Periop 101 Study Guide

✔ What do you do when patient reports an allergy to prep solution you had planned to use? Notify
surgeon/team; follow MD orders – MD may still want to use the prep even with allergy noted
**document!

✔ What nerve is most frequently injured as a result of improper arm positioning? Brachial plexus
✔ What is meant by event-related sterility?
Items are considered sterile unless the integrity of the packaging is compromised or suspected of
being compromised

✔ How should you clean instruments on the sterile field?

With sterile water b/c saline can cause pitting on instruments

✔ Humidity range for OR: 20-60%

✔ Describe how a breast cancer tissue specimen should be handled & processed including time frame for
processing. FROZEN SECTION

 Require immediate exam by pathologist w/ a verbal report of the findings

 Only a small amount of saline used to keep the specimen moist during transport
 Should be placed in a specimen container, basin or on a piece of non-adherent material (ex. Telfa)
**prevent it from drying out
 Don’t use a counted surgical sponge for specimen transport
 Specimen should be verbally verified by the surgeon & periop RN
 Record time of specimen removal and the time placed in fixative

✔ What is the best way to assess for pain in PACU when patient is awake and alert?
 0-10 Numerical Rating Scale (NRS)
 FACES pain scale
 FLACC (faces, legs, activity, cry and consolability) scale – nonverbal patients
 PAINAD scale (Pain Assessment in Advanced Dementia)

✔ What should you be most concerned with in a patient with a hx of smoking & DM?
A. Wound healing
B. Pain control
C. Normothermia
D. Fluid management

✔ Which sensory assessment is common for elderly patient?

A. Decreased ability to understand explanations
B. Decreased vision including color and depth perception
C. Increased pain perception or memory impairment
Elderly experience decrease sensation to pain, varying body temps, color & depth perception & dry
eyes
✔ Know wound healing phases/body’s defense mechanisms.
PHASES

 Inflammation phase - starts immediate after incision is made; lasts for first 6 days
▫ Hemostasis - 0-2°
 starts at incision time
 occurs within seconds by vascularization
 platelets aggregate to form a clot
 erythrocytes & leukocytes appear to start infiltration
▫ Phagocytosis - 0-4 days
 neutrophils & macrophages appear to digest/dispose pathogens/debris
 macrophages stimulate fibroblast formation & proliferation
 wound is usually red & swollen
▫ Edema - 0-6 days
 occurs within a few mins of injury
 capillary walls become permeable to plasma
 plasma leaks into the wound, causing edema
 Proliferation phase - starts the second day after incision and continues until 22nd day
▫ Epithelialization 1-4 days
 fibroblasts migrate toward the wound site during the first 12-72° after
surgery/injury
 keratinocytes begin the formation of a scab sealing the wound (epidermal
regeneration)
▫ Neovascularization 2-7 days
 where granulation tissue comes from
 new vessels form & endothelial cells are replenished
 typically red, beefy & granular characteristics
 time when most disruptions occur (5-10 days post-op)
▫ Collagen synthesis 2-22 days
 fibroblasts synthesize collagen molecules (basic protein substance of connective
tissue)
 **contributes to the tensile strength of the wound**
▫ Contraction 2-20 days
 contraction caused by fibroblasts transforming into myofibroblasts
 myofibroblasts help strengthen the wound & close any remaining defect
 Remodeling phase starts 21 days after the incision & may continue for 2 years
▫ Collagen remodeling
 fibers weave themselves into a more organized pattern determined by the stress
demands of the wound
▫ Tensile Strength takes YEARS
 scar tissue remodels as fibroblasts disappear from the wound site & the amount
of collagen decreases
 scar tissue regains only 80% (max) of the strength of uninjured tissue
BODY’S DEFENSE MECHANISMS
  Stop the blood loss (hemostasis)
 Clean up pathogens/debris in the wound
 Seal the wound against infection
 Regenerate the natural epidermal covering
 Repair deeper tissue damage

✔ Know category of instruments. For example: army navy, kelly, rongeur, needle holder
 CUTTING – used to incise, cut, dissect, or separate tissue
▫ SCALPELS/KNIVES
▫ SCISSORS
 Tissue | Curved Mayo scissors (dissect heavy tissue), Metzenbaum scissors
(dissect delicate tissue)
 Suture | Straight scissors
▫ OTHER: (mostly ortho) chisels, curettes, rongeurs, osteotomes, & variety of powered
surgical instruments
 CLAMPS – used to hold, join, or compress parts together
▫ HEMOSTATS – grasp bleeding vessels
 Crile clamps – control bleeders in subcutaneous tissue
 Mosquito clamps – control superficial bleeders and handle delicate tissue in
plastics & hand
 Kelly (/Peon) clamps – control bleeders in muscle tissue, to hold Kitner sponges,
& to pass drains
▫ OCCLUDING clamps – clamp bowel, ducts, vessels & other tissue
 Usually have vertical serrations or special jaws with finely meshed multiple rows
of longitudinally arranged teeth
 EX. Kochers, Oshsner, and hemostats
 GRASPERS/HOLDERS - used for tissue retraction
▫ BABCOCK clamps – have curved fenestrated tips with no teeth; used for delicate
structures such as bowel, appendix, urethra, or fallopian tubes
▫ KOCHER (/Ochsner) clamps – have transverse serrations as well large 1”x2” teeth at
the tips; grasp tightly on heavy, tough, slippery tissue like fascia, bone and cartilage, and
uterine broad ligaments
▫ ALLIS clamps – have multiple, tiny fine teeth that curve slightly inward & hold tissue
gently but firmly; hold tissue without crushing, devitalizing or injuring it; used to retract
tissue & to grasp fascia, cysts, and knee cartilage
 NON-CLAMPING GRASPING INSTRUMENTS
▫ FORCEPS/”PICKUPS” - Used for handling tissues & dressings
 Tissue forceps -
 Atraumatic forceps (DeBakey forceps) – grasp fine tissue with minimal tissue
 Smooth forceps – have simple serrations and smooth, tapered points for holding
delicate tissue & vessels. EX. Adson forceps, Cushing/bayonet forceps
▫ NEEDLE HOLDERS – used to hold needles during suturing, used to apply blade to
knife handle
 CLAMP-LIKE GRASPING INSTRUMENTS
 ▫TENACULA – penetrate the tissue & used to retract/pull tissue into position for
dissecting
▫ SPONGE FORCEPS
▫ TOWEL FORCEPS – usually attach and secure drape material but may also be used on
cartilage or scar tissue or to grasp tissue to apply traction
 Perforating
 Non-perforating
 RETRACTORS
▫ HANDHELD
 Richardson
 Senn
 Malleable
 Volkmann
 Army-Navy
▫ SELF-RETAINING
 Balfour
 O’Connor
 Weitlaner
 Jansen

✔ Describe primary and secondary dressings and their functions.

 1° - used directly on incision; used to absorb drainage & wick it away; should have non-adhesive
layer (prevent debridement)
 2° - placed over 1° dressing; used for drainage absorption, applying pressure for hemostasis & to
protect wound

✔ What type of needle should be used for the liver?

Blunt point needle (rounded blunt tip & will not cut tissue); used for dissection of friable tissue

✔ What has an increased risk for periop hypothermia?

A. Female sex – more prone than men
B. Higher than normal weight
C. Hyperthyroidism
D. Hypertension

✔ What is the strongest and most secure suturing technique?

A. Purse-string
B. Interrupted
C. Subcuticular
D. Continuous

✔ Know when IUSS is appropriate to use. Can the instrument be used later? Can the decontamination
step be omitted?

 IUSS = Immediate Use Steam Sterilization

  Only used when there is not enough time to process by the preferred wrapped or container
method
 Cannot be stored for later use
 Cannot omit decontamination – must be properly cleaned & decontaminated

✔ Know information that is acceptable to give someone inquiring about a patient (HIPAA).
Health Insurance Portability and Accountability Act
Access to information should be limited to authorized individuals based on their health care role,
responsibilities, and function; only people working with the patient should have access!

✔ Know safety measures for ESU, i.e. holster, volume, general electrical safety principles, nothing on top
of generator, only surgeon activates foot pedal, use lowest setting for desired effect

 Used at the lowest power setting possible to achieve the desired effect – power settings should be
confirmed verbally between the periop nurse & surgeon before and during surgery
 The cord should have no kinks or knots so that it lies flat on the floor
 Fluids should never be poured on the generator or foot switch
 Foot switch should be kept dry; encase foot switch in a clean, clear, impervious cover if needed
 Alarms/lights present to alert for potential danger
 Never use the ESU in the presence of alcohol-based prep agents until they are dry & vapors have
dissipated
 The generator should be turned off after use
 When using multiple ESUs, the dispersive electrodes should not touch each other
 When not in use, the active electrode should be stored in an insulated safety holster (minimize
risk for injury from unintentional activation)

✔ Preps: know which ones can be used on head (eyes, ears), on open skin
 Aqueous iodophor = Betadine
 CHG + alcohol = Chloroprep
 Iodine + alcohol = Duraprep
Iodophors (Povidone iodine) can be used on mucous membranes.
Cationic phenolic mixture (PCMX) can be used on mucous membranes, open wounds or around eyes.
Alternative to iodophors when patient has iodine allergy.
Do NOT use CHG: above the neck (d/t potential corneal damage & toxicity when introduced into the
auditory canal), brain/meninges (toxic to nerve tissue), or vaginal/mucous membrane preps

✔What are examples of mechanical, thermal & chemical hemostasis?

 Mechanical: pressure, hemostats, ligating clips, ligature, pledget, bone wax
 Thermal: Argon Beam Coagulator (ABC), ESU, Cryosurgery, hypothermia, laser, other –
diathermy, photocoagulation, plasma or harmonic scalpel
 Chemical: microfibrillar collagen, collagen sponge, gelatin sponge, fibrin sealant, thrombin,
styptics

✔ Which one has no teeth? Babcock, Kocher, Allis

  Babcock – clamps that have curved fenestrated tips with NO teeth; grip/enclose delicate
structures like bowel, appendix, urethra, or fallopian tube
 Kocher (aka Ochsner) – clamps that have transverse serrations + large 1”x 2” teeth at the tips;
grasp heavy tough, slippery tissue like fascia, bone cartilage, & uterine broad ligaments
 Allis – clamps that have multiple, tiny fine teeth that curve slightly inward & hold tissue gently
but firmly; used to hold tissue w/o crushing/devitalizing/injuring it

✔ Why do you let prep solutions dry? Minimize risk of a surgical fire
✔ For what does argon enhanced electrosurgery increase a patient’s risk?
Gas emboli formation – caused by argon gas pressure exceeding venous pressure; secondary source
of gas can result in a rapid rise in patient’s intra-abdominal pressure

✔ What is phase 1 in PACU and what is nurse’s priority there? What is the nurse to patient ratio when
patient arrives from OR?

 Phase I:
▫ Priority is patient’s AIRWAY
▫ patient must meet discharge criteria to go to phase II -- ex. Aldrete Score of at least 9/10
 Ratios reflect patient acuity – nurse:patient

1:1 From time of admission until critical elements are met

For the patient with an unstable airway or who is hemodynamically unstable
1:2 1 unconscious, stable patient w/o an artificial airway >8yo
1 conscious, stable patient who is free of complications
 2 conscious, stable patients free of complications
2:1  1 critical, unstable, complicated patient
✔ Know the safety measures of insufflation, i.e. pressure and supply alarms are functioning
 Make sure alarm is on, audible & working correctly – to indicate level of gas (CO 2)
 Make sure tank:
▫ contains the appropriate gas
▫ is labeled appropriately
▫ is sufficiently full
▫ has back supply of gas available
▫ valve is open
 Insufflator should be positioned on the cart at the level of the patient’s heart or higher to prevent
intra-abdominal fluids/gases from contaminating the device
 Tubing should include a two-way disposable filter to prevent contaminants from the gas cylinder
from flowing into the abdominal cavity
 NG tube and indwelling catheters may be placed to decompress the stomach & bladder to prevent
potential injury during needle/trocar insertion

✔ Know Spaulding classification system, ie high level/low level disinfection requirements for critical &
semi-critical items
Classification system used to categorize items to be disinfected
  Critical: include instruments or objects that are introduced into the human body, either into or in
contact with the blood stream or normally sterile areas of the body,
Ex. surgical laparoscopic instruments, implants, cardiac catheters
Disinfection level: must be sterilized before use. If all microorganisms are not removed,
including bacterial spores, the risk of infection is HIGH. If sterilization is not feasible, these items
must receive high-level disinfection
 Semi-critical: items that come in contact with mucous membranes and do not ordinarily
penetrate body surfaces
Ex. endoscopes that are passed through natural body orifices, anesthesia equipment (including
laryngoscope handles & blades) and respiratory equipment
Disinfection level: High-level disinfection! Rationale – intact mucous membrane usually resists
common bacterial spores but may be susceptible to other organisms
 Noncritical: items come in contact with the patient’s unbroken skin
Ex. BP cuffs, bedpans, pulse oximeters
Disinfection level: intermediate or low-level disinfection. Rationale – intact skin serves as a
barrier to most microorganisms

