2022/2023 AORN PeriOp 101 Exam 1. distraction (background noise, conversations, radios) 2. fatigue & sleep loss 3. drugs (including alcohol & caffeine) 4. juggling multiple activities 5. stress 6. boredom 7. frustration 8. anxiety 9. anger 10. physical stamina d/t occupational muskuloskeletal injury (back/shoulder) ✔situational factors which play a significant role in medical errors 1. healthcare organizations 2. healthcare professionals 3. FDA - ✔should strengthen the focus of existing processes on patient safety issues 1. sense of trust among team members 2. development & support of proactive approach 3. dissemination & verification of receity of info to all levels of staff & management 4. sincere commitment to affirming safety as 1st priority - ✔Culture of Safety 316L-SS low-carbon iron allow wire - ✔surgical stainless steel sutures a responsibility of the scrub person ahead of laparoscopic procedure - ✔checking and tightening any screws on endoscopic instruments active hemostatic agents - ✔contain thrombin and products mixed with thrombin to ENHANCE CLOTTING at the bleeding site *ex: thrombin topical bovine, thrombin topical human, thrombin topical recombinant advantages of MIS include - ✔1. earlier return to normal activities & lifestyle 2. performed through smaller incision 3. shorter postOp recuperation 4. decreased pain --> decreased need for pain meds 5. ambulatory or shortened length of stay alimentary tract - ✔digestive tract always set your endoscopic light source parameters - ✔according to the manufacturer's instructions (IFU)
an additional consent - ✔the circulating RN should always get _____ covering the possibility of an open procedure prior to a MIS/endoscopic procedure an electrical current transfer through intact insulation - ✔capacitive coupling at the time of insertion - ✔when the body reacts to the suture material Benefits of a standardized count procedure: - ✔1. Assists accuracy 2. Assists efficiency 3. Human error studies have shown that many errors result from deviation blunt point needle - ✔rounded tip that will not cut tissue - used for dissection of friable tissue ex: kidney, liver, spleen, and uterine cervix ligation bone wax - ✔mixture of beeswax, isopropyl palmitate and a softening agent, which provides a mechanical tamponade effect to stop oozing from cut bone surfaces. capacitive coupling - ✔A specific burn hazard of monopolar endoscopic surgery. It occurs when current passes unintentionally through instrument insulation and adjacent conductive material into tissue. capillarity - ✔ability to soak up fluid along a strand causes of healing by second intention - ✔infection, excessive trauma, tissue loss, or imprecise approximation of tissue chemical hemostasis methods: pharmacological - ✔epinephrine vitamin K protamine lysine analogues (aminocaproic & tranexamic acid) chemical hemostasis methods: topical ACTIVE agents - ✔thrombins chemical hemostasis methods: topical PASSIVE agents - ✔1. collagen-based gelatins 2. spheres 3. flowable agents 4. sealants chest tubes - ✔drains used in thoracic and cardiac surgeries chromic gut = treated w/chromium salts to slow absorption *natural absorbable surgical gut - ✔10-21 days = used in infected tissues and slowhealing tissue *ligation of larger vessels such as biliary, urinary tracts, and muscle/fascia closure
CO2 is the gas used for abdominal insufflation because it is - ✔rapidly eliminated collagen - ✔the basic protein substance of connective tissue *synthesis of collagen by fibroblasts, contributes to the tensile strength of a wound collagen & surgical gut (plain catgut & chromic) - ✔packaged in fluid that may be irritating to eyes, therefore, should always be rinsed, but not soaked!, as they can prematurely break down *packages should be opened over a basin to prevent splashing on the field or into eyes* collagen sutures - ✔natural absorbable, made from cattle tendons = ophthalmologic surgery colon resection (colectomy) - ✔Class 2: Clean-contaminated common uses of a pledget - ✔vascular closure, septal repair, myocardial closure, heart valve suturing, hepatic repair common uses of bone wax - ✔orthopedic and neurosurgical procedures and on the sternum during heart procedures components of medical video imaging used during minimally invasive (endoscopic) surgery = MIS - ✔1. video monitor(s) 2. camera control unit (CCU) 3. fiberoptic light cable 4. video cables 5. light source 6. peripheral devices for recording/documentation contributes to potential complications of minimally invasive surgery - ✔1. positioning 2. distention gases 3. irrigation fluids conventional cutting point needle - ✔triangular shape with cutting edge on INSIDE curvature -creating a very small path that heals quickly *ligaments/tendons, skin, nasal & oral cavities, and pharynx correct needle placement in the needle holder - ✔1. clamp the body 1/4 to 1/2 of the distance from the eye to the point 2. place needle securely in jaw tip 3. close the needle holder to the first or second ratchet Counts should be conducted: - ✔1. before the beginning of the operation
2. before any closure begins 3. when skin closure is begun 4. before circulating RN or scrub relief takes over 5. end of operation desirable characteristics of surgical needles - ✔1. strong, do not break easily 2.rigid yet flexible enough to bend without breaking, to prevent excessive bleeding 3. sharp point to penetrate with minimal resistance 4. equal to diameter of suture material for less damage 5. free from corrosion/burrs to prevent infection/trauma diameter - ✔a designation of "4-0" on a suture package indicates the suture material's do NOT turn on the endoscopic light source until - ✔the light cable is connected to the telescope docking and undocking the robot - ✔should NOT be interrupted for any other activities Drains that allow for passive drainage of fluid from the body: - ✔Penrose and T-tube elasticity - ✔ability to regain original form and length after being stretched Factors affecting wound healing - ✔1. maintenance of sterile and aseptic techniques to prevent infection 2. hemostasis 3. removal of necrotic tissue and foreign material 4. choice of closure material 5. closing with sufficient tension fibrin sealants hemostatic agents - ✔promote blood clotting by INCREASING the AMOUNT OF FIBRINOGEN and THROMBIN at the bleeding site - from pooled or individual human plasma, equine or bovine collagen & bovine thrombin *Tisseel, Tachosil, Vitgel, Coseal, Duraseal, Progel, Bioglue, and Omnex flowables hemostatic agents - ✔combinations of passive and active hemostatic agents that work by mechanically OBSTRUCTING FLOW of blood - require direct contact with blood to work *Floseal, Surgiflo flush the insufflator and insufflation tubing with the selected gas before - ✔the tubing is connected to the cannula French-eye or split-eye needle - ✔PROS - diameter of the needle should match the type of suture used - easy to thread
CONS - canNOT double wrap w/2 sutures, may cause trauma - may unthread prematurely granulation or second intention - ✔term describing a wound left open, allowing it to heal from the inner layer -> the outer surface without additional surgery intraOp factors that negatively affect wound healing - ✔1. surgical complication 2. failure to eliminate dead space when closing 3. implantation of ortho hardware 4. incision in area of high mobility irrigation, distention, stored - ✔Fluids to be used for _____ and as _____ media at a temperature other than room temperature should be warmed or cooled and ____ in a safe manner. IV, irrigation, hyponatremia, hypervolemia - ✔Achieving correct fluid management for the patient during MIS/endoscopic procedures includes monitoring overload of _____ and _____ fluids, to avoid _____ and _____. knot tensile strength - ✔when knotted, the force in pounds, which the suture can withstand before it breaks knowlege-based performance errors occur - ✔when a nurse misinterprets a situation or incorrectly applies a rule ex: misinterpretation of test results, or a nurse fails to respond to a device alarm ligature aka "tie" - ✔strand of material tied around a vessel to occlude the lumen a nd prevent bleeding linear staples - ✔type of staplers used in the alimentary tract and in thoracic procedures mechanical hemostasis methods - ✔bone wax ligature pledget clamps sutures staples sponges direct pressure memory - ✔capacity of a suture to regain former shape after being reformed methods of producing hemostasis - ✔1. administer blood 2. apply pressure 3. use electrocautery
4. use topical hemostatic agents micro point needle - ✔reverse cutting used for the eye more, apparent - ✔The scrub person should devote _____ time to inspecting laparoscopic instruments vs. instruments used in open cases because the problems they present may not be _____ upon casual observation. Nasogastric drain used for decompression of the stomach: - ✔Levin tube Nasogastric drain used to treat obstructive lesions of the small intestine: - ✔MillerAbbott Nasogastric suction: - ✔Salem sump tube natural non-absorbable sutures - ✔1. surgical silk (used in the serosa of GI tract) 2. surgical cotton 3. linen 4. stainless steel no-touch, hands-free, neutral zone method - ✔recommended technique for passing sharps, where the scrub person and surgeon use a magnetic pad or container to hold and pass instruments to keep them from slipping *hand-to-hand passing should be avoided if possible to prevent percutaneous injuries nursing considerations for MIS/endoscopic procedures - ✔1. previous incisions = may require add'l supplies/sutures 2. history of DVT or venous stasis 3. consent obtained for possible open procedure 4. voiding prior to surgery 5. risk of hypothermia d/t irrigation or distention fluids 6. compromised positioning = use of pads, safety straps, & arm/foot boards on, audible, working correctly, CO2 backup tank - ✔Always make sure the insufflator alarms and displays showing actual CO2 pressure and supply levels are turned _____, are _____, are _____, and that you have a full _____ prior to beginning any MIS procedure!!! open or fresh traumatic wound - ✔Class 3: Contaminated parameters of insufflator CO2 pressure are set according to - ✔1. manufacturer's instructions for use (IFU) 2. surgeon's preference
passive or mechanical hemostatic agents - ✔applied at the bleeding site, and PROVIDE A BARRIER to stop blood flow *collagens = ex: Avilene, Ultrafoam, Helistat, Helitene, and Instat *cellulose = ex: Surgicel, Nu-Knit *Gelatins = ex: Gelfoam, Surgifoam *Polysaccharide spheres = Aristak, Hemostase, & Vitsure patients having MIS/endoscopic procedures are at risk for - ✔1. hypothermia 2. hypervolemia 3. hyponatremia Penrose drain is used for: - ✔abdominal surgery, peritoneal cavity, or skin wounds. perioperative RN actions during the intraOp phase to assist with wound healing - ✔1. focus on efficiency to reduce the length of surgery - longer surgeries = greater risk of infection 2. reduce risk of complications - ex: hemorrhage, break in aseptic technique periumbilical - ✔region of the patient's abdomen traditionally used to establish pneumoperitoneum for laparoscopic surgery Phase 2: Proliferation = day 2 post-incision -> day 22 - ✔1. EPITHELIALIZATION = 1-4 days, fibroblasts migrate to wound site, keratinocytes begin formation of scab sealing wound (epidermal regeneration) 2. NEOVASCULARIZATION = 2-7 days, granulation tissue **time when most disruptions occur!! 3. COLLAGEN SYNTHESIS = 2-22 days, fibroblasts synthesize collagen, important phase contributing to the tensile strength of the wound 4. CONTRACTION = 2-22 days, contraction caused by fibroblasts transforming into myofibroblasts, which help strengthen the wound and close any remaining defect Phase 3: Remodeling = 21 days postOp -> 2 years - ✔1. COLLAGEN REMODELING = fibers weave themselves into an organized pattern determined by stress demands of wound 2. TENSILE STRENGTH GAIN = over a period of years, the scar tissue remodels as fibroblasts disappear froj the wound site, collagen decreases **scar tissue regains only 80% of its original strength Phase I: Inflammation = immediately postOp -> 6 days - ✔1. HEMOSTASIS = 0-2 hrs, begins immediately vasoconstriction, platelets form clot, erythrocytes/leukocytes appear to start infiltration 2. PHAGOCYTOSIS = 0-4 days, neutrophils & macrophages cleanup, macrophages stimulate fibroblast formation & proliferation, wound is red & swollen 3. EDEMA = 0-6 days, capillary walls become permeable to plasma -> leaks into wound
phase of wound healing where contraction occurs - ✔proliferation phases of wound healing - ✔Phase 1. inflammation Phase 2. proliferation Phase 3. remodeling Phase 4. granulation or second intention plain catgut = treated w/aldehyde to strengthen *natural absorbable surgical gut (fast-absorbing!) - ✔7-10 days = used for subQ tissue and repair of rapidly healing tissues + ligation of superficial blood vessels *ideal for skin or facial suturing + subQ fat and tissue under tension while healing pledget - ✔non-absorbable suture used when there is a possibility of sutures tearing through tissue. point in the healing process when most wound disruptions occur - ✔during neovascularization in the early proliferation phase (Phase 2) 2-10 days Poliglecaprone (Monocryl) = violet or undyed - ✔synthetic absorbable - wound closure, bowel surgery (mucosa), cosmetic *Specialties = General & Plastics Polydiaxanone sutures (ex: PDS & PDS II) - ✔synthetic absorbable - used for slow-healing tissues and extended wound support *abdominal and thoracic closure, subcutaneous tissue, and colorectal surgery Polyglactin 910 (Vicryl) = violet in size 9-0 to 10-0 - ✔synthetic absorbable - ophthalmic procedures *available in 2 forms: uncoated or "Vicryl suture Polyglcolic acid (Dexon) = uncoated (Dexon S) -green size 2 to 8-0 -undyed nat'l beige size 2 t0 7-0 -green monofilament 9-0 = coated (Dexon Plus) -slick surfactant covering - ✔synthetic absorbable - peritoneal, fascia, and subcutaneous closure *replaces surgical gut in many applications Polyglyconate (Maxon) = green or clear - ✔synthetic absorbable - general soft tissue approximation *NOT for cardio, neural, or eyes position the insufflator - ✔at the level of the patient's heart or higher *to prevent intra-abdominal fluids or gases from contaminating the device
