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Operating Suite Student Orientation

Manual

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Orientation Package

Operating Suite

Welcome to Operating Suite This information package has been put together to assist your orientation to this area. It is a broad package aimed at providing information about the different facets and functions, specific to our hospital, and this department. We aim to provide a supportive working environment that will assist you in reaching both your personal and professional objectives.

If you have any concerns or require assistance with anything, please speak to the Nurse Unit Manager or senior staff. Most importantly, enjoy your time in Operating Suite.

Nurse Unit Manager

Unit Core Purpose Provision of evidence based, holistic care for all patients treated within the Perioperative Suite to individuals in the Bass Coast Shire and the surrounding districts.

Provision of a safe, supportive environment with emphasis on optimal patient outcome. To ensure all customers and stakeholder needs are met in a timely, efficient and safe manner.

Unit Core Values Excellence, efficiency, dignity, competency, compassion, equity of care, confidentiality, innovation and fiscal responsibility.

Operating Suite The operating suite consists of a number of different parts that made the whole perioperative experience, those parts include the following:

Pre operative assessment

Admission

Anaesthetic care

Intraoperative care

Recovery stage 1

Recovery stage 2

Discharge/transfer to inpatient accommodation Routine theatre lists are accommodated from 0830 – 1630 Monday to Friday. Semi urgent and Emergency cases can be booked at any time, that there is medical and nursing cover. Out of hours and at the weekend, the theatre suite is covered with both medical and nursing staff. Surgery undertaken includes general, colo-rectal, orthopaedic, urological, ear, nose and throat, ophthalmological, dental, plastics, gynaecology and endoscopy. We are presently seeking new services to complement existing services, so that more service can be offered at a regional level. Anaesthetic services provide a full range of services including, general anaesthetic, spinal, epidural, regional, local and intravenous sedation The Central Sterilizing Department provides sterilizing services to the Operating Suite and the wider organization, with documented evidence, this service meets all published guidelines and legislative requirements

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Staff Structure Each day there are differing operating lists, therefore varying numbers of nursing staff are required, but generally there is one nurse for each of the peri-operative fields. Division 1 and Division Two (medication endorsed) nurses can work across the full range of specialities, but this depends on skill level and individual preference.

Perioperative Zones & Attire There are basically three major areas - PACU, Theatre. CSSD The staff tearoom is a not a restricted area, this area allows personnel to wear clean clothing. All other areas in the perioperative suite are restricted areas, where theatre attire must be worn.

Attire can be found in respective change rooms.

Jewellery is not allowed in the Operating Suite, with the exception of stud earrings.

Staff are provided with uniforms. Unless you are required to attend meetings during the shift, it is permitted for staff to wear casual attire to and from work.

Portfolios Within the Operating Suite most staff members take care of a particular portfolio pertaining to their interest and expertise. Responsibility for portfolios can change and are as follows: Management Education Infection Control Policy & Procedure OH &S Back Injury Prevention Day Surgery Ophthalmology PACU/ Anaesthetics Dental General Surgery Colorectal Surgery Sutures Plastic Surgery Gynaecology Urology Orthopaedics Endoscopy Ear, Nose & throat

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Perioperative Fields

We hope to provide a multi-faceted experience for you; the areas that you will be required to work in are;

Day Surgery A large number of our input through operating suite comes through Day

Surgery. This is inclusive of their nursing admission, pre and post anaesthetic care unit, stage 2 and 3 recovery, and final discharge. Responsibility – Admission/discharge planning, pre op preparation of patient PACU A four bed Post Anaesthetic Care Unit exists for all post-operative patients. Those

patients not following through Day Surgery will be discharged to the Surgical Ward from this point. This area is close to the theatres therefore support, if needed, is nearby. Responsibility – Care of the patient post anaesthetic until stable or discharged to Stage 2/3 recovery/surgical ward. Restocking/checking resuscitation trolley Stage 2 This area is for the final recovery of patients through Day Surgery. A small

kitchenette facility lets staff attend promptly to food and fluid desires of the patients. After satisfactory recovery has been achieved, post-op education is given, and they are discharged home. Responsibility – Further observation within the confines of lounge chairs. Food and drinks to patients as tolerated. Planning and implementation of discharge. Anaesthetics Anaesthetics include; General, Local, Biers Blocks, Spinals, Epidurals,

Sedation and Brachial Plexus Blocks. These are all common types of anaesthetics used. Responsibility – Assisting the Anaesthetist with anaesthetic. Pre op checklist with patients prior to anaesthetic. IV orders, fluid balance charts, pain relief. Care of the unconscious patient. Circulating/Instruments As we provide a vast number of different operative procedures,

all nursing staff are educated to be proficient in at least one or both of these areas. Both these fields have a large emphasis on the importance of sterile fields, sterile packaging and handling of sterile instruments. Responsibility – Maintaining sterile field/technique. Assisting surgeon/s as required. Counting procedure with circulating nurse. Instrument preparation and checking for sterility

CSSD Instruments are decontaminated, packaged and sterilized within this area. A strict

tracking system of instruments ensures the effectiveness of the sterilizing process. Responsibility – Decontamination, packaging and sterilizing of instruments and equipment. Maintaining Tracking system for all instruments.

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Theatre Navigation

On your first working day one of the nursing staff will give you geographical orientation of the unit, walking you through all areas of the operating suite. You will then complete a Staff Induction Program Treasure Hunt.

Graduate Peri-operative Objectives

To gain an understanding of the role of the peri-operative nurse across all areas of clinical practice.

To be able to function within a supportive framework as a member of the peri-operative nursing team. Specifically, the Graduate Nurse should be able to function autonomously in the areas of Admission & Discharge, PACU, Scouting, Scrubbing (for minor procedures), and Stage 2 Recovery. It is expected that the Graduate Nurse will be able to assist another Registered Nurse (Division 1) in the areas of Anaesthetics and CSSD.

To gain a sound understanding of the ACORN Standards and Policy and Procedures relevant to the Operating Theatre Suite. A list of specific Standards is provided below.

To understand the importance of functioning within the Graduate Nurse’s capabilities and skill level.

Graduate Peri-operative Allocations

The perioperative staff will endeavour to ensure that Graduates receive the following experiences for the specified periods of time. It should be remembered that this can only be achieved without compromise to client safety and appropriate support mechanisms being available. All endeavours will be made to achieve the following placements according to staffing levels at the time.

Perioperative Evaluation The Operating Suite will supply an evaluation form for your comments in relation to this placement. In addition, the Graduate Nurse will complete a final evaluation with their Peri-operative Clinical Preceptor, with regard to the aims and goals set by the individual nurse and their Preceptor at the onset of the placement. If you have any concerns during this placement the correct process to ensure that these are correctly resolved includes:

Discussion with nurse in-charge of shift

Discussion with Perioperative Clinical Preceptor

Discussion with Nurse Unit Manager

Discussion with Education Coordinator.

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YOUR SCHEDULE

The Operating Suite schedule is divided up into 4 week periods. The first week of your rotation may occur on any given week of the schedule. The first 3 weeks are supernumerary.

First Week

FOCUS of EXPERIENCE

MONDAY 0800

Orientation to the Unit

0800 - 0815 Tour of Department

0815 - 1200 Staff Induction Program Treasure Hunt

1200 - 1230 Lunch

1230 - 1630 Scrubbing, gowning & Gloving – Task

Aseptic Technique – Task

Duty of Care – Task

Sharps Handling - Task

TUESDAY 0800

Case Studies

AM Short Day Case *

Long Day Case *

PM Complete tasks from Monday

WEDNESDAY 0900

PACU Orientation

THURSDAY 0730

Admissions – aim to complete an admission independently by the end of the day.

FRIDAY 0800

Anaesthetics – complete anaesthetic tasks

* Day Cases – the aim of this exercise is to follow one patient each who is undergoing a

short day case and an overnight admission case, from admission to theatre, through anaesthetics, scrub / circulate, PACU & Stage 2 Recovery / Discharge to the ward.

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2nd, 3rd & 4th Weeks – If the second week falls on Weeks 1 or 3 of the

Operating Suite Schedule – the week will be spent in PACU as follows:

FOCUS of EXPERIENCE MONDAY Orientation to PACU

0900 Familiarise & check Resuscitation Trolley

Complete PACU Treasure Hunt

Observe airway management & LMA removal

Complete PACU task

Be confident to handover a patient by the end of the day.

TUESDAY Familiarise & check Resuscitation Trolley

0900 Airway management

WEDNESDAY Familiarise check Resuscitation Trolley

0900 Familiarise with monitors

THURSDAY Familiarise & check Resuscitation Trolley

0900 Stage 2 Recovery & Phone calls (pre-op & post-op)

FRIDAY Familiarise & check Resuscitation Trolley

0900 Pain Management incl. pain protocol

Airway Management

LMA removal if possible

If the second week falls on Weeks 2 or 4 of the Operating Suite Schedule – the week will be spent as follows:

FOCUS of EXPERIENCE

MONDAY Scrubbing

0800 Focus on instrumentation – types, handling

Sharps safety

Haemostasis

Aseptic Technique & PPE

TUESDAY Scrubbing

0800

WEDNESDAY 0800

Scrubbing consolidation Should be able to independently scrub for very minor procedure by end of day.

THURSDAY Specimen collection

0800

Paperwork – Perioperative Care Plan

Endoscopy Circulation if applicable

FRIDAY 0800 Consolidate paperwork Count Procedure & Circulating

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Student Nurse Aims

Please list below those experiences that you wish to achieve during your placement in the Operating Suite, and discuss them with your Preceptor or Clinical Educator.

Terminology

Common Terms

Term Meaning Anastomose join together Curette to remove tissue from a cavity by scraping Dissect to push away Embolism obstruction of a blood vessel by a : bubble of air blood clot (thrombus) fatty plaque vegetation (mico-organisms) Excise to cut out Incise to cut into Haemostasis to arrest haemorrhage Ligate to tie a knot Resect to remove a part of Torsion twisting of

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Common Prefixes Adeno: Arthro: Blepharo: Cardio: Chole: Cholecyst: Col: Cranio: Cysto: Derma: Entero: Gastro: Haema: Haemato: Hepato: Laparo: Myo: Myringo: Nephro: Neuro: Orchi: Ortho: Osteo: Oto: Pharyngo: Phlebo: Pneumo: Procto: Rhino: Septo: Spermato: Teno: Thoraco: Urethro: Uro: Vas:

Common Suffixes Suffix: Meaning: Desis fixation of Ectomy removal of Itis inflammation of Orraphy suture (repair) of Oscopy examination of Otomy opening into Pexy suspension and fixation to Plasty reconstruction of Ostomy to make an opening into Scopy looking into

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A working exercise of prefixes and suffixes:

Cholecystectomy: Colostomy: Hepatitis: Proctitis: Ileostomy: Colectomy: Splenomegaly: Pancreatitis: Gastroscopy: Laryngoscopy: Pharyngitis: Bronchoscopy: Arthroscopy: Laminectomy: Nephrectomy: Cystitis: Salpingo-oophorectomy: Cystectomy: Orchitis: Orchidectomy: Cardiomyopathy: Cardiomegaly: Thrombophlebitis: Tracheostomy: Laparotomy: Gastroenteritis: Meningitis: Haematemesis: Laparoscopy: Prostatectomy: Pneumonitis: Hypovolaemia:

DUTY OF CARE IN THE OPERATING ROOM All members of the multi-disciplinary team have a duty of care to the patient who is visiting the operating suite. The issue of duty of care for the nurse is even more prevalent in the Operating Suite because for a certain period of their stay, the patient will undergo a period of unconsciousness or sedation whereby they cannot defend themselves, and/ or make decisions. Therefore, please take some time to consider the following duty of care issues, and discuss them with your preceptor.

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CORRECT PATIENT, CORRECT PROCEDURE, CORRECT SIDE, CORRECT SITE

According to the RACS, “adopting a “team approach” in the theatre will reduce risk but the operating surgeon is ultimately responsible. Every member of the operating theatre team has a duty to be aware that the correct patient, side and site are operated on. If any member of the team believes the incorrect patient, side or site is being prepared for surgery, they should immediately voice their concerns. There should be no criticism of persons raising concerns even if their concerns prove to be unfounded. Surgeons should be aware of the level of risk for wrong site or side surgery for a particular procedure.” (www.surgeons.org 2009)

Consent and Documentation The consent form must include and the patient or representative must verify:-

(Must be recorded in full i.e., no abbreviations).

Marking the Site of the Procedure

The side of the operation should be written in full (i.e. RIGHT or LEFT) and not abbreviated.

The surgeon should be satisfied on which side and site the procedure is to be performed. This should occur in consultation with the patient.

An indelible pen is used to unambiguously mark the side/site of the procedure. This is done by the surgeon in consultation with the patient and medical record. The patient is informed that the pen mark indicates the site of the operation.

The mark needs to be visible within the operating field after preparation and draping.

The pen mark is checked by the nurse as the patient leaves the holding area for the operating theatre. The pen mark is checked by the anaesthetic nurse prior to the patient entering the operating suite. This mark is then verified by the instrument

The surgeon visibly checks the pen mark prior to commencing surgery and ensures this is in accordance with his or her intended operation before induction of anaesthesia.

At all stages of this process, there should be consistency of documentation of side/site. If any inconsistency arises progress towards operation should be suspended, the incorrect documentation should be changed and signed, and an explanation of the inconsistency recorded in the patient’s history. A Riskman Incident Form should be completed.

Final Verification – “Time Out” A “Time Out” is carried out in the Operating Theatre, in the presence of the entire operating team, including surgeon and anaesthetist, immediately prior to commencement of surgery to confirm:

Presence of correct patient

Correct side / side is marked

Correct procedure to be performed

Availability of correct implants where applicable. Time Out is a verbal exercise, initiated by any member. Time Out is documented on the Count Sheet by the circulating nurse.

Emergencies In emergency (life or limb threatening situations) some of these steps may be omitted. (BCRH Policy NS-A 2.12.1)

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DUTY OF CARE TASK

1. Explain the notion of surgical conscience. 2. Discuss the peri-operative count and other documentation. 3. Discuss the issue of informed consent. 4. Discuss the legal ramifications of correct checking of the patient. 5. Discuss the various roles of the operating theatre nurse. 6. Discuss the issues of negligence and assault and battery related to the operating suite. 7. Discuss the notion of prevention of harm to the patient and the ways that this can be achieved pre-operatively. 8. Discuss the notion of “operating room etiquette”. Graduate Nurse’s Signature: ___________________________________ Preceptor’s Signature: ___________________________________ Dated: ___________________________________

DOCUMENTATION IN THE OPERATING SUITE The Operating Suite has a document collection that the Graduate Nurse may be unfamiliar with. A collection of these is attached at the back of this booklet. Please peruse them to increase your familiarity with each sheet. Some of the common forms include:

MR/100 Pre-Operative Checklist MR/092 Consent to Treatment MR/151 Peri-operative Care Plan MR/150 Record of Sterile Packs MR/101 Pre Anaesthetic Assessment MR/106 Anaesthetic Record MR/110 Recovery Room Observation Chart MR/113a Operation Report & Post Operative Orders MR/190 Intravenous Orders Mr/193 Fluid Balance Chart MR/165w Medication Chart MR/111 Spinal Observation Chart MR/140 Short Stay Admission Form MR/114 Day Case Admission Form MR/171 PCA Infusion chart MR/118 Endoscopic cleaning record MR/030 Pre Operative Telephone Checklist MR/031 Post Operative Telephone Checklist

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Intra-operative Nursing Care

Definition – Instrument Nurse

The Registered Nurse shall demonstrate a competent knowledge with regard to perioperative nursing practice standards and principles that include: aseptic technique, documentation, infection control, quality improvement, resource management, waste management and risk management. (ACORN Standards NR4 2008)

Specifically, the Instrument Nurse is responsible for:

Having a detailed knowledge of the procedure so as to assist the surgeon as required and anticipate their requirements as the procedure progresses.

Maintenance of the sterile field and aseptic technique, including safe handling of sharps.

Correct documentation throughout the procedure including checking of the consent, “Time Out”, performance of the surgical count. (ACORN Standards 2009 NR4)

ASEPTIC TECHNIQUE

The definition of sterile is the complete absence of all living micro-organisms, and the inability to produce any form of life. This is as opposed to the word de-contaminated which means that an item has been cleaned of any gross micro-organisms, but that some micro-organisms may still be found on the item. The basic principles of aseptic technique prevent contamination of the open wound, isolate the operative site from the surrounding unsterile physical environment, and create and maintain a sterile field in which surgery can be performed safely. Please read ACORN Standard S2 now.

ASEPTIC TECHNIQUE TASK 1. The Preceptor shall demonstrate the closed scrubbing, gowning and gloving technique. 2. The Graduate Nurse will demonstrate correctly this technique. 3. Practice draping of a pretend patient in a sterile manner. 4. Practice gowning and gloving another person. 5. Demonstrate knowledge with regard to skin preparation and the issue of “strike through”. Graduate Nurse’s Signature: ___________________________________ Preceptor’s Signature: ___________________________________ Dated: ___________________________________

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INSTRUMENTATION

The function of the instrument, rather than the name is important at this stage of learning. However, some common names have been included to assist with familiarity. Instruments can be divided up in to three sections, holding, cutting and retracting. Almost all instruments will fall in to one of these categories.

HOLDING INSTRUMENTS

Sponge holding forceps – these are very long, atraumatic forceps that are used to hold a swab for skin preparation with antiseptic, and to keep the sterile gloves well clear of unsterile surfaces whilst prepping. Rampley is a common sponge holding forceps.

Towel clips – are used to secure the drapes in position.

Artery forcep – used to achieve haemostasis. Spencer Wells are short curved and straight arteries.

Tissue forcep – used to hold tissue at a maximum tension in order to maximise exposure of the operative site, enabling the surgeon to see all possible anomalies whilst proceeding with the operation. The tips of the forceps are serrated to allow a firm, non-crushing grip, and prevent slipping. Common types are Allis, Babcock, Morrison and Kocher.

Dissector – used to hold tissue in order to either cut it or repair it. Common types include Gillies, Adson, Bonney, McIndoe, and Debakey.

Needle Holder – used to hold suture material. They have a variety of “jaws” at the end to secure the needle. The size of the needle holder and consequently the “jaws” is relative to the size of the needle being used.

CUTTING INSTRUMENTS

Scalpel Blade – are a “sharp” and therefore must be considered dangerous throughout the entire operative period. They must always be applied and removed with an artery forcep or needle holder, and must be housed in a sharp safety container during the case. The correct disposal of all sharps at the immediate end of the operation is the responsibility of the Instrument Nurse.

Scissor – surgical scissors are normally delicate. They fall in to two groups – fine and heavy. Fine scissors include Metzambaum or Princes scissors, are commonly used for fin tissue. Heavy scissors include Mayo curved scissors which are commonly used for tougher tissue. Straight Mayo scissors are used for cutting sutures and dressings.

RETRACTING INSTRUMENTS

Retractors – are used to hold back the edges of the operative site to maximise exposure for the surgeon. They may also be used internally to retract away internal structures to further maximise exposure. They can be held manually or be self retracting.

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SUTURE MATERIAL There are many types of suture material, but they can all be broken up into a couple of categories to make it easier to understand. It is important for the Instrument Nurse to have a sound knowledge of suture materials, so that he / she can offer the most appropriate material to the surgeon when requested. In order to do this, the nurse must be acutely aware of the requirement of the surgeon for the particular suture. Sutures are either: Man-made or natural fibre Absorbing or non-absorbing (meaning they will either break down or stay indefinitely) Braided or mono-filament Needles are either: Tapered or cutting. Tapered means that the tip of the needle is conical. Cutting means that the tip of the needle is bevelled. Ties are suture material without a needle attached, and are used to ligate bleeding vessels. See the attached chart at the back of this booklet for different suture names and types.

SUTURE TASK Discuss the different types of sutures with the person in charge of sutures within the department. In particular discuss: 1. What type of suture would you offer the surgeon for closing a small wound after removal of a BCC from the hand? Would this differ if the BCC was taken from the back? 2. What type of suture would you offer a surgeon for closing bowel tissue? 3. What type of sutures are used for ophthalmic surgery? 4. What type of sutures are used for plastic surgery? 5. What type of suture would you offer a surgeon to close rectus sheath muscle? 6. What is the difference between a tapered needle and a cutting edge needle? 7. Explain all the different uses and descriptions of a Polysorb G123 using a suture pack. Graduate Nurse’s Signature: ___________________________________ Suture Nurse’s Signature: ___________________________________ Dated: ___________________________________

HAEMOSTASIS

Haemostasis is the control of bleeding. It is of paramount importance that the Instrument Nurse is aware of the haemostasis status of the patient at all times in order to adequately assist the surgeon and offer relevant advice if required. The Instrument Nurse must know how to, and the reason for assessing blood loss. Haemostasis is achieved with the use of several different methods.

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INSTRUMENTATION & SUTURING Clamping artery forceps are applied directly to the bleeding vessel to occlude the vessel and therefore arrest bleeding. The bleeding vessel is then ligated with a suture (with or without a needle attached).

MANUAL PRESSURE The surgeon holds a pack on to the bleeding area applying manual pressure in a bid to decrease bleeding.

DIATHERMY Diathermy is the use of an electrical current to control haemostasis. It can also be used for cutting tissue. There are two types of diathermy. Mono-polar diathermy is where the electrical current is supplied from the wall outlet, through the diathermy machine, down the electrical cord, to the tissue in contact with the pencil or forcep where it coagulates the tissue. The current then travels through the body looking for a way of completing the circuit. It is normal practice for the patient to have a return electrode plate (otherwise known as a “diathermy plate”, placed on a large, fleshy area. Common places for placement of the pad include thigh, back or abdomen. The pad should not be placed on bony prominences, which could prevent the current from “escaping” and returning to the machine. The current then travels back to the machine and wall via the return electrode cord, thus completing the electrical circuit. Mono-polar diathermy is used for thick tissues such as skin and muscle. It can also be used on more delicate tissues such as bowel and bladder. Bi-polar diathermy is where the electrical current is supplied from the wall outlet, through the machine, down one side of the electrical cord, down one side of the forceps, through the tissue, back up the other side of the forceps, up the other side of the cord and back to the machine and wall to complete the electrical circuit. Bi-polar diathermy is used for delicate tissue such as eyes, brain, testicles, and ovaries. It is also used extensively in plastic surgery where fine tissue is being dissected.

There are several safety issues that are relevant when using diathermy. 1. Always ensure that no part of the patient is touching, or has the potential to touch any metal, as this could cause a serious burn as the electrical current seeks an alternate easier route to exit the body. 2. Always ensure that a patient has a return electrode placed on a fleshy area, and not over any bony prominences when using mono-polar diathermy. 3. Always ensure that the forceps or pencil have good insulative covering, and that the insulation is not flaking or cracked, as this could cause a burn at the operative site. 4. Ensure that any skin preparation has not pooled under the buttocks, lower back or knees, as this can cause a burn when left for a long period of time.

HAEMOSTATS There are several different types of haemostats on the market. These include: Surgicel is an absorbable haemostat that is:

applied dry

laid on, held against, wrapped around or sutured to a bleeding surface

forms a brownish or black gelatinous mass in contact with blood

acts as a physical matrix to which platelets can adhere which, in turn, aids in clot formation

additional pressure of the mass also contributes to the haemostatic process

Spongostan is a porcine gelatin sponge. It takes 4-6 weeks to absorb, but it liquefies in 2-5 days in mucosa. The sponge performs as a manual mode of action, in that it physically stops the bleeding with pressure. It can absorb up to 40x its own weight.

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ABDOMINAL INCISIONS Upper Midline (stomach and duodenum) Paramedian (upper and lower abdominal surgery) Kochers (cholecystectomy and spleen) Gridiron (McBurney’s) (Appendicectomy) Oblique (Inguinal Hernia) Pfannenstiel (lower abdomen)

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SHARPS DISPOSAL IN THE OPERATING SUITE The adequate and safe disposal of sharps is always of paramount importance, however it may be more so in the operating suite due to the increased number and variety of sharps used for each patient. At Bass Coast Regional Health a number of safety measures are common practice in order to minimise the chances of a needle stick injury. These include: 1. The use of a yellow dish to hand up all sharps to the operating table by the instrument nurse. 2. The use of a sharps discard-a-pad to contain sharps on the sterile trolley. 3. The availability of sharps disposal containers in all areas to minimise transport of sharps. 4. The availability of a blade remover in each operating room. It is the responsibility of the instrument nurse to dispose of all sharps at the end of each operation. It is for this reason that no-one should touch the top of the sterile trolley at the end of a procedure until the instrument nurse says that it is safe to do so.

SHARPS TASK The graduate nurse must be able to demonstrate:

1. Safe securing and removal of a blade. 2. Safe securing of a needle on a holder. 3. Correct procedure for the handing up of sharps to the surgeon. 4. Safe storage of sharps on the sterile trolley. 5. Safe disposal of sharps at the end of a procedure.

Graduate Nurse’s Signature: ___________________________________ Preceptor’s Signature: ___________________________________ Dated: ___________________________________

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Definition – Circulating Nurse The Registered Nurse shall demonstrate a competent knowledge with regard to peri-operative nursing practice standards and principles that include: aseptic technique, documentation, infection control, quality improvement, resource management, waste management and risk management. (ACORN Standards NR4 2008) Specifically, the Circulating Nurse is responsible for:

Correct documentation throughout the procedure including checking of the consent, “Time Out”, performance of the surgical count.

Creation and maintenance of the sterile field, including correct handling of sterile equipment and delivery to the sterile trolley.

Correct handling of specimens.

Assist with safe transfer and positioning of the patient. Remain vigilant throughout the surgical procedure in order to recognise and respond to a patient’s changing condition, recognise intra-operative complications and respond appropriately, and anticipate the needs of the team. (ACORN Standards 2009 NR2)

COUNT PROCEDURE The aim of the surgical count is to ensure that all accountable items used during an operative procedure are removed from the patient, unless retained intentionally as part of the procedure. Accountable items are instruments and other items, which by their nature are at risk of being retained in the patient and require mandatory documentation. Accountable items other than instruments may include

Absorbent items such as sponges, swabs, prep swabs, etc…,

Sharps including needles, detachable needles, scalpel blades and diathermy tips

Vascular items such as vessel loops, ligature reels, clip cartridges, etc…

Disposable retractor devices such as fish hooks,

Additional instruments opened during the procedure. The Circulating Nurse and the Instrument Nurse are primarily responsible for ensuring that the surgical count is accurate and appropriately documented. Two nurses perform the count, one of whom must be a Division 1 nurse. Wherever possible, the same two nurses should perform all the surgical counts for the procedure. If either nurse needs to be permanently replaced, a complete count is conducted and documented. (ACORN Standards 2009 S3) At BCRH, the count documentation is called the Peri-operative Care Plan, and is an extensive document. Please familiarise yourself with this document, and read the attached ACORN Standard.

CARE OF THE PATHOLOGY SPECIMEN Demonstrate correct handling of specimens. -receive the specimen - place specimen in suitable container - label the specimen, place specimen in the designated area and document - formalin safety OH&S - formalin spill kit, knowledge of use

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STERILITY

There are several ways that the circulating nurse can ensure that an item is sterile. These include:

1. The packaging is intact with no holes or water stains. 2. The sterile indicator has changed colour appropriately. 3. The sterile indicator tape on instrument trays and drapes has changed colour. 4. The sterile indicator on the tracking sticker has changes colour appropriately. 5. The expiration date is intact. 6. The sterile indicator strip on the inside of the packaging has changed colour

appropriately. (This is an indication for the Instrument Nurse to check).

TRACKING PROCEDURE All items sterilised within the Operating Suite Central Sterilising Departments (CSD) have are tracked with a system that enables the team to track all instruments and drapes used on a patient back to the sterilising load in the autoclave. Every item placed in to the autoclave has a sticker attached that tracks the load number and date of sterilisation. Each sterilising load is manually written in a Steriliser Log Book with a description of all contents, the type of load and the operator. When an item is used on a patient, the sticker is placed on the Tracking Form for identification afterwards if required. If an item is opened and not used on a patient, the sticker is placed in the log next to the relevant load number.

CIRCULATING TASK The nurse will demonstrate:

1. Identification that an item is sterile and correct tracking procedure. 2. The correct procedure for opening an item in a sterile manner and handing it to the

Instrument Nurse. 3. The ability to pour fluid on to the sterile field in a sterile manner. 4. The principle of “Time Out”. 5. The correct conduction of surgical count. 6. The correct documentation of relevant peri-operative information contained in the

Peri-operative Care Plan. 7. Duty of care measures with regard to specimen collection 8. Diathermy and suction considerations 9. The ability to correctly prepare for operations through set-ups.

Graduate Nurse’s Signature: ___________________________________ Preceptor’s Signature: ___________________________________ Dated: ___________________________________

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POSITIONING THE PATIENT

The important aspects of care during patient positioning are prevention of injury and patient comfort. Nursing assessment involves recognition of a patient’s risk factors affecting positioning and potential patient problems.

Vulnerable situations include: 1. Long procedures (2+ hours) of direct skin pressure 2. Vascular surgery whereby optimal blood perfusion may already be compromised due to the patient’s disease process and by anaesthesia. 3. Demineralising bone conditions such as malignant metastasis or osteoporosis, which put the patient at risk of stress fractures 4. Excessive sustained pressure to certain body areas because of the procedure or retraction which increases the potential for damage to skin integrity.

Vulnerable patients include: 1. Geriatric patients, whose thin skin layer and circulatory system make them more prone to the development of pressure areas 2. Paediatric patients, whose size and weight must be taken into account when selecting positioning aids 3. Patients who are malnourished, anaemic, obese, hypovolaemic, paralysed, arteriosclerotic or diabetic, who are prone to skin breakdown due to pressure 4. Patients with artificial prostheses or arthritic joints 5. Patients with oedema, infection, cancer or conditions of lower cardiac or respiratory reserves.