✔ Know methods of gloving: closed assisted, open assisted, closed, open

 Closed Glove Technique
▫ The scrub person’s hands remain inside the gown sleeves and should not touch the cuff edges
▫ Used for the initial donning of sterile gown & gloves
▫ NOT to be used when the scrub person is changing his or her gloves
 Open Glove Technique
▫ The scrub person’s hands slide all the way through the sleeves and out beyond the cuffs
▫ Used for subsequent gloving & when performing procedures which a gown is not worn (ex.
inserting Foley or IV insertion on the floor)
▫ Used when a glove must be changed w/o assistance during a surgical procedure
 Assisted Gloving
▫ While gloving another team member, the other person’s right hand should always be
gloved first. May be reversed for a left-handed person.
 Assisted Regloving
▫ When a team member other than the scrub person contaminates a glove during the
surgical procedure, the RN circulator, using exam glove to protect his or her hands, will
grasp the outside of the glove and pull it off inside out. The team member should be
regloved by the scrub person
▫ Options for the scrub person that needs to change gloves:

1. Remove both gown & gloves

2. Have another team member assist with gloving
3. Use the open glove technique
▫ *** Don’t do close glove technique – hands already contaminated after passing through
cuffs
 Double Gloving
▫ Wearing two pairs of gloves
▫ Decreases number of perforations to innermost gown
 ▫ Easily/rapidly see when outer glove is perforated (inner glove is a brighter color)

✔ What is included in a psychosocial nursing assessment?

1. Expectations of perioperative care including patient levels of anxiety or stress
2. Understanding of the surgical procedure
3. Philosophical and religious beliefs
4. Cultural beliefs and practices

✔ What is the purpose of patient/family education?

 To increase knowledge and satisfaction
 Ultimate goal is to achieve long-lasting changes in patient health status by providing the
knowledge to allow them to make autonomous decisions & take ownership of their care as much
as possible
 IMPORTANCE: improvement in quality of care & patient satisfaction, increased adherence, &
there are ethical, legal & regulatory mandates

✔ Which is most likely to occur with lithotomy position?

A. Venous pooling in the legs - pooling in the lumbar region; nerve damage to femoral nerve
B. Hip dislocation - can occur if legs are not raised or lowered simultaneously or not positioned
at equal height
C. Damage to brachial nerve - damage to external iliac arteries from compression of thighs against
abdomen
D. Severe hypertension - significant drop in BP if legs lowered too quickly

✔ When should gloves be changed? (time frame for long procedures) 90-150"
✔ Know symptoms of stage 1, 2, and 3 of an immediate latex allergic response.
Stage I: Stage II: Stage III:
Contact urticaria – presents as Reactions can spread beyond Reactions can progress to a
swelling & redness at the site of area of contact; edema & itching sudden drop in BP w/ increased
exposure; can also be around the eyes, acute rhinitis, HR; can lead to circulatory
accompanied by itching & nasal itching, sneezing, asthma, collapse & anaphylactic shock
burning SOB & bronchial obstruction
✔ What does SBAR stand for?
S – Situation
B – Background
A – Assessment
R – Recommendation
✔ When should the dressings be placed on the field?
After sponge count is done – to prevent dressing w/ radiopaque sponge.

✔ How long should a patient be NPO for solids for surgery?

Fried foods, fatty foods, meat – 8 hours
 Light meal (toast & a clear liquid) – 6 hours

✔ What is a neutral zone? A designated area on the sterile field where the scrub person & the surgeon
place all sharp instruments. May be a magnetic pad, a basin or a specially designed disposable pad

Hand-to-hand method | When passing a knife, it should be carefully held between the thumb & the
index finger and the cutting edge of the knife should point away from the surgeon & periop nurse
✔ The periop nurse can manage a patient who is receiving what type of anesthesia?
 Local anesthesia – BP, ECG, pulse ox & HR monitored continuously during procedure
▫ Monitor for LAST (Local Anesthetic Systemic Toxicity) - occurs if unsafe amounts enter
bloodstream; s/s: tinnitus, tingling around lips, metallic taste, dizziness
 Moderate sedation – cannot circulate or having other competing responsibilities that would
compromise monitoring
▫ Need access to & the ability to administer reversal meds: Flumazenil (Romazicon) for
benzodiazepine & Naloxone (Narcan) for narcotics

✔ Where should dispersive electrode be placed? (Bovie pad)

 As close to the operative site as feasible
 Over a large, well perfused, muscle mass
 Apply smoothly – no tenting or gaps
 AVOID: bony prominences, area over an implanted prosthesis (may contain metal that will
attract the current & impede flow), scar/burned tissue (may act as insulation), hairy areas (may
act as insulator), areas distal to tourniquets (adequate tissue perfusion cannot be assured)

✔ What does PICO stand for? PICO method is one way to develop an evidence-based question.
P – Patient, Population, Problem
I – Interventions: education, self-care, best practices
C – Comparison: current practices, another intervention
O – Outcome

✔ What are the basic surgical positions?

