Universal Protocol for Surgical Procedures, Exams of Nursing

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CCI CNOR Certified Nurse Operating Room

Perioperative Nursing Certified 2024 Exam

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Administrator [Date] [Course title]

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1. What is Peri- operative Nurs- ing?
2. AORN Domains of Concern
3. PNDS What it is & Nurs- ing Application
4. RNFA What it is & Nurs- ing Application Following 4 areas are emphasized in the AORN Pa- tient-Focused Model: 1) Patient safety: right patient, right site, limb padding, grounding 2) Physiologic responses: VS, allergic rxns, UOs 3) Behavioral responses: anxiety, depression, fear, delirium, agitation 4) Health System: collaboration, multidisciplinary plan of care What it is: - Perioperative Nursing Data Set (PNDS) - Standardized nursing vocabulary for diagnoses, out- comes, and implementations r/t perioperative nursing - Focus is on prevention of problems instead of identifica- tion of problems Nursing Application: The PNDS, 3rd edition, contains 44 nursing diagnoses, 53 interventions, and 40 nurse-sensitive patient out- comes. However, a periop nurse may also identify and include additional relevant patient outcomes. In other works, the PNS should be used as a guide, not as a limitation. What it is: - Registered Nurse First Assist (RNFA) - Expanded role that includes direct assistance to the surgeon during the intraoperative phase

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5. Surgical Assis- tant The RNFA functions under the surgeon's supervision, and may even be an employee by the surgeon instead of the facility as part of surgical practice. The RNFA qualifi- cations are noted in the AORN Position Statement on RN First Assistants. - May be an RNFA, a PA, a resident, or another surgeon - Part of the sterile surgical team - Practice of the assistant is governed by the state, med- ical board, nursing board, and hospital policy, among other regulatory bodies - Duties may include: ~Suctioning the wound ~Exposing the operative site ~Handling tissue samples or organs ~Suturing
6. Scrub Person - May be an RN, LPN, or surgical tech
   • Part of sterile surgical team
   • Works with equipment and instruments
   • Duties include: ~Gathering correct surgical kits for the procedure ~Establishing and maintaining the sterile field ~Placing instruments and supplies within the sterile field ~Anticipating needs of the surgical team ~Performing surgical counts of sponges, instruments, etc. ~Preparing used instruments for terminal sterilization
7. Circulating Nurse - Usually a nurse functions in this role due to its elements of assessment and teaching - Part of the non-sterile surgical team - Functions as care coordinator in the intraoperative phase - Duties include:

5 / ~Supporting patient's emotional needs prior to anesthe- sia ~Assessing the patient throughout needs prior to anes- thesia

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• Involve the patient in confirmation if possible
• Confirm availability of necessary items: signed consent, test results, blood products, implants, specialty equip-

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10. Surgical "Rights" ment)
    2. Mark the site (see "Mark the Site" card [#11]) 3.Time-out (see "Surgical Time-Out" card [#12])
    3. Right person
    4. Right site
    5. Right side (laterality)
    6. Right procedure
    7. Right documentation
11. "Mark the Site" - Must occur prior to the procedure

• Must be permanent enough to still be visible after skin prepping and sterile draping
• Adhesive markers cannot be only site markers
• Not necessary for bilateral surgeries (tonsils, ovaries)
• When site marking is not possible, not necessary, or refused by the patient, follow facility policy on alternative procedures Non-marked Procedure Examples: -Cardiac catheterizations -Tooth procedures -Any procedure on premature infants (ink may leave a permanent mark) -Perineal procedures

12. Surgical "Time-Out"

• Perform the "time-out" right before the procedure starts
• Conduct according to a standardized procedure
• Include all active participants in the procedure
• Require active communication from all active partici- pants
• All participants must agree on (at minimum) the patient's identity, the site of the procedure, and the type of proce- dure
• If multiple procedures are to be performed, a new

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13. Preoperative Teaching (during preadmission workup)
14. Pediatric Preop Teaching
15. Spaulding Clas- sification the person performing the procedure changes
    • Document the "time-out" Should include following information about:
    • Procedure(s), expected duration and outcome(s)
    • Pre-procedure diagnostic tests
    • IV placement and sedation procedures
    • NPO instructions
    • Showering/bathing
    • Medication management (i.e., what to take, what not to take)
    • Intraoperative events
    • Maintenance of patient dignity
    • Expected staff communication with family
    • Recovery/PACU following the procedure Learning Characteristics
    • Toddler (ages 1-3): short attention spans and oral fixations may require special management
    • Preschooler (ages 3-5): active imaginations may inter- pret surgery as punishment
    • School-age (ages 6-12): logical thinking may benefit from knowing steps of the surgical process Teaching
    • Allow pediatric patients to handle items such as a face mask to increase familiarity and a sense of control
    • Demonstrate application of devices on a doll similar in gender and ethnicity to the child Spaulding Classification of Devices (1986) is used by CDC to determine if disinfection or sterilization is more appropriate. Critical Items (sterile)
    • Any item that penetrates internal tissues/organs or the vascular system

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• Examples: sutures, cardiac catheters, surgical instru- ments

13 / require- ments)

• Phenolics
  • Quaternary ammonium compounds

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18. Quality: DISIN- FECTION
19. Disinfection Doc- umentation
    • All items to be disinfected should be cleaned, rinsed, and dried before immersion in order to avoid contamination or dilution of the disinfectant
    • Observe the expiration dates of all solutions
    • Do not sure contaminated solutions (dirty, diluted)
    • Test solutions for minimum effective concentrations (MECs) before every use with test strips or other indica- tors specific to a particular solution
    • Hazard warnings that include chemical properties for each solution should be posted Applies to liquid germicidal solutions:
    • Expiration dates
    • Results of manufacturer-recommended quality control testing
    • Results of concentration testing
    • Solution dating (e.g., when opening, prepared, mixed, etc.)
    • Person who mixed the solution
    • Which items were disinfected with the solution
    • Patients on whom the disinfected items were used
20. STERILIZATION Sterile: completely absent of all microorganisms and spores Spore: dormant but viable state of a microorganism that resists killing by disinfection and/or sterilization Sterilization: process of removing all

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21. Sterility Assur- ance Level (SAL)
22. Sterilization Methods Summary: High-temp & Low-temp
23. Steam Steriliza- tