1. Introduction to Operation Theatre Nursing

These lecture is prepared for BSc Nursing students of Haramaya University

1. INTRODUCTION TO OPERATION Room TECHNIQUE By Ame Mehadi (EMCCN, Assis tant Professor) 1

2. Learning Objectives At the end of this Session, the learners will be able to: Describe specific areas within the OR Identify major OR equipment Discuss how the OR environmental layout contributes to the aseptic technique. Differentiate the OR personnel Identify basic principles of aseptic technique 2

3. OR design and administration 2 Hrs. CSSD ----- Central Sterile Services Department ( CSSD ) 2 Hrs. Micro surgical instruments Suture Materials Administering anesthesia to a patient 4 Hrs. Introduction 2 Hrs. Monitoring & Recording Physiological Status 2 Hrs. Infection prevention in OR Maintaining anesthesia during an operation Hazards in anesthesia 6 Hrs. Surgical conscience Surgical conscience Consent Areas affected by surgical conscience Protection of the patient Situations that Undermine Surgical Conscience Legal aspects of surgery Criminal responsibilities Common areas of negligence Nursing responsibility 2 Hrs. Principles of Anesthesia Introduction Types of anesthesia Methods of administering Stages of general anesthesia Choices of anesthesia Pre-medication 4 Hrs. Introduction to ventilation Cardiopulmonary resuscitation Emergency drugs – protocols for use Defibrillation Fluid replacement therapy Homeostasis – mechanisms for maintenance Patients presenting with multiple pathology Stress management 4 Hrs. Surgical Asepsis General surgical instrumentation Receiving and positioning of surgical patients 3 Hrs. Staff conduct and practice OR attire 2 Hrs. WHO‘s 10 objectives for surgery Instrument handling Suture Materials and Needles Positioning and operation 2 Hrs. Hazards in the OR Precautionary Measures Teams in OR 6 Hrs. Hazards in the operating theatre Principles of Anesthesia 2 Hrs. 3

4. Operating Room Technique SN SDL Allocated Hrs . SDL 1 Gowning and gloving 2 Hrs. SDL 2 Identification of surgical instruments 1 Hr. SDL 3 Material processing 2 Hrs. SDL 4 Surgical attire, surgical scrub 2 Hrs. SDL 5 Wound care Suturing Suture removal 4 hrs. 4 Fundamentals of Nursing Perioperative patient care --4 Hrs. Pre-operative Intra operative Post-operative Ongoing postoperative patient care

5. OR Design & Administration (2 Hrs .) 5

6. Definitions of Terminologies OPERATING DEPARTMENT: A unit consisting of one or more operating suites together wz ancillary accommodations such as; Changing room, Reception Transfer room, Restroom RR, Circulatory room OPERATING SUITE: comprises of operating theatre/room together wz immediate ancillary areas such as; Anesthetic rooms Sterile layup or preparation room Disposal room Scrub up & gowning areas Exit room. OPERATING/OPERATION THEATER: is a facility within a hospital where surgical operations are carried out in a sterile env’t . is where surgical operations & certain diagnostic procedures are performed. Real area of operation is the entire area in which surgeries are performed and materials are prepared and stored for surgery. specifically for use by the anesthetist & surgical teams must not be used for other purposes. Includes OR/or surgical suite recovery room(RR) 6

7. Definitions of …… OPERATING ROOM is where surgery is performed is organized & designed differently from other wards. is a special room wz washable walls & ceilings made of ceramics equipped wz special instruments RECOVERY ROOM(RR) is a place where the pt stays until recovers from anesthesia after surgery. Both rooms ( OR & RR) require: Good lighting & ventilation Dedicated equipment Monitoring Equipment Sutures & extra equipment Drugs 7