 SUPINE | on back
▫ Patient lies flat on back w/ arms extended <90° angle on padded arm boards
▫ Decrease in diaphragmatic expansion
▫ Use a heel-suspension device to redistribute heel pressure
▫ Trendelenburg | upper torso lowered, feet raised
▫ Reverse Trendelenburg | feet lowered, upper torso raised
▫ Sitting/Semi-sitting/Modified Fowler
▫ Lithotomy
 LATERAL | on side; anesthetized on stretcher & then log rolled onto the nonoperative side on
OR bed
 PRONE | on stomach; anesthetized on stretcher & then log rolled over to OR bed
▫ Jack-Knife | bed flexed 90°, raising the hips & lowering the head/trunk
✔ How many staff should there be to safely move a patient who is unable to move themselves?
4 – one at the head, one at the feet, one on each side; also for COMBATIVE patients
✔ Define types of wound healing i.e. delayed primary closure, granulation, etc.
 Primary union/First intention
▫ Clean edges, made aseptically with minimal tissue damage
▫ Staples, sutures, etc. used to approximate wounds
▫ No dead space, no ' postop complications
▫ EX. Surgical incision, simple laceration
 Granulation/Second intention
▫ Left open & allowed to heal inside out
▫ Significant tissue loss – may require tissue grafting
▫ More complicated & prolonged healing process
▫ Wound is debrided, cleansed & occluded
▫ EX. Infected wounds (decubitus ulcers), drains, trauma, tissue loss
 Delayed primary closure/Third intention
▫ Contaminated/dirty wounds
▫ High risk for infection, extensive tissue loss
▫ Wound kept open to monitor for infection
▫ These wounds are packed
▫ Kept open for several days (3-5) & brought back for closure
▫ EX. Compartment syndrome, burns, debridement, wound disruption, excessive trauma

✔ How do you prep an area when there is a contaminated area within the surgical site?
Clean 🢡 Dirty

 Area with a lower bacterial count prepped first, followed by the area of higher contamination
 An antiseptic-soaked sponge may be applied to the contaminated area during prepping of the
surrounding skin
 When prepping the anus or vagina or a stoma, sinus, ulcer or open wound, the sponge should be
applied once to the area & discarded

✔ Know zones: restricted, semi-restricted, non-restricted

 Restricted | operating room, invasive procedure room
▫ Surgical attire + head/facial hair covered + masks if there are open sterile supplies or
surgical team members
▫ Located within the semi-restricted area
▫ Limited to authorized personnel & patients accompanied by authorized personnel
▫ Specific heating, ventilation, and air conditioning (HVAC) parameters
 Temp 68-75° F but can be increased for peds, elderly, or pts who have trouble
maintaining body temp| Humidity 20-60% | Air exchanges 20/hr with a min of 4
of the exchanges from outdoor air
 Semi-restricted | sterile processing area, equipment & sterile supply storage, sterile processing
decontamination area
 ▫ Surgical attire + head/facial hair covered
▫ Specific HVAC parameters
 Temp 68-75° F | Humidity 20-60% | Air exchanges 6-15 w/ 2-3 outdoor air
exchanges/hour (dependent on the functions performed)
 Non-restricted |PACU, endoscopy suite, pain clinic/procedure room, locker room
▫ Street clothes permitted, traffic flow more liberal

✔ List fire safety precautions when surgery is above the xiphoid.

 Above the xiphoid is an oxygen rich environment so higher risk for fire
 When performing electrosurgery, administer the lowest practical level of O2 to pt

✔ List the phases of general anesthesia.

Phase I – Induction Phase II – Maintenance Phase III – Emergence
Anesthetic agents are Anesthesia provider continues to At the end of the procedure,
administered to “put the patient administer inhalational and/or anesthetic agents are d/c and/or
to sleep.” IV agents (most IV agents to keep the patient reversed and the patient is
adults) or inhalation agents anesthetized allowed to “wake up”
(many small children) can be
used
✔ What can over-pressurization of a tourniquet cuff cause?
A. Blood in the field - occurs from under-pressurization
B. Compression injury to blood vessels (+ nerve, muscle, or skin)
C. Muscle spasms
D. Shock - occurs from under-pressurization

*Over-pressurization also causes muscle weakness & extremity paralysis

✔ Know the following organizations and what they are known for: Joint Commission, CMS, Institute of
Medicine, World Health Organization (WHO)