POSITIONING AIDS There are a numerous aids for assisting with positioning the patient. Some common ones include:

Gel pads for arms and feet

Stirrups

Arm boards

Arm rests

Light weight table ends

Common positions include:

Supine – where the patient’s back and spinal column are resting on the surface of the

operating bed mattress.

POSITIONING TASK 1. Discuss positions commonly used in the Bass Coast Regional Health Operating Suite 2. Discuss the equipment required for each of these positions. 3. Discuss OH & S and patient safety issues related to each position identified. Graduate Nurse’s Signature: ___________________________________ Suture Nurse’s Signature: ___________________________________ Dated: ___________________________________

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Trendelenburg – a variation of supine where the upper torso is lowered and the feet

raised. This position provides a better view for pelvic organs during open or laparoscopic surgery of the lower abdomen and pelvis. This position is also frequently used if the patient becomes hypotensive, as it improves circulation to the cerebral cortex.

Reverse Trendelenburg – head up and feet down. This position is used to provide

access to the head and neck. The patient’s body is supported by a padded footboard and a lumbar roll under the shoulders.

Lithotomy – with the patient lying supine, the legs are raised and abducted to expose

the perineal region for procedures involving the pelvic organs and genitals. The stirrups must be level. The height is adjusted to the length of the patient’s legs. The legs should be raised at the same time to avoid hip dislocation and back strain. The lower part of the leg should be free from pressure against the stirrup to prevent pressure on the peroneal nerve.

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Modified Fowler’s – is the sitting position. Extra padding should be placed under the

buttocks and small of the back to avoid prolonged pressure on the sciatic nerve.

Prone – the patients is lying with the abdomen on the surface of the operating bed mattress.

This allows for access to the spine, back rectal area and lower extremities. The patient is induced and anaesthetised supine. A minimum of 4 people are required to perform the positioning safely. The patient is positioned using a series of pillows under the chest, pelvis and knees, as well as the head. The arms are placed either by the patient’s side or out on arm boards.

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Lateral – the patient lies on their unaffected side, providing access to the upper chest,

kidney or upper section of the ureter. A special bean bag is used between the knees and the upper arm is held in an arm support.

Arms In all positions, care should be taken with the patient’s arms. They should never be abducted or externally rotated more than 90 degrees to prevent damage to the brachial plexus, and the palms should be facing up to diminish damage to the median and ulnar nerves. Hyperabduction could result in damage to the subclavian and axillary vessels.

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ANAESTHETICS Definition – Anaesthetic Nurse The role of the Anaesthetic Nurse is to collaborate with the Anaesthetist during the preparation, induction, maintenance and emergence phases of the anaesthesia, analgesia or intravenous sedation. During the maintenance phase of anaesthesia, the Anaesthetic Nurse collaborates with the Anaesthetist to specifically:

Assess and monitor the patient

Maintain the fluid balance

Assess for potential hazards to the patient and personnel

Provide equipment and supplies for anticipated and unanticipated critical events. The Anaesthetic Nurse also collaborates with the Anaesthetist to ensure a smooth emergence from anaesthesia, analgesia or intravenous sedation. This includes:

Assessment of the patient’s physiological parameters

Assisting the patient to maintain a clear airway

Assessment of the patient’s level of pain

Assessment of the patient’s fluid balance The Anaesthetic Nurse also is responsible for:

Checking the validity of the surgical consent.

Marking of the surgical site / side

Confirming the identification of the patient

Initiating “Time Out”

Ensuring the appropriate diagnostic images and results are available

Assessing the patient’s current health status with regard to allergies and fasting status

Ensuring all equipment required for safe anaesthesia is available

Assisting with the patient’s transfer and positioning

Acting as a patient advocate whilst under their care

Ensure that the patient is free from harm, respecting the patient’s right to privacy, dignity and confidentiality

Be aware of, and observe for the possible side effects of anaesthetic medications

Ensure safe transport of the patient from the Operating Theatre to PACU

Provide an appropriate handover to the PACU Nurse (ACORN Standards 2009 NR1)

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WHAT IS AN ANAESTHETIC? Anaesthesia involves a state of unconsciousness and the abolition of all sensation to pain, touch, posture and temperature. The effects of anaesthesia are amnesia, analgesia and muscle relaxation. This is known as the ‘triad of anaesthesia’. Stages of anaesthesia First stage – analgesia From the beginning of induction to a loss of consciousness. Second stage – excitement From the loss of consciousness to onset of automatic breathing. There may be struggling, breath-holding, vomiting, coughing or swallowing. Third stage – surgical anaesthesia From the onset of automatic respiration to respiratory paralysis. Fourth stage – overdose From onset of diaphragmatic paralysis to apnoea and death. All reflex activity lost and pupils widely dilated.

MONITORING –every patient is connected to the following monitors during

anaesthesia: Oxygen Saturation This monitors the amount of oxygen in the patient’s bloodstream, and indicates this as a percentage. Blood Pressure Heart Rate Capnography. This monitors the level of expired carbon dioxide. The trace also indicates if the airway, either Laryngeal Mask (LMA), or Endotracheal Tube (ETT), has been positioned correctly. Additional monitoring might include: Temperature – this is monitored either via tympanic thermometer or oral temperature probe. Arterial Line – this is used to continuously monitor blood pressure and heart rate Nerve Stimulator – this is used to test the level of paralysis MEDICATION TASK – COMPLETE THE TABLE

DRUG DOSE ONSET OFFSET SIDE EFFECTS

Thiopentone sodium

4 – 7 mgs/kg

30 secs 3 – 5 mins ↑ HR, laryngospasm, apnoea

Propofol

Ketamine 15-20 mins

Nitrous oxide

Sevoflurane

Isoflurane

Suxamethonium fasciculation, arrhythmias

Atracurium 3-4 mins

Neostigmine 20-30 mins

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TYPES OF ANAESTHETICS Local anaesthesia – used to encircle the operative field, achieving a total pain-free area for a specific time frame. Topical – surface Powder/liquid eg. Cocaine: Used on gauze and placed up the nose for ENT surgery. Spray eg. Cophenylcaine: Used to spray the back of the throat prior to gastroscopy. Cream eg. Emla: Used on the hand or cubital fossa for children prior to I.V cannulation. Local infiltration – prilocaine, lignocaine, ropivicaine. Regional anaesthesia – an insensibility to pain caused by the interruption of sensory nerves conduction to any region in the body. Nerve block – injecting local anaesthetic agent as close tas proximity to eht nerve supplying that area. E.g. Brachial plexis block, femoral nerve block, axillary block. Spinal anaesthetic – sub-arachnoid space. Injected into the CSF. The local anaesthetic agent picks up every nerve at that level and below. Epidural anaesthetic – outside the dura. It lasts longer than a spinal and is good for post-op pain. General anaesthesia - a drug induced depression of the central nervous system, resulting in an unconscious state and an insusceptibility to pain that is either reversed by metabolic elimination in the body or by pharmacological means. An anaesthetic can be divided into two phases – 1. induction 2. maintenance Methods and types of administration: Intravenous – a rapid induction. The unconscious state generally occurs within 30 seconds and up to 3 minutes after the initial IV administration. Inhalation – using a mixture of volatile liquids and gases with oxygen. Advantageous because of their ease of administration and elimination through the respiratory system. Often used with paediatric patients to induce anaesthesia and then an IV can be inserted. Muscle relaxants – act by antagonising the effect of acetylcholine at the muscular end plate, causing muscle paralysis. Muscle relaxants are given intravenously and are given mainly to facilitate intubation, relax the muscles within the surgical field, ease laryngospasm and reduce the amount of general anaesthesia required.

RAPID SEQUENCE INDUCTION The administration of an anaesthetic to a patient who may regurgitate their gastric contents. These patients may include – patients who require caesarean section, - patients with intestinal obstruction, - the non-fasted patient / emergency case. Drugs used for rapid sequence induction; Propofol Suxamethonium

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CRICOID PRESSURE This is a procedure that the person intubating the patient might ask of the assistant prior to intubation. The aim of cricoid pressure is to reduce the chance of aspiration. Locate the most prominent protuberance on the front of the neck in the midline (the thyroid prominence). Find this point then run your finger towards the patient’s feet (staying in the midline) until you feel your finger drop into the cricothyroid notch or membrane. The next horizontal bar is the cricoid cartilage. Place the thumb and index finger on either side of the cricoid cartilage and press directly backwards at a force of 20-30 newtons against the cervical vertebra. Maintain pressure until directed to remove fingers by the person performing the intubation.

BURP – Backwards, Upwards, Right hand Pressure. This is used to manipulate the

larynx to improve the anaesthetists’ view of the vocal cords during intubation.

TRANSFER of the PATIENT FROM THE OPERATING THEATRE TO RECOVERY ROOM. Patients are escorted by the anaesthetist and anaesthetic nurse. Patients who are not breathing require manual ventilation with a bag and mask. Patients should be extubated by the anaesthetist.

POST ANAESTHESIA CARE Definition – Post Anaesthetic Care Unit (PACU) Nurse

The primary role of the PACU Nurse is to provide clinical nursing care including the anticipation, prevention and clinical management of complications. The PACU Nurse must demonstrate patient assessment and management of the following:

Patent airway techniques

Obstructive airway interventions

Knowledge of advanced life support techniques

Patient monitoring and resuscitation

Acute Pain relief

Nausea & vomiting

Temperature control

Life threatening complications

Infection control principles and practices The PACU Nurse must also have knowledge of:

Peri-operative nursing practice standards

Modes of anaesthesia and pharmacology

Intra-operative procedures and care

Appropriate documentation

Advanced decision making skills (ACORN Standards 2009 NR6) Bass Coast Regional Health has a four bay Recovery Room with a 5-6 bay Stage 2/3 step down Recovery Area for day procedure patients. There are a range of Start of Day Procedures and checks that are carried out on a daily basis, which you will be shown on orientation.

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RECEIPT OF THE PATIENT IN THE RECOVERY ROOM On receipt of a patient post-operatively the Recovery Room Nurse takes handover from the Anaesthetic Nurse and the Anaesthetist whilst connecting the patient to oxygen and oxygen saturation and blood pressure monitoring. The anaesthetic ‘handover’ should include;

patient’s identification and allergy status

operation performed

type of anaesthetic administered to the patient

drugs given

predisposing medical conditions / complications encountered in the operating room

details of surgical wounds, drains, blood loss, etc…

special treatment to be given in PACU

INITIAL ASSESSMENT The following assessment is then made: Time of arrival, Airway – patent? Breathing – rate and depth? Circulation – rate and regularity Conscious state – rousable or unconscious? Temperature – need warming or cooling? IV therapy - patent Wound site – intact and wound ooze? How much? Drains – patent? Catheter – output and patent? Pain relief required?

ONGOING ASSESSMENT Observations - 10 minute intervals or more frequently if the patient’s condition warrants it. The length of stay - varies with the patient’s condition and the degree of surgical intervention. Patient must score >8 on the PACU notes to be discharged.

PAIN PROTOCOL There is a Pain Protocol for Morphine, Pethidine and Fentanyl. There is a poster on the PACU wall describing the pain protocol. Please appraise yourself with this poster.

CARE OF REGIONAL INFUSIONS We have patients with both spinal and epidural infusions in PACU. Both have observation charts. Spinal infusions are the most common. The patient is scored using a Bromage Motor Block score and a sensory spinal level. I.e. C8 to T10. These observations are performed in conjunction with pain, sedation, and vital signs. Vigilance is required if there are any signs of respiratory distress indicating a high spinal.

HYPOTHERMIA Hypothermia is common in PACU as patients often arrive cold from home or the ward, and are then exposed during surgery. It is important to ascertain temperature as soon as is practical, and to implement measures to rectify hypothermia. Warm cotton blankets, a warming blanket machine or space blanket are applied as a first measure. Warm fluids and/ or a fluid warming machine can also be utilised.

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MAINTENANCE OF A PATIENT’S AIRWAY Feel: for air exchange by placing a hand over the patient’s mouth. Look: for movement of the intercostal and diaphragmatic muscles. Listen: for stridor (crowing noise as air passes through the partially occluded larynx)

PATIENT DISCHARGE All surgical ward patients leave Recovery on their bed, escorted by the ward nurse and porter. The escort nurse should receive a complete handover regarding the patient’s condition from the recovery room nurse. The escort nurse travels at the head of the patient, ensuring the patient’s safety and welfare, and assists with guiding the trolley/bed. Day surgery patients are transferred to stage 2/3 recovery and then discharged home once follow up appointments are made and written information is given.

PACU TASK Upon receipt of a patient in PACU post GA, take a “handover” from the anaesthetist. 1. What information do you require for an adequate handover? 2. What documentation do you implement? 3. Look through the surgeon’s operative notes. What are the surgeons post operative requests? 4. What are the anaesthetist’s requests for post operative management? Graduate Nurse’s Signature: ___________________________________ Suture Nurse’s Signature: ___________________________________ Dated: __________________________________

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MANAGEMENT OF THE PATIENT WITH A LARYNGEAL MASK Recommendations when removing a LMA 1. Check that the airway is clear as soon as the patient arrives in the recovery area. Attach the blue rebreather bag to the LMA and look for the bag refilling as the patient breathes. 2. Do not stimulate the patient. This may cause premature rejection of the LMA or provocation of incomplete and therefore in effective reflex responses, with consequent hazard to the patient. 3. Do not deflate the cuff. Secretions in the upper pharynx may otherwise flood into the larynx, causing spasm. 4. Do not pull the jaw forward with the LMA in position. This may cause spasm. 5. Coughing is not necessarily an indication for removal, although it may be if the patient is also then able to open the mouth on command. 6. Oxygen should be administered via the blue plastic bag or “T-piece” system. This enables the airway patency to be continuously checked by observation of expired breath condensation on the plastic surface and filling of the bag. 7. Only remove the LMA when the patient can open the mouth on command. 8. Look for the onset of swallowing as a sign of the imminent return of reflex function. This does not mean it is time to remove the LMA but often gives an indication that the patient will soon be able to open the mouth on command. 9. Young people often struggle or are restless during recovery from anaesthesia. This is not an indication for removing the LMA. This may be followed by a phase during which the patient is unable to maintain the airway without assistance. If the LMA is accidentally dislodged because of struggling, you may need to hold the jaw forward to maintain the airway.

Safe removal of a LMA TASK 1. At what stage of recovery did you remove the LMA? 2. What signs did you look for prior to removing the LMA? 3. Did the patient suffer any spasm? 4. Discuss the difference between laryngeal spasm and stridor. Graduate Nurse’s Signature: ___________________________________ Suture Nurse’s Signature: ___________________________________ Dated: ___________________________________

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COMPLICATIONS OF ANAESTHESIA AIRWAY PROBLEMS Airway Obstruction: Recognised by:

Noisy breathing

Reduced or absent breathing

Use of accessory muscles

Sternal retraction.

Contributing factors include:

Poor positioning

Tongue obstruction

Foreign body

Vomitus, sputum, blood

Haematoma or oedema

Treatment:

Jaw thrust

Suctioning

Guedel airway

Contact Anaesthetist

Laryngeal Spasm Recognised by:

Stridor

Distress

Diaphoresis

Upper airway noise on auscultation

Contributing factors include:

Difficult intubation

Blood or sputum on cords

Pain

Anxiety

Treated by:

Mild – position, oxygen, inform anaesthetist

Moderate – as above, anaesthetist may give Diazepam

Severe – as for mild, and prepare to re-intubate

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BREATHING PROBLEMS Apnoea Caused by:

Incomplete reversal of muscle relaxant

Narcotics

Respiratory Arrest

Cardiac Arrest

Breath holding in babies Treated by:

Assisted ventilation with 100% oxygen

Re-intubation

Decreased Respiratory Rate (<8 per minute)

Caused by:

Narcosis Treated by:

Narcan (Naloxone hydrochloride)

Increased Respiratory Rate (> 28 per minute)

Caused by:

Pain

Anxiety

Pulmonary emboli

Diabetic coma

Aspiration pneumonia Treated by:

Positive pressure ventilation

Decreased Respiratory Volume (less than 1/3 normal total volume)

Caused by:

Pain

Sedation

Obstruction

Muscle relaxants Treated by:

Pain relief

Suction

Reversal of muscle relaxation

Re-intubation and IPPV

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CONSCIOUS STATE PROBLEMS Patients who do not regain consciousness within 15 minutes, or whose conscious state deteriorates Contributing factors:

Drug induced

Metabolic

Renal, hepatic and septicaemic patients

Hypothermia

Cerebral problems Treated by:

If narcosis – Narcan

If diabetic – serum glucose and serum potassium levels are checked

If neurological disorder – full neurological assessment

If hypoxia – full blood gases

Disorientation and / or Delirium Contributing factors:

Effects of general anaesthesia

Drug induced

Possible alcohol and/ or other drug withdrawal syndrome

Electrolyte imbalance / dehydration Treated by:

Re-orientation to time and place

Constant reassurance

Re-hydration

Neuroleptic medication (I.e. Haloperidol)

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CIRCULATORY PROBLEMS Colour and Perfusion Observe for cyanosis, pallor, flushing

Search for a cause for each

Is the skin warm to touch?

Is the skin cold?

Core Temperature If temperature <35 ºC – actively warm the patient

If temperature > 37.5 ºC – actively cool the patient

Bradycardia

Caused by:

Drugs

Hypoxia

Athletecism

Tachycardia: Caused by:

Drugs

Pain

Anxiety

Myocardial ischaemia

Sepsis

Shock

Hypertension Caused by:

Pre-morbid condition

Pain

Anxiety

Hypocapnoea

Drug induced

Hypotension: Caused by:

Pain

Shock

Drugs

Sympathetic regional block

Treated by:

Vasoconstrictor medication

Fluid replacement

Position change