Transcript APNC Role of a Scrub - Alaska State Hospital and Nursing Home

Welcome to Role of
the Scrub Nurse
Agenda for this afternoon
*Terms and definitions
*OR Traffic and Surgical attire
*Case and room prep
*Role of the Scrub
*Counting
*Safety
Key Terms & Definitions
• Asepsis: Absence of microorganisms that cause
disease; freedom from infection; exclusion of
microorganisms.
• Contaminated: Soiled or infected by microorganisms
• Cross Contaminated: Transmission of microorganisms
from patient to patient and from inanimate objects to
patients and vice versa.
• Decontaminated: Cleaning and disinfecting or sterilizing
processes carried out to make contaminated items safe
to handle.
• Fomite: Inanimate object that may be contaminated with
infectious organisms and serves to transmit disease.
Key Terms & Definitions continued
• Sterile: Free of living microorganisms,
including all spores.
• Sterile Field: Area around the site of incision
into tissue or site of introduction of an
instrument into a body orifice that has been
prepared for the use of sterile supplies and
equipment. This area includes all furniture
covered with sterile drapes and all
personnel who are properly attired in sterile
attire.
• Sterile Technique: Methods by which
contamination with microorganisms is
prevented to maintain sterility throughout
the surgical procedure.
O.R. Traffic
• Unrestricted Area – Any area outside the
department; street clothes acceptable
• Semi-restricted Area – Support areas within the
department (PACU/recovery, store rooms). OR
scrubs and caps required.
• Restricted Area – OR suites, procedural rooms,
central cores, and scrub sinks. Complete OR attire
required, including cap, mask, face shield or eye
protection
• 1st gloves worn in 1890
Surgical Attire
• Gauze masks were advocated in
1897 when a “droplet theory of
infection” was demonstrated
• 1st Cap and sterile gowns were
worn in Germany in 1827
• In 1910 the use of sterile
instruments, gowns, gloves, masks
and caps became standard
practice in the larger university
hospitals
• The white morning coats changed
to aprons, then to gowns. They later
changed the color to a green for
eye comfort.
Surgical Attire
• Check each of your facilities policy
on surgical attire
• You need a head cover to cover all
your hair, side-burns, and neckline
• Sterile gowns must be worn when
setting up the sterile field or
assisting at the surgical field
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Sterile gloves must be worn for
each case.
• Shoe covers should be worn to
protect your shoes and prevent
tracking blood throughout the
facility. They are recommended
Surgical Attire Continued
• Masks decrease the spread of microbial droplets from
the mouth and nose of the OR personnel to the patient. It
also provides protection to the staff from aerosolized
pathogenic organisms from the patient
• eye protection, googles, or masks with eye shields
• Jewelry must be contained within scrubs. No long
earrings and studs must be contained under your cap.
No rings, bracelets, or watches as they can harbor
bacteria or harm a patient
• Fingernails must be short and clean. Nail polish can be
worn if not chipped or cracking, but not good practice.
NO ARTIFICIAL NAILS. Fingernails can harbor gram
negative organisms
Pre-op Preparation
Case preparation
• Choose cases with your preceptor
• Review procedures for the day before you
scrub
• Review anatomy, procedure, instruments
• Review preference cards- see following
example.
• Pick case (if applicable)
Room preparation
– Team work is vital, sharing of work, the circulator may
be getting positioning supplies and the scrub may be
getting sterile supplies
– Establish necessary room furniture i.e. beds, back
tables, suction, cautery.
– Damp dusting the flat surfaces and
overhead lights for first case
– "Throwing the case around
the room" a term used to set
around supplies and sterile
instruments.
OR Room
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Correct OR table
Back Table
Mayo Stand, 1 or 2
Ring Stand, 1 or 2
Anesthesia machine
Positioning equipment
Kick bucket , 2
Counting bags
Prep stand
Additional equipment (i.e.
IV Poles, SCD, Suction,
Bovie, & Bair Hugger)
Roles of the Scrub RN
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Establishing the sterile field
Scrubbing, gowning, and gloving
Counting
Anticipating needs of Sterile Team
Sharps Management
Medication on the field
Draping
Drains
Specimens
Passing Instruments
Maintains neatness and
functionality of sterile field
Draping the Back Table
Draping the Mayo Stand
• The scrub steadies the stand
with one of their feet as he
places the drape over the end
of the stand nearest him. The
circulator assists by pulling
the unsterile end of the cover
over the stand
• The scrub touches the
sterile portion of the
cover with sterile gloves.
Note the scrub stands
away from the stand as he
places the cover on the
Mayo stand. Both
circulator and scrub are
holding the stand in place
with their feet.
Opening Supplies
• Verify procedure and supplies to the
preference card
• Check package integrity, indicator tape, &
expiry date
• Opening packages aseptically onto sterile
field. Never reach over the sterile field
• Don’t drop heavy items to prevent tearing
and strike through
• Place sharps where they are clearly visible
Opening Supplies
*Place the scrub’s gown and gloves on a separate
table or mayo stand
*The back table is only sterile at table level
*There is nothing sterile below the edge of the table.
Do not grab the table by the edge, place hands on top
move it with your hands
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*Do not bring anything back UP to table level
*Once drape is in place, do not move or shift it
*Solutions poured into containers on the sterile field
should not be recapped to save for later. The edge of
the container is considered unsterile….
Opening Supplies Continued
IF there is any doubt, do not place the item
in question on the field
Do not place hot instruments/instrument
pans on the COOL back table.
When adding a sterile solution, have the
scrub nurse hold, or place, the sterile
receptacle near the table’s edge
Establishing the Sterile Field
Sterile Field Manners
• Observe good sterile technique
• Always face the sterile field
• Never leave the room unattended
when you have an open sterile field
• Never cover a sterile field (*)
• Always place a scalpel where it can
be clearly seen and use an instrument
to attach the blade to the handle.
• Always be aware of O.R. traffic; do
not allow anyone unsterile to walk
between two sterile fields
Sterile Field Manners Continued
• Needles need to be placed so they will not
penetrate the drapes, and they are clearly visible
• Arrange the instruments, pans and supplies on
the back table and mayo stand per department
routine or as your preceptor instructs
• Never turn your back to the field
• Never lean on sterile field
• Secure all cords and ALWAYS holster your
cautery pencil
• Do not stand with your hands folded in your
armpits
• Remember, in an emergency you will do what is
habit. Develop good habits.
Draping
 Incisional area is squared off with towels
 Up or down sheets may or may not be used (U Drapes)
 Primary drape placed, usually starting at incisional area, then
unfolded to the sides, then to the head and feet.
 Should not be moved once placed.
 Basic types of drapes: fenestrated, limb, split, or lithotomy
 Can add a sterile, plastic, adhesive drape to incision site (Ioban)
 Drapes can be secured using suture, staples, towel clips
Back table set-up: the 8 P’s
1. Proper Placement – drapes, suction,
tourniquet, ESU, bed, back table.
2. Proper function – all equipment
tested for proper function before use.
3. Place it Once – Instrument location
should remain similar on back table,
mayo.
4. Point of Contact – passing
instruments securely to prevent
fumbling, keep scalpel blade down in
passing.
8 P’S
5. Position of Function – C-arm, laser
position should be preplanned to
prevent disruption
6. Point of Use – Items like basins,
cautery should remain near the area
of use.
7. Protected Parts – Pad the patient,
use safety devices, don’t rest on the
patient with arms, secure needles to
prevent harm.
8. Perfect Picture – keep environment
uncluttered, free of hazards.
Anticipate
• Review the procedure before entering the
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case
Watch the field, pay attention
Practice listening to the surgeon, they
mumble!
Ask questions to your preceptor or surgeon
Learn the routine sequences – Clamp, cut,
tie or suture, scissors
Know your instruments
Ask for more supplies before they
run out
Scrubbing, Gowning , Gloving
The purpose of the surgical hand
scrub is:
 To remove dirt and skin
oils
 To remove transient
microorganisms
 To reduce the number
of resident organisms
 To prevent the growth
of microorganisms for
as long as possible
 The surgical hand
scrub may be timed or
anatomical
 New to the practice is
the alcohol based,
waterless hand scrub;
follow hospital policy
and manufacturers
directions
Types of Surgical Hand Cleansers
“Surgical Scrub”
• Surgical hand scrubs
should be broad
spectrum, fast acting,
effective, non irritating,
prolonged action
• Common types of
scrubs
– Chlorhexidine Gluconate
(CHG)
– Iodophors (Iodine)
*Recommend
Chlorhexidine
Gluconate
*Scrub brush or
waterless technique
*Waterless technique
-do mechanical wash 1st
-then use 1 pump, dip nails,
then go up arm, 2nd pump
dip nails and go up other
arm, 3rd pump, just do hands
-rub hands to create friction
and let completely dry
Demonstration of Gowning,
Gloving
 Closed gown gloving
 Open gown gloving
 Gowning and gloving someone else
 Re-gloving during a case
 Removing gown and glove at end of case
Scrubbed Personnel Traffic Patterns
Meds and Solutions on the Field
 Confirm all medications from Preference Cards,
with the Surgeon, prior to case
 Always read the label
 Verify the medication, strength &
expiry date with circulator and scrub nurse
 Confirm patient allergies
 Label all receptacles on the field before administering
the medication/solution to field
 Always verbally identify the medication to the
surgeon before you pass it to the surgeon to be
administered
 Check for temperature of solution before using as
irrigation
5 R’s of Administering
Medications/Solutions
• Right Patient
• Right Medication
• Right Dose
• Right Route
• Right Time
Always use two Identifiers before administering
Medication (i.e. Pt. name, MRN, DOB…)
Counts
Sponges, Sharps, Needles and
Instruments
Before Procedure Begins
•Count sponges, sharps and instruments and misc items
in their categories before moving on to another
category. (i.e., all Lap sponges, then all Raytecs (4x8
sponges), then all suture needles then all blades)
•Count with two people viewing each item; one of which
must be a licensed personnel (RN). Count out loud
together
Only x-ray detectable sponges and items to be used
during procedure
•Never remove counted items from the room,
•Keep all garbage in room until end of case
During a Procedure
 Count before closure of a
cavity within a cavity,
uterus, bladder
 Before wound closure
begins, 1st layer, fascia
 At skin closure or the end of
the procedure, final count
 At permanent relief of either
scrub and/or circulator
Nearing the end
• Start at the surgical site, move to
the mayo and back table then to
items off the field
• Sponges must have
a radiopaque strip &
must not be used for
dressing sponges
• Notify surgeon of
final count
Incorrect Counts
 Notify Surgeon so he/she can search the wound.
 Search the sterile field, floor, trash, linen and
room
 Recount thoroughly all bagged items and
countable items from the field.
 X-ray done prior to patient
leaving the room
• Complete Event Report.
General Information
• Never remove counted items from the room
• Count all parts of a disassembled instrument
• Count suture needles as identified on
package
• Raytec’ s are not to be used
• as dressings/packing
• Remove from the field/room
any newly opened packages
of sponges that have an
incorrect number count
Counting Sharps and
Instruments
 Account for all parts
of a broken item,
needle, instrument,
vessel loops,
sponge
 Establish a zone
where sharps are
passed hands free
 Keep needles in a
needle container
SHARPS SAFETY
IN THE OPERATING
ROOM
OSHA’S COMPLIANCE
DIRECTIVE
*Directs field inspectors to cite employers
for failure to eliminate or minimize
occupational exposure to blood.
*Stated recommendations for safe
practices include: “No hands passing” of
sharps, blunt suture needles where
applicable, and use of other safety
devices like safety scalpels, magnets,
and safety needles.
Protect yourself and protect your team!!
Don’t be the next
statistic!!
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OR usually accounts for the most significant
amount of total injuries
Utilize Safety Devices
Do not disable safety
devices!!
They are here to protect
YOU!
Utilize a “No Pass Zone”
When receiving and returning
Sharps
Remember…
Practice Safe
Sharps!!!
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Intra-op Instrument Care
Keep set up neat and
organized
Keep instruments clean of
debris and blood, wipe with
sterile water
Remove broken or dull instruments from the
field and tag for repair/replacement.
Never dump heavy instruments onto delicate
ones
Keep tips visible for ready identification.
Keep sharps visible and safe, use needle pad
or magnet
Keep the cautery pencil in its holster when not
in use
Incisions
1 - Subcostal - Biliary procedures,
gallbladder and pancreas ( Lt.
Subcostal for the spleen)
2 - Midline – most common for
exploratory lap
3 - McBurney – RLQ for
appendectomies
7 - Transverse – General access
8 - Oblique – Open Inguinal
Hernias
9 - Pfannenstiel – for C-sections
Drains
 Drains may be placed deep or superficial.
 Drains may or may not be tied/sutured in place.
 Reservoir may be used.
Dressings
• Deliver dressings after counts
are done and wound is closed.
• Types include, 4x4’s, Telfa, ABD,
Benzoin, Kerlix, Ace wrap etc.
• May be placed over a drain site.
• Apply appropriate adhesive.
Specimens
• Can consist of blood, soft tissue, bone, body fluid,
and foreign bodies
• Document & Label the specimen (pt. name, type
of specimen, source/location, required tests, and
special handling needs)
• MD must provide the description and RN repeat it
back, very important
• Need a diagnosis on the Pathology card
Specimen treatments
– Fixed: place specimen in a container of preservative,
label with patient information and send to Pathology.
– Frozen Section: placed on a saline moist Telfa and put
in an empty container, send to Pathologist as soon as
possible. A frozen section pathology report is usually
called into the O.R. by the pathologist. The wound is
usually not closed until that report is called into the
room.
– Fresh Section: placed on a saline moist Telfa and put in
an empty container, send to Pathologist as soon as
possible. A fresh specimen will require special
treatment, but does not need an
immediate report back to the O.R.
by the pathologist.
Preventing Surgical Fires
Momentary Lapse of Caution
Surgeon
Heat
Fuel
Oxidizer
Nurse/Surgical
Technologist
Anesthesia
Provider
 Lasers
 ESU/ECU
 Fiberoptic
Light Sources
 Drills and Burs
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Draping
Gauze
Gown
Hair
Ointment
 Oxygen
 Nitrous Oxide
4 Types of Fires
(On or In Patient)
• Endotracheal Tube/Laryngeal
Mask Airway (Airway)
• Oral Cavity/Oropharyngeal
(Airway)
• Surgical Site/Hair/Skin/Sponges
• Drapes
*SURGICAL TEAM MUST PUT IT OUT!!!
Saline on Sterile Field on ALL
Cases
Small Surgical Fires: Smother or
Remove
DO NOT FAN IT!!
P.A.S.S.
• PULL the activation pin
• AIM the nozzle at the base of the
fire
• SQUEEZE the handle to release
the extinguishing agent
• SWEEP the stream over the base
of the fire
If evacuation is necessary:
R.A.C.E.
• REMOVE the source, RESCUE the
patient
• ACTIVATE; call emergency
number/code and activate the
alarm
• CONTAIN flames and smoke; pull
doors closed
• EVACUATE & EXTINGUISH the fire
and prepare to evacuate
Post op Responsibilities
Dispose of sharps appropriately.
Dispose of biohazardous linen, sponges,
properly.
Dispose of biohazardous material (blood
and fluids) appropriately.
Open all instruments and place in water,
heavy instruments on bottom, sharp and
delicate instruments protected.
Once sharp and non-disposable items are
cleared, roll up back table cover and
throw away.
Be alert to patient needs.
Assist with patient transfer.
Room
Turnover
• Wipe surfaces
• Wash splashes from
walls and equipment
• Wet mop floors
• Replace anesthesia
supplies
• Wipe & replace the room
furniture
• Restock room per
department procedure
PNDS
Domain
Outcome
Nursing
Intervention/Action
Safety
O2. The patient is free from
signs & symptoms of injury
caused by extraneous objects.
I11. Prepares, applies, attaches, uses,
and removes devices and takes action
to minimize risks.
I93. Ensures that the patient is free
from injury related to retained
sponges, instruments, & sharps.
O3. The patient is free from
signs & symptoms of
electrical injury.
I72. Prevents skin & tissue trauma
secondary to active electrode handling.
O10. The patient is free from
signs & symptoms of
infection.
I70. Initiates the actions necessary
related to risks associated with diseasecausing microorganisms by creating
and maintaining a sterile field,
preventing contamination of open
wounds, and isolating the operative
site from the surrounding non-sterile
physical environment.
I81. Restricts access to patient care
area to authorized individuals only.
Health System
Additional PNDS for the Scrub
Nurse
Domain
Outcome
Nursing
Intervention/Action
Safety
O2. The patient is free from
signs & symptoms of injury
caused by extraneous objects.
I84. Collects, identifies, labels,
processes, stores, preserves, and
transports specimens.
O3. The patient is free from
signs & symptoms of laser
injury.
I73. Provides safety equipment and
protective measures during a
procedure using laser sources.
O9. The patient receives
appropriate medication(s),
safely administered during the
perioperative period.
I8. The correct prescribed medication
or solution is administered to the right
patient, at the right time, in the right
dose, via the right route.
I123. Identifies allergies, sensitivities
to medications.
O10. The patient is free from
signs & symptoms of
infection.
Designates the appropriate wound
classification category for each surgical
wound site according to the CDC and
Prevention.
Health System
Newly graduated Scrub Nurses, circa.
1900’s