 Joint Commission – promote specific improvements in patient safety by focusing on

problematic areas & accreditation requirements (National Patient Safety Goals – NPSGs)
▫ Universal Protocol – goal is to eliminate wrong site, wrong procedure, & wrong person
surgery
 Applies to all operative & other invasive procedures
 Includes procedures done in non-OR settings; ex. endoscopy units, ED, IR units,
& special procedure units
▫ Correct Site Surgery Tool Kit – steps to implement Universal Protocol
1. Patient participation
2. Identifying the patient
3. Marking the site
4. Time Out
 WHO – direct & coordinate authority for health throughout United Nations (UN)
▫ World Alliance on Patient Safety launched Oct 2004 to examine patient safety in acute &
primary care settings
 ▫ Initiatives: Clean Care is Safe Care (hand hygiene), Safe Surgery Saves Lives (the WHO
Surgical Safety Checklist), & Surgical Hand Preparation (preop hand antisepsis, enc
brushless hand scrubs, & review hand scrub preps)
 Centers for Medicare & Medicaid Services (CMS) - government agency that takes care of the
admin of Medicare/Medicaid services, include payment regulations
▫ Administers HIPAA
 Institute of Medicine (IOM) - released report (2000) To Err is Human: Building a Safer Health
System
▫ Report discusses the importance of regulators & accreditors requiring health care
organizations to implement meaningful patient safety programs
▫ Motivates health care organizations to “do the right thing” for patient safety
▫ Recommendations applicable to health care organizations, health care professions,
medical device manufacturers, and the FDA
The four elements required to create a culture of safety are 1. a sense of trust among team
members, 2. dissemination of receipt of information to all levels of staff, 3. a sincere commitment
to affirming safety as the first priority, and 4.support of a proactive approach.

✔ What are the consequences of specimen mishandling?

Misdiagnosis, delayed treatment, wrong treatment or even additional surgery

✔ What is the correct number of air exchanges per hour in an hour? 20

✔ Know signs of MH including most common early sign.
Triggered by inhaled general anesthetic agents & the muscle relaxant succinylcholine
SIGNS:
 Tachycardia and hypertension – common early signs but not specific to MH
 **Tachypnea and increased minute ventilation – more specific to MH but can be masked
if patient has muscle relaxants on board & ventilations are controlled
 **Increased end-tidal carbon dioxide – most specific to MH
 Skeletal muscle rigidity
 Mottling of the skin
 Ventricular dysrhythmia
 Hyperthermia
 Myoglobinuria
Tx: Dantrolene

✔ What are the latex sensitivity categories and what are the associated signs of each?
 Irritant Contact Dermatitis |Usually confined to the area of contact
▫ Red, swollen, dry skin
▫ Thickening & fissuring of the skin
▫ Pruritis (itching)
▫ Burning
▫ Formation of papules
  Immediate Type I Hypersensitivity Reaction/Latex Allergy |occurs within 5-30 mins of
exposure
▫ Contact urticaria (hives)
▫ Eczema
▫ Eyelid, facial swelling, orbital edema
▫ Generalized wheal & flare reactions
 Delayed Type IV Hypersensitivity Reaction/Allergic Contact Dermatitis | occurs within 10-
12 hours

✔ What drug reverses heparin? Protamine sulfate

 Hypersensitivities to heparin: chills, rash, urticaria, pruritus, fever, respiratory allergic reactions,
anaphylactic reactions

✔ What is the main reason to ensure laparoscopic instruments are in good working order?
The problems presented may not be apparent on casual observation (compared to instruments
used in open cases).

 Is the variety of instruments correct for the procedure?

 Are the jaws clean and channels open?
 Do they function properly?
 Are screws present and tight?
 Were the insulated instruments checked for cracks and breaks?
Special attention to the condition of insulation! Electrical current will escape through any break
in insulation and cause THERMAL BURNS & burns may be hidden from the surgical team if not
in the view of the camera

✔ What is the first thing you do when your count is incorrect?

NOTIFY SURGEON/TEAM

 The surgeon suspends closure and performs a systematic wound exploration.

 A search for missing objects is performed on the sterile field, back table, kick buckets, floor, etc.
 If the count is still incorrect, x-rays are taken.

✔ Know types of human factor errors.

 Skill-based – occurs when our attention is diverted & we fail to monitor the actions we are
performing
▫ Ex. Nurse forgets to retrieve a unite of blood when called to conduct a sponge count,
nurse inadvertently hits the wrong control button – the correct button is near the incorrect
button
 Situational – lack of attention
▫ Ex. Distraction (eg, background noise, conversations), fatigue, drugs (alcohol &
caffeine), stress, anger, etc
 Knowledge-based/Rule – occur when a nurse misinterprets a situation or incorrectly applies a
rule; includes errors in perception, judgement, inference & interpretation
 ▫ Ex. Nurse fails to properly assess a patient, nurse misinterprets test results, nurse fails to
provide indicated prophylaxis

✔ Know formalin handling safety measures.

VERY TOXIC if inhaled or splashed on mucous membranes of the eyes, the face or skin of hands.

 Hands & arms covered

 Eye protection
 Mask
If exposed, wash with copious amounts of water or saline

✔ List steps to properly remove gown and gloves.

REMOVE GOWN
1. The RN circulator unfastens the neck & back closures of the gown.
2. The scrub person should then fold the contaminated side of the gown to the inside, roll it up &
discard it
a. Grasp the shoulders of the gown or cross arms & pull it downward from the shoulder and
off the arms
b. Turn the sleeves inside out
c. Fold the contaminated surface of the gown to the inside & roll it up
d. Discard the rolled gown in the appropriate receptacle
REMOVE GLOVES
1. Glove-to-glove technique 🢡 skin-to-skin technique

✔ You relieve a circulator and find a medication that is not labeled on the field, what should you do?
Replace the medication

✔ Know the steps of reprocessing instruments and the purpose of indicators (including biological).
1. CLEANING - removing & moistening gross soil at the point of use
2. DECONTAMINATION - the bioburden is reduced & contaminants removed (by hand cleaning
or mechanical methods) *critical step toward reducing the potential hazards associated w/ direct
contact w/ blood, fluids, or tissues on contaminated instruments
3. ASSEMBLY - assembling the instruments; instruments should inspected for cleanliness, proper
function/alignment, corrosion/pitting/burrs/nicks/cracks, sharpness of cutting edges, looseness of
set pins, wear/chipping of inserts & plated surfaces, etc
4. PACKAGING - should be:
 compatible w/ sterilization method & equip that will be used
 allow sterilization to take place
 maintain sterility until the package is opened or integrity compromised
 provide aseptic delivery of the contents onto the sterile field
 be easy to use for personnel who prepare, transport & open package
 be used according to the manufacturer’s written instructions
 be labeled according to the policies & procedures of the practice setting &
manufacturer’s instructions
 5. STERILIZATION - process by which all forms of microbial life, including bacteria, viruses,
spores & fungi, are destroyed to an acceptable sterility assurance level
6. STORAGE - should be labeled & stored in such a way to ensure sterility; shelf life should be
event-related (not time-related); utilize FIFO (first in, first out)
 Length of time that an item is sterile depends on:
▫ Type & configuration of packaging materials used
▫ # of times package is handled before use
▫ # of personnel who may have handled the package
▫ Storage on open or closed shelves
▫ Condition of the storage area (cleanliness, temp, humidity, air exchange)
▫ Use of sterility maintenance covers (dust covers) & method of sealing
▫ Conditions during transport
7. TRANSPORTATION
Indicators are PCDs (process challenge devices) that provide info to demonstrate that conditions for
sterilization have been met
▫ Ex. Chemical indicators, biological indicators, physical monitoring devices

✔ List types of transmission-based precautions.

 CONTACT | C. Diff, MRSA, VRE, Acute viral infections, draining abscesses
▫ Direct – infectious microorganisms are transferred from a reservoir to a susceptible
person by direct contact; skin-to-skin contact, kissing, & sexual intercourse
▫ Indirect – no human physical contact occurs; transmission occurs with contaminated
objects, ex. Used scalpel, surfaces (door handles, computer keyboards), food (oral/fecal
route) or water (contaminated source) or spread by vectors like mosquitoes, flies, fleas,
etc.
▫ HAND HYGIENE (frequent – before/after gloves, touching pt/pt environ, eating,
personal hygiene; handwashing necessary if hands visibly soiled or pt w/ C. Diff), PPE
(gloves and gowns when providing care to the patient, using patient equipment or
touching environmental surfaces that are potentially contaminated), ENVIRON
CLEANING (follow manufacturer’s instructions)
 DROPLET | influenza, pertussis, streptococcus, rhinovirus
– large, heavy microorganisms that are expelled fall to & within 3 feet
▫ HAND HYGIENE (alcohol-based hand rub is acceptable, handwashing if hands are
visibly soiled or pt has C. Diff), PATIENT PLACEMENT (single-pt room or w/ another
droplet prec pt), MASKS (surgical masks for healthcare providers when interacting with
pt, pt during transport, & pt’s visitors –exception: visitors w/ documented exposure but
are not ill; N-95 respirators or PAPRs donned during aerosol-generating procedures, ex.
Intubation & bronchoscopy)
 AIRBORNE | measles, chickenpox, shingles, pulmonary TB
– small, pathogenic microbes that are expelled travel via air currents over time & distance
▫ Patients placed in an AIIR – airborne infection isolation room
▫ Healthcare providers – wear respirator: N-95 or higher mask, if fit tested or powered air-
purifying respirator (PAPR)