precision point needle - ✔routinely used for plastic/cosmetic procedures ex: Prolene & Surgilene preoperative systemic factors that negatively affect wound healing - ✔1. INADEQUATE NUTRITION = protein, carbs, fat, and vitamin A, B, C, and Zinc deficiencies 2. PHYSICAL CONDITION 3. older AGE 4. MEDICATIONS 5. OBESITY 6. SMOKING 7. CHRONIC DISEASE (ex: diabetes) previous incisions may alter - ✔trocar insertion technique primary dressing - ✔used directly on the incision to absorb drainage and wick it away (*include a non-adhesive layer to prevent debridement of tissue when removed) prolonged high doses of steroids preoperatively delay - ✔collagen formation radiopaque - ✔Never use _____ sponges for postoperative wound dressings. Radiopaque sponges are used to: - ✔drain pus, purulent, or necrotic material from a wound. reduces the risk of systemic hemodynamic changes - ✔maintaining intra-abdominal pressure at the lowest level necessary to achieve pneumoperitoneum required to perform the sponge count - ✔2 people, with one being the circulating RN Responsible for the accuracy of the sponge count - ✔all perioperative personnel involved in a surgical case reverse cutting point needle - ✔triangular shape with cutting edges on OUTER curvature *fascia, ligaments, tendon sheath, nasal & oral cavities, and oral mucosa ruptured appendix - ✔Class 4: Dirty safety straps and a foot board - ✔should be used to keep patient from slipping while in the Trendelenburg or reverse Trendelenburg position secondary dressing - ✔placed over top of the primary dressing, and used mainly for the absorption of drainage and for hemostatic pressure, and protection of the wound
sequence of events involved in the body's defense mechanisms - ✔SCSRegRep 1. stop the bleeding (hemostasis) 2. cleaning - pathogens & debris 3. sealing - against infection 4. regeneration - of the natural epidermal covering 5. repair - deeper tissue damage side cutting point needle - ✔flat on top and bottom with angulated edges on sides - split tissue layers but do NOT penetrate underlying tissues *ophthalmic surgery simultaneously, audibly, separated - ✔The scrub person and circulating RN should count sponges _____ and _____as each sponge is _____ from the others in the pack. skill-based behavior errors generally occur - ✔when our attention is diverted and we fail to monitor the actions we are performing ex: a nurse inadvertently hits the wrong control button - the correct button is near the incorrect button skin adhesive - ✔involves the use of liquid polymers sponges with radiopaque markers must be used: - ✔during any invasive procedure standard, PPE - ✔Use _____ precautions and _____ to prevent exposure to blood and body fluids when handling sponges. suction drain used in abdominal or breast surgery - ✔Jackson-Pratt (JP) suction drain used in orthopedic surgery - ✔hemovac suppress, contraction, collagen - ✔Steroids _____ the inflammatory response but delay _____ and _____ synthesis. surgical gut - ✔natural absorbable, made from small intestine of sheep or serosa of cattle = 2 types: plain gut & chromic gut surgical stainless steel - ✔non-absorbable = used for abdominal wall closure or sternum, respiratory tract, orthopedics and neurosurgery synthetic absorbable sutures - ✔1. made of polymers 2. used for ligating and suturing except when tissue is under stress 3. inert, nonantigenic, nonpyrogenic 4. long lasting 3 weeks --> 6 months
T-tube drain - ✔inserted into the biliary tract to allow for bile drainage. *generally left in place for 10 or more days, to develop a tract through which bile can drain after tube is removed taper point needle - ✔smooth point with no cutting edges that pushes tissue aside when passing through - used for aponeurosis, biliary tract, dura, fascia, GI tract, muscle, myocardium, nerve, peritoneum, pleura, subQ fat, and vessels *ex: vascular anastomosis The CDC's Classification of Surgical Wounds system is intended to - ✔monitor postoperative infections and suggest steps to take to reduce these infections the circulating RN should always consider the risk of hypothermia - ✔during MIS/endoscopic procedures d/t the use of fluids for irrigation or distention the circulating RN will need to gather additional sterile supplies and sutures if the ✔Hasson mini-laparotomy technique is used d/t previous incisions/scarring thermal burns in MIS/endoscopic procedures - ✔can result from breaks in the insulation of instrument cords because they allow electrical current to escape Thermal/Energy hemostasis methods - ✔1. High-frequency electric current from an ESU 2. Bipolar vessel-sealing devices 3. Laser energy sources 4. Ultrasonic energy 5. Radio frequency energy generated by Argon gas thyroidectomy - ✔Class 1: Clean transfixion suture - ✔type of ligature = crisscross stitch placed to control bleeding from a tissue surface or small vessel when it is tied trocar point needle - ✔has 3 cutting edges at the very tip - used to penetrate tough tissues Type of dressing used to prevent drying of the wound and increase the proliferation of epithelial cells: - ✔Occlusive What precaution should be taken when microfibrillar collagen is used as a hemostatic agent intraoperatively? - ✔Avoid using it with an autologous blood salvage unit
When handling hemostatic agents such as collagen or gelatin sponges: - ✔Must not be injected or allowed to enter large vessels, as extensive intravascular clotting may occur. when not in use, the light source should be placed in - ✔standby mode