8. OR Design Principles Common basic OR design principles criteria: Simple design & easy to clean simple & easy to clean & keep it clean suitable to prevent cross-contamination: smooth wall & floor surfaces made of nonporous materials separate rooms for clean, sterile & soiled instruments sufficient space to ensure safe transportation of pts & staff. convenient layout for the supervisor to control traffic RR attached to OR Major consideration during OR designation Designing and planning consideration of the physical facility of a theatre: determination of the numbers of OR. future surgical needs of the community. future development in surgical technology. Surgical support system e.g. Temperature, Humidity, Ventilation Lighting Doors Communication and information Administration units

9. 9 Doors OR doors are designed to ensure the safety of patients and medical staff by controlling access to sterile areas and providing a secure environment.  Ideally should be sliding doors. microbial count is usually at its peak at the time of the skin incision because this follows the disturbance of air by: gowning, draping, personnel movements and opening and closing of doors. During the surgical procedure, the microbial count rises every time doors swing open from either direction. Also, swinging doors may touch a sterile table or person. The risk of catching hands, equipment cords, IV line tubing, or other supplies is high. Some common types of OR doors include:  Sliding doors eliminate the air currents caused by swinging doors. disturbs MOs that have previously settled in the room with each swing of the door. heavy, steel doors are often automated & slide horizontally on tracks.  good choice for areas with limited space & when many people need to enter quickly. Hinged doors Opened like regular doors using hinges. good choice for providing a strong seal when closed. Folding doors Opened up & folded together to make a space bigger.  Can also slide apart like a sliding door. Smart glass doors can change from transparent to opaque to offer privacy when needed. Fire-rated doors are made of strong materials like steel or wood to help stop fires from spreading. Other features of OR doors include:  Soundproofing, Durability, Easy to clean, Automatic closing, Air pressure regulation.

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11. Lighting in the Theatre Can be Natural light Service light Artificial light Lights should be overhead freely movable, shadowless and less heat emitting. 11

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13. Ventilation in the Theatre purpose: Supply heated or cooled, humidified, contamination-free air to the room. Introduce air into the theatre to remove contaminants liberated there. Prevent entry of air from adjacent contaminated areas. Should be 25 times air exchange/hr. Humidity To prevent ventilating air not to be dry. must be b/n 50-60%. Controlled by an instrument called a Hygrometer to measure the level. Heating The room temp of OR must be b/n 18.5–22 o C may exceed to 24 C. 13

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15. Organizational Areas…… LOCATION centrally located so that easily & quickly reached from all areas of the hospital, thus enabling personnel to transfer pts with the least possible delay. near such support activities as ICU, RR, Lab. Pharmacy, X-Ray & CMS/CSR in a passage with only one outlet , or at least away from those areas of the hospital through which most of the traffic flows. sufficiently isolated to prevent annoyance, anxiety, & disturbance to other pts. near easily reached elevators for transportation of pts or supplies. 15

16. Organizational Areas …….. 16

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18. Zoning … Zonal division are designated by the physical activities performed in each area. Three Vs Four Zone Concept Three Zone Division more common and includes Unrestricted area, Semi-restricted area and Restricted area. Four Zone Division Protective zone/limited access area/unrestricted area Clean/Semi Restricted zone Sterile/restricted Zone Disposal Zone Four Zone Division Concept not necessarily used for all hospitals, but whenever feasible the OR is segregated into four areas for traffic control . Purpose to assure maximum protection against infections. Traffic control design needs determination of specific traffic patterns . dependent on the entrances and exits for both personnel & materials. is aided by designation of the four-zone concept (as shown below):

19. A. Protective Zone is an unrestricted Area but limited Access Area street clothes permitted. A corridor on the periphery accommodates traffic from outside, including patients. isolated by doors from main corridor and other areas of the suite. Usually separated by RED or green line from the next area. serves as an outside-to-inside access area. Exit from clean zone & sterile zone Transfer or change over section. is 1st stage of entry to operation Dep’t Includes: RR, Plaster room Change room Offices (e.g. reception, staff, head) Seminar & teaching rooms. B. Clean/Semi Restricted Zone is a transitional zone Traffic is limited to properly attired/dressed personnel pt transferred to a clean side & stretcher is on entry to this area. Approach sterility to the operating theatre. Approach to the sterile preparation room coverings are required Head, face, entire body pt’s hair must be covered. includes peripheral support areas access corridors to the OR. Scrubbing room. Gowning area Anesthetic room Exit lobby, Clean movements Rest area, Sterile store. 20

20. C. Sterile/Restricted Zone is the place where actual surgery and other sterile procedures are performed. is the main OR itself. is where complete surgical attire/OR attire including masks, caps, shoes & trousers are required is where sterile instruments are used is sterile team members wear (don) sterile gowns & gloves. The zone includes: OR. sterile preparation rooms. scrubbing rooms, scrubbing sink areas. Sub-sterile rooms or clean core area(s) where unwrapped supplies are sterilized. RR or PACU is by. D. The Disposal Zone least clean area of the whole department includes: The disposal room Interim storage area The disposal corridor 21

21. Organizational Areas…

22. Illustration of areas within the OR

23. By Ame M.

24. OR Major Equipment 25

25. Major equipment required in Major OR

26. Major equipment required in Major OR 27

27. OR Major Equipment 28

28. Major equipment required in Major OR 29

29. Anesthesia Equipment

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31. Electro-cautery (cautery machine) Used for cutting tissues and stopping of bleeding by sealing blood vessels. Suction machine Used to suck body fluids

32. OR Essential Equipment Checklist

33. Recovery room (RR)

34. Materials required in RR 35

35. Operation Theatre Cleaning 36

36. Need for fumigation Surveillance studies of different zones in operation theatre showed that the isolates were Staphylococcus aureus (16%) Coagulase-negative staphylococcus aureus (26.7%) Acinobacter species (2.03%) Klebsiella (0.3%) E.coli, Pseudomonas species, & Proteus species were also found in majority 37

37. Daily cleaning should be carried out after the operating sessions are over. All the surfaces should be cleaned with detergent and water and maybe wiped over with a phenol if any spills with blood/body fluid are present. All the walls must be wiped down to hand height every day . Floors should be scrubbed with warm water and detergent and dried. No disinfectant is necessary. OR table and other non-clinical equipment must be wiped to remove all visible dirt and left to dry. Weakly cleaning of all the areas inside the operating theatre complex should be done thoroughly with warm water and detergent and dried. Storage shelves must be emptied and wiped over, allowed to dry, and restacked. 38

38. Surgical Team Members & Their Responsibilities 39

39. Objectives Discuss the surgical team composition Discuss the responsibilities of each surgical team member Discuss the responsibilities of Unsterile team members Discuss the responsibilities of sterile team members List the responsibilities of a scrub nurse List the responsibilities of circulator nurse 40

40. Surgical Team ……. 41 Definition : A group of professionals providing the continuum of care during:- pre-operative. intra-operative and postoperative and recovery Includes Surgeon, Assistant surgeon (One or two), Anesthesia provider (Anesthetist/Anesthesiologist), Scrub, Circulator/runner, Janitor/cleaner, Others ( cardiologist, perfusionist, radiographer, etc. ) is subdivided according to the functions of its members as Sterile Vs Unsterile Sterile team: Surgeon First assistant (RN or PA) Scrub Nurse Unsterile team: Anesthesia provider Circulator nurse Janitors Others cardiologist, perfusionist, radographer , etc.

41. Surgical Team …cont’d Sterile t eam members those working together in the sterile field during operation. wash (scrub) their hands and arms, put on (don) a sterile gown and gloves, and enter the sterile field, work within limited area (only sterile field) and handle only sterile items. the sterile field is the area of the OR that immediately surrounds the patient is specially prepared for the patient. established by all sterilized items needed for the surgical procedure. Consists Surgeon Assistant surgeon Scrub nurse The patient OR team members while performing operation

42. Responsibilities of the Anesthesia Provider I. Anesthesia provider ( AP ) AP Can be Anesthesiologist is a physician specialized in anesthesia. Anesthetist a university or college graduate in anesthesia Nurse anesthetist a registered professional nurse who is trained in administering anesthetics.