✔ Know specimen types: frozen, routine, culture, forensic, cytology

  Frozen section specimen – require immediate examination by the pathologist
▫ Ex. breast biopsy, bx of tumors, bx of lesions, bx rectal biopsy for ganglion cells
 Routine specimen – do not require immediate processing by the pathologist
 Culture specimen – tissue or fluid suspected of being infected
▫ Done when ID of pathogens is needed
▫ Test is called a culture & sensitivity test
▫ *do NOT go in formalin
 Forensic specimen – physical evidence retrieved from a person involved as a suspect or victim in
a crime
▫ Chain of custody very important to preserve! *Document who you gave it to
▫ Body fluids (blood, urine, gastric contents, seminal fluid)
▫ Hair & fibers (loose strains, shaved hair from around wound sites, carpet remnants,
strings)
 May be transferred between the victim & suspect perpetrator or victim & crime
scene
▫ Fingernails
 Striations unique to each person
 Can determine sex, race & blood type
▫ Debris (glass, wood chips)
 May connect victim or suspect perp to the crime scene
▫ Foreign object (bullet, knives)
 Excessive handling may alter the specimen
▫ Fabric/clothing
 Bacterial/fungal growth increases when evidence is stored in closed plastic
▫ **Avoid referring to injury sites as entrance/exit wounds – this determination should be
left to the experts
 Cytology specimen – obtained for studying cell biology
▫ Done when malignancy suspected
▫ Can be obtained through “washings” - physician injects saline & aspirates fluid
▫ Ex of washings: bronchial, bladder, pelvic
 Gross examination specimen – is not looked under a microscope; IDs what it is as a whole
▫ Surgery to remove implanted items; item is called an “explant”
▫ Explants are sent to pathology dept for gross exam, returned to the pt or discarded
▫ Ex orthopedic plates and screws, pacemaker generators and lead wires, foreign bodies
(coin)

✔ Be able to correctly identify would class, i.e. purulent inflammation encountered

Not infected or inflamed
Thyroidectomy,
Result of non-penetrating, blunt
mastectomy, ganglion
I CLEAN trauma
excision, skin biopsy,
Respiratory, alimentary &
herniorrhaphy, laminectomy
genitourinary tracts NOT entered
II CLEAN CONTAMINATED Entered respiratory, alimentary or Cholecystectomy without
genitourinary tract under spillage, colon resection,
controlled conditions & w/o tracheostomy, D&C, total
contamination of surrounding abdominal hysterectomy,
tissue gastrectomy, elective
 Non-traumatic
No evidence of infection appendectomy
No major break in aspect technique
Dirty instruments, open
Major break in sterile technique fractures, inflamed but
Wound is fresh, open or accidental unruptured appendix,
III CONTAMINATED Gross GI tract spillage traumatic wounds – gunshot,
Acute non-purulent inflammation stab wound without perf of
viscera
Purulent inflammation encountered
Retained devitalized tissue
I&D of abscess, total
Involve EXISTING clinical
IV DIRTY/INFECTED infection or perforated viscera
evisceration, perforated
viscera
and/or delayed primary closure of
wounds

✔ What type of needle should be used on a vascular anastomosis? Taper point needle (smooth point with
no cutting edges)

✔ Know best practice for draping, i.e. minimize handling, once placed should not be repositioned, do not
reach over patient to drape
 Handle drapes as little as possible – do not flip, fan or shake drapes
 Use only sterile drapes/Inspect drapes for integrity
 Barrier protection – most essential to maintaining sterile field
 Drapes incorrectly placed should be discarded by the unscrubbed person
 Don’t allow drapes to fall below waist – contaminated!
 Don’t contaminate the gown when placing drapes
 Never reach across an unsterile area to drape
 After drape placed, do not move/reposition
 Keep drapes in control
 After a perforating towel clip placed, do not remove – points of clip are contaminated
 Be mindful that head & neck area is oxygen-rich under drapes if ESU is used
Drapes should be
 Impermeable to fluids but porous enough to eliminate heat buildup (so pt does not sweat)
 Antistatic to eliminate risk of a spark from static electricity
Drape Removal – Proper Order
Last suture placed 🢡 Incision site dressed 🢡 Removal of instruments 🢡 Removal of drapes 🢡
Disposable materials disposed of