation, conditions arise to
modify the procedure.
• Anesthesia risks are stated.
Informed Consent
• Patient must sign before preoperative
medication have been given.
• If patient is unable to give consent, a
spouse, legal parent or guardian, or 2
agreeing physicians.
Informed Consent
Informed Consent
Patient Possessions
• Patient is instructed to keep all valuables
at home, but any remaining will be
collected and given to family members or
locked in a secure place.
• Religious medals
• Dentures, Glasses, Hearing aids
• Wedding rings.
Preoperative Routines
• Pre-Op enemas may be indicated for
certain Gastrointestinal or Gynecological
procedures.
• Nail polish should be removed as it will
interfere with the pulse oximeter.
• Preoperative showers are performed by
the patient before surgery with
antimicrobial soap.
Preoperative Routines
• Pre-Op sedation medications may be
administered to help alleviate anxiety 1-2
hours before surgery.
– Must have consent signed first.
– Patient should not be left alone.
– Safety devices such as safety strap and bed
rails must be used.
Preoperative Routines
• Pre-Op shave if indicated will
be performed by a nurse or
nursing assistant in pre-op
hold area.
• Clippers (preferred) or razor
will be used.
• Take care not to nick or cut the
skin.
• Remove any loose hair so it
will not end up on sterile field.
Preoperative Routines
• To prevent aspirations, patients will be
placed NPO (nothing by mouth) at least
4-8 hours before surgery.
– Nothing after midnight
• May be modified if patient is to have local
or spinal anesthesia.
• Notify surgeon if patient consumed food
or drink, procedure may be rescheduled.
Preoperative Routines
• Patients are instructed not to wear makeup, as it may contaminate sterile field and
interfere with skin coloration.
• Patients typically are required to remove
all clothing and change into hospital
gown.
Preoperative Routines
• When the operating room is ready, the
patient will be asked to void if indicated.
– Foley catheter will be placed after anesthesia
• Patient ID checks and vital signs are
taken just prior to transport.
• Accompanied family are moved to
waiting room and informed about
approximate time and update process.
Patient Transportation
• Patients are taken to the OR in many
ways.
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Gurneys
Ward beds
Wheelchairs
Walking
Isolettes or cribs
Patient Transportation
• Ensure that proper safety devices and
body mechanics are used at all times.
– Rails, Safety straps, Wheel locks, etc.
• Extra personnel available if needed.
– Large patients, extra equipment.
• Patients transported feet first.
– Elevators head first.
• Never leave patients unattended.
Patient Transfer to OR Bed
• Obtain correct number of personnel.
– At least 2 for patients able to move
themselves.
– At least 4 for patients that are not able to
move themselves.
• Position gurney next to OR bed and lock
the wheels.
Patient Transfer to OR Bed
• Instruct the patient not to move until you
give the command.
• Position personnel at the sides and ends
of the gurney and brace themselves
against it.
– Take care to protect IV, Catheter, and
Oxygen tubing, so they do not become
entangled.
Patient Transfer to OR Bed
• Keep patient covered and assist them in
moving over to the OR bed.
– May use roller or draw sheet.
• Apply the Safety Strap and remove
gurney from the room.
• Ensure comfort of the patient for
induction.
Patient Positioning
• Goal is to provide best access and
visualization of surgical site without
causing physical harm to the patients
joints, skin, or other body parts.
• Must also provide for IV and anesthetic
agent administration.
Patient Positioning
• Factors to consider when positioning:
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Planned surgical procedure
Surgical approach
Conditions of the patient
Age/Size
Anesthetic
Patient Positioning
• Safety considerations when positioning:
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Ensure adequate personnel
Provide for warmth and comfort
Bed locks, safety straps.
Do not move patient without permission.
Arm not extended more than 90*
Do not rest mayo stand and other equipment
on the patient during the procedure.
Patient Positioning
• Supine position
Supine Position
– Patient flat on back with arms at side or on arm
boards.
– Pad all bony prominences.
– Safety strap 2 inches above knees.
– Used for procedures of the anterior surface of
the body.
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Abdomen
Chest/Breast
Upper and anterior lower extremity
Pelvis
Patient Positioning
• Trendelenburg/Reverse Trendelenburg
Trendelenburg/Reverse
Trendelenburg
• Patient in modified supine.
• Uses gravity to assist with procedure.
• T-Berg
– Pelvis and lower abdomen.
• Reverse T-Berg
– Upper abdomen and Head/neck.
Patient Positioning
• Fowler’s position
Fowler’s Position
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Also known as “beach chair”.
Modification to supine position.
May be modified further to sitting position.
Procedures involving:
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Breast
Neck
Shoulder
Cranial
Patient Positioning
• Lithotomy position
Lithotomy Position
• Supine position with legs resting in
stirrups.
– Candy cane
– Allen
• Procedures involving:
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Perineum
Anus and Rectum
Vagina
Urethra
Patient Positioning
• Prone position
Prone Position
• Patient is lying on “face down”.
• Anesthesia and catheter insertion are
performed on the gurney before patient is
positioned.
• Procedures involving:
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Posterior lower extremity
Dorsal body surface
Spine
Posterior cranium
Patient Positioning
• Kraske/Jackknife position
Kraske/Jackknife Position
• Modification to prone position.
• OR bed if flexed in the middle.
• Procedures involving:
– Anus
– Pilonidal cyst
Patient Positioning
• Lateral position
Lateral Position
• Patient is placed on their side with
affected side facing up.
• Left lateral/Right lateral
• Bottom leg flexed/Upper leg straight.
• Axillary roll and double or universal arm
board.
• Procedures involving:
– Retroperitoneal space, Hip, or Thorax
Patient Positioning
• Kidney position
Kidney and Sims Position
• Modified lateral positions.
• Kidney
– Used for kidney surgery
– Table is flexed slightly
• Sim’s
– Used during colonoscopies
Thermoregulation
• Controlling the patients body temperature is
important.
• Patients lose much of their heat early on.
– Moved into cooler OR
– Little or no clothing
– Wet skin preps
• Hypothermia affects 60% of all surgical
patients.
Thermoregulation
• Heat loss occurs from:
– Radiation
– Convection
– Conduction
– Evaporation
• 80% of heat loss is thru
radiation and convection.
Thermoregulation
• Hypothermia causes problem intra and
post operatively.
• Vasoconstriction leading to increased
blood pressure.
• Shivering increases oxygen demand.
• Damage to surgical repairs.
• Strain on cardiovascular and respiratory
systems.
Thermoregulation
• Reduce heat loss by:
– Raising room temperature initially.
– Overhead heater
– Warm solutions.
– Warm blankets.
• Water circulating blankets
• Forced air warming blankets
Vital Signs
• Baseline vital signs are taken before
the procedure.
• Temperature, pulse, respirations,
and blood pressure are monitored
during the procedure.
Temperature
• Hypothalamus controls body temp.
• Several factors affect body temp.
– Environment, age, health, time of day.
• Can be monitored:
– Orally
– Rectally
– Axillary
Pulse
• 2 phases of the heart.
– Systole
– Diastole
• Measured by health care provider by
palpating an artery.
• Radial (wrist) –Most common
• Apical (Apex of heart) - Stethoscope
Pulse Points in the Body
Bradycardia <60 BPM / Tachycardia >100 BPM
Respirations
• Exchange of O2 and CO2.
– Internal and External
• Rate, rhythm, and depth are
monitored by the health care
provider.
• Normal adult 12-20 per minute.
Blood Pressure
• Pressure of the blood against the
walls of the blood vessels.
• Expressed as 2 numbers
– Systole – Contraction of heart
– Diastole – Relaxation of heart
Blood Pressure
• Measured by inflating a cuff around the
upper arm of the patient and listening to
the brachial artery.
• 5 Phases
• Systolic BP is recorded upon hearing first
heartbeat.
• Diastolic BP is recorded when the
heartbeat sounds disappear.
Circulator’s Sterile Tasks
• Among the various non sterile duties of a
circulator, some tasks require the
circulator to don sterile gloves.
– Urinary Catheter Insertion
– Surgical Skin Prep
Open Gloving
• Open glove wrapper on suitable surface,
touching only the outer edges.
• Pinch 1st glove at the cuff and pull onto hand.
• Using the 1st gloved hand, scoop the 2nd glove
behind the sterile cuff and pull onto other
hand.
• Make adjustments only touching the sterile
area of the glove with other sterile parts of the
glove.
Open Gloving
Open Gloving
Open Gloving
Urinary Catheterization
• Introducing a flexible tube into the
bladder via the urethra, to drain the
bladder of urine.
• Physician’s order in needed.
• Performed under sterile conditions.
Urinary Catheterization
• Indications:
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Decompression of bladder
Drainage of urine
Irrigation of the bladder
Control bleeding
Urinary Catheterization
• Considerations:
– Sterile technique
– Size, style, and materials
• Indwelling
• Latex allergy
– Balloon filled with sterile water
– Drains by gravity
– Secure to patients thigh
Urinary Catheterization
• Surgical techs may be called upon to
insert a urinary catheter.
• Sizes 8-30 French (14-16 Most common)
• Various materials and types
• Males in supine, Females should be “frog
legged”
Urinary Catheterization
• Procedure:
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Gather supplies
Open sterile catheter kit
Don sterile gloves
Drape the patient
Prepare catheter
• Test balloon
• Lubricate tip
Urinary Catheterization
• Procedure:
– Clean urethral meatus with antiseptic
• Females retract labia
• Males retract foreskin if indicated
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Keep “contaminated” hand on genitalia
Insert catheter until urine is seen flowing
Inflate balloon
Hang drainage bag
Surgical Skin Prep
• Performed to remove transient
organisms, and reduce resident
organisms from the patients skin.
• Similar to surgical hand scrub by sterile
team members.
• Skin cannot be sterilized!!
Surgical Skin Prep Solutions
• Alcohol – Provides rapid, significant
reduction in microbes. Drying effect.
• Iodine - Provides rapid, significant
reduction in microbes. May irritate skin.
• Iodophors – Less irritating to skin.
• Chlorhexidine – Reduction effect is not as
rapid, but longer lasting.
• Hexachlorophene – Must be used several
days prior to surgery. Build up effect.
Surgical Skin Prep
• Considerations:
– All necessary procedures are carried out
prior to skin prep.
– Site must be free of gross contaminates.
– Do not let prep solution accumulate under
the patient.
– Patient allergies
– Area to be prepped
Surgical Skin Prep
• Procedure:
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Check patient allergies.
Gather supplies.
Expose surgical site and place chux pads.
Aseptically open prep kit on appropriate
surface.
• Mayo stand or Prep stand
Surgical Skin Prep
• Procedure:
– Ask permission from anesthesia to begin
prep.
– Don sterile gloves using open glove technique.
– Check expiration dates on solution and pour
onto appropriate sponges.
• Scrub solution on scrub sponges
• Prep solution on paint brushes sponges
Surgical Skin Prep
• Procedure:
– If abdominal prep, begin with cleansing the
umbilicus with cotton tipped applicator.
– Take scrub sponge with scrub solution and
begin washing at the surgical site moving
outward in a circular pattern.
• Moving from clean to dirty
• Ensure that soiled sponges are not brought back
over an area already prepped.
Surgical Skin Prep
• Procedure:
– After all scrub sponges have been used, pat
the area dry with sterile towels provided.
• Be sure not to contaminate.
– Take a paint brush sponge, and begin
applying prep solution to the surgical site
moving outward in a circular pattern, using
the same rules as the scrub sponges.
• Continue with all paint brush sponges.
Surgical Skin Prep
• Procedure:
– Without contaminating remove chux pads,
and allow the prepped area to air dry.
• Tips:
– Do not allow prep solution to pool.
– If a sponge becomes contaminated, discard
and start with a new sponge.
Surgical Skin Prep
• Abdominal Prep
Surgical Skin Prep
• Left Chest/Breast Prep
Surgical Skin Prep
• Lower Extremity
Prep
– May have a
tourniquet
applied.
Surgical Skin Prep
• Upper
Extremity
Preps
– May have a
tourniquet
applied.
Surgical Skin Prep
• Perineum/Vaginal Preps
– May include internal vaginal prep.
Hemostatis
• Hemostatis is the arrest of the loss of
blood or hemorrhage.
• Occurs:
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Naturally
Mechanical methods
Thermal methods
Pharmacological methods
Natural Hemostatis
• Hemostatis is produced naturally by clot
formation (Coagulation) and vessel
spasm (Vasoconstriction).
• Injured blood vessels releases a
Prothrombin activator.
• Thrombin, calcium, and fibrinogen work
together to form a clot.
– Platelet plug
Factors Affecting Hemostatis
• Congenital preexisting disorder
– Hemophilia
• Acquired disorders
– Liver disease
– Anticoagulant therapy
• Heparin
– Aplastic anemia
– Aspirin therapy
• Discontinue 1 week prior to surgery
Mechanical Hemostatis
• Clamps
– Hemostats
– Vascular Clamps
• Ligature
– Using suture to tie off a blood vessel
– Stick tie
• Clips
– Small stainless steel or titanium used to
occlude the vessel
Mechanical Hemostatis
• Sponges
– Laps, Raytex, Cottonoids
– Used to absorb blood and apply direct
pressure to bleeding areas
• Pledgets
– Small squares of Teflon felt
– Used as suture buttresses exerting pressure
on needle holes to promote clotting
Mechanical Hemostatis
• Bone Wax
– Refined and sterilized bee’s wax.
– Mechanical barrier to seal off oozing blood
from bone.
• Suction
– Used during surgery to clear the surgical site
of blood and body fluids.
– Variety of sterile tips for different surgeries.
Mechanical Hemostatis
• Drains
– Used post operatively to remove blood and
fluid from wound.
• Tourniquets
– Often used during extremity surgery to
keep the operative site “blood free”.
– Careful application is needed.
– Must be periodically deflated for longer
surgeries.
Thermal Hemostatis
• Electrosurgery
• Monopolar
– Active electrode (Sterile)
– Dispersive electrode
(Grounding Pad) (Unsterile)
• Bipolar
– Forcep like tip
– Does not require placing a
grounding pad
Thermal Hemostatis
• Laser
– Intense concentrated beam of light.
– Able to cut and coagulate tissue with very
little surrounding damage.
– Follow all safety protocols when working
with a laser.
Pharmacological Hemostatis
• Absorbable gelatin (Gelfoam)
– Composed of collagen in pad or powder form.
– Deposits fibrin over bleeding area.
• Collagen (Avitene)
– Absorbable powdery substance of 100%
collagen.
– Forms sticky fibrin material.
Pharmacological Hemostatis
• Oxidized Cellulose (Surgi-Cel)
– Creates a rapid forming blood clot applied
directly to the bleeding surface.
• Silver Nitrate
– Used to control cervical or nasal bleeding.
• Epinephrine
– Vasoconstrictor
– Used with local anesthetics and Gelfoam.
Pharmacological Hemostatis
• Thrombin
– Bovine origin blood clotting
enzyme
– May be used directly onto
bleeding area, or used in
combination with Gelfoam.
Blood Loss
• Blood loss intraoperatively is monitored
by several methods:
– Suction containers
• STSR must keep track of amount of irrigation
fluid used.
– Weigh soiled sponges
• If blood loss is determined to be
significant, a transfusion may be ordered.
Blood Transfusions
• Blood typing and cross matching are needed
to ensure proper match.
• 4 types
– A, B, AB, and O
– RH + or RH –
• Careful checks are completed before blood is
given to patient to avoid hemolytic reaction.
Blood Transfusions
• Whole blood or blood products
may be indicated.
– Plasma
– Packed Red Blood Cells
– Platelets
• Homologous (Donated)
• Autologous (Stored patient blood)
– Cell Saver machine
Emergency Situations
• The STSR must be able to anticipate
emergency situations and prepare in
advance.
• This skill comes with time, but entry level
techs must be able to recognize basic
signs.
• The STSR must be able to react in a
quick and calm fashion.
Emergency Situations
• Indicators of emergency situations:
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Rapidly dropping blood pressure
Cardiac dysrhythmia
Changes in vital signs
Chest pain/difficulty in breathing
Changes in skin color/temperature
Confusion/Disorientation
Emergency Situations
• Treatment includes
– Ensure a patent airway and restore breathing.
– Maintain or restore cardiovascular status.
– Treat injuries:
• Chest
• Shock
• Wound closure
• Fractures
• Vital sign monitoring
• Reassurance and comfort for patient
Emergency Situations
• CPR
– All healthcare providers must be familiar
with this lifesaving technique.
– Certification by AHA or Red Cross
• Recert every 2 years
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A = Airway open
B = Breathing
C = Circulation
D = Definitive treatment
Emergency Situations
• CPR in the O.R.
– Primary responsibility of the
STSR is to remain sterile and
protect the sterile field.
– Keep track of instruments and
needles.
– May be asked to do open chest
massage.
– Sterility may become secondary.
Emergency Situations
• Malignant Hyperthermia
– Life-threatening, acute pharmagogenetic
disorder, triggered by an anesthetic agent.
– Rapid increase in body temperature
– Unexplained tachycardia
– Unstable BP
– Muscle rigidity
– May lead to renal failure, heart failure, or
death.
Emergency Situations
• Malignant Hyperthermia Prevention
– When patients have a predisposition to MH,
nontriggering anesthetic agents are used.
• Propofol
• Vecuronium
– Vaporizer, filter, circuit hoses are changed
and/or flushed with oxygen to ensure
removal.
– Careful monitoring by anesthesia provider.
Emergency Situations
• Malignant Hyperthermia Treatment
– Stop the triggering agent immediately
– Surgery may be stopped ASAP
• STSR must be ready for quick closure
– Various cooling methods may be used.
• Chilled peritoneal lavage
• Packing patient in ice
• Dantrolene is administered.
Emergency Situations
• Syncope
– Sudden loss of consciousness
– Caused by several factors:
• Disorders of arterioventricular conduction
• Ventricular asystole or fibrillation
• Bradycardia
– Notify physician
– Protect from aspiration
– Treat injuries
Emergency Situations
• Seizures
– Grand Mal (Most common)
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Loss of consciousness
Convulsions
Incontinence
Pre seizure warning signs
May have no memory afterwards
– Petit Mal
• Shorter in duration
Emergency Situations
• Seizures
– Focal
• Arise from motor and sensory nerves in
brain.
• Occur in patients with brain tumors and
arteriovenous malformations.
• Following all seizures patients may feel fatigued
and may have no memory of the event.
Emergency Situations
• Seizure management
– Primary duty of STSR is to protect the
patient.
– Maintain an airway
• Aspiration risk
• Mouth clenching
– After seizure calm and reassure the patient.
– Document
Emergency Situations
• Anaphylactic reaction
– Exaggerated allergic reaction to a
substance.
• Local anesthetics
• Contrast media
• Latex
– First signs are usually mild itching
and swelling.
– Leads to difficulty breathing due to
bronchospasm and laryngeal edema.
Emergency Situations
• Anaphylactic treatment
– Maintain airway and provide oxygen.
– Myocardial infarction is possible.
– Treat for possible shock.
– Give epinephrine to reduce spasm and raise
blood pressure.
– Levophed to increase blood pressure
• Key is to act quickly and be sure to check for
any allergies before giving medications, etc.
Review and Summary
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Preoperative routines / Consent
Patient transportation and positioning
Vital signs
Open gloving
Urinary catheterization
Surgical skin prep
Hemostatis
Emergency situations