43. Scrub Nurse……

44. Surgical Count

45. Counting Procedure

46. Counting Procedure…………

47. Qualities ……

48. Qualities …… Respect respect for the patient’s rights for privacy, for other team members, and for own self is very important in the OR. The OR relies on chain of command for efficient and safe patient care. Those who experience problems in responding to authority should not work.

49. Qualities …… Stable health If one person is ill, the workload of other team members is increased because they must perform the work of the absentee. The surgery department relies upon the daily presence of its employees. If one person is ill, the workload of other team members is increased because they must perform the work of the absentee. Cases are generally not cancelled because of absenteeism. Since the OR is a stressful situation and because stress can contribute to ill health, you must be careful to guard against illness and injury. Of particular importance are prevention of injury to the back and maintenance of healthy skin and respiratory tract (common areas of illness).

50. Qualities …… Good Humor is having a proper perspective on the day’s events and to share in good spirit. It is a senseless waste of energy for a team member to allow one distressing episode to influence an entire day’s work. Team members who are consistently sullen can lower the morale of the whole department, while those who are cheerful can raise everyone’s spirit. In a difficult and demanding env’t such as the OR, it is important to have a proper perspective on the day’s events and to share in good spirit. Team spirit is very important in surgery. is the ability to work with team members toward a common goal. The patient expects and should receive the undivided attention of all who care for him/her. To accomplish this, you should recognize the importance of not only your job, but also those of the other team members. You should either put personnel problems aside or bring them to the attention of the supervisor, who might able to resolve them.

51. Co-operation and Economical Use of Hospital Supplies, Equipment and Time 73

52. Co-operation and Economical Use of Hospital Supplies, Equipment and Time The team approach to care should involve a coordinated effort with the cooperation of all caregivers. Team members should communicate and have a shared division of duties to perform specified tasks as a unified body. The failure of any member to perform her/his role can seriously impact the success of the entire team. Performing as a team requires that each member exert an effort to attain the common goals competently and safely. No individual can accomplish the goal without the cooperation of the rest of the team. 74

53. A. Economical use of supplies & hospital Equipment Most of hospital equipment is being imported from abroad and it is costy and, therefore economical and proper usage is mandatory. As the cost of supplies and equipment increases, the OR team members should be conscious of ways to eliminate wasteful practices. e.g.,, throw away disposable items only. Avoid throwing away reusable items. OR is one of the most expensive departments of a hospital. Adequate instruments & supplies are necessary for patient care, & cost is not always the primary consideration. Economy becomes a hazard when exercised beyond the point of safety. Nevertheless, supplies do not need to be used lavishly, just b/c they are available. Most of the hospital equipment is being imported from abroad and it is costy and, therefore economical and proper usage is mandatory.

54. A. Economical use …….. “Just Enough Is Enough” Variety & number of instruments & supplies needed for each surgical procedure can be kept to a minimum. Materials no longer used can be eliminated. Items to “ have available ” are not opened unnecessarily. The following procedures should be observed: Pour just enough antiseptic solution, Follow the procedures for draping, Do not open another packet of sutures for the last stitch unless absolutely necessary, A few leftover pieces are usually long enough to complete the closure, Supplies should be opened only as needed, not routinely “ just in case ” they may be needed, Turn off lights when they are not needed.

55. B. Time Economy Time is money; do not waste it. Know the policies and procedures, and follow them efficiently. Learn to do things right the first time and continue to do them that way; time is wasted in correcting errors. Time is an important element in the OR. If time is wasted between surgical procedures, the day’s schedule is slowed down and later procedures are delayed. The patients and families become anxious during these delays. By reducing time we can reduce the prolonged administration of anesthetic agents, and other medication. The hazards of surgery will also be decreased with reduced time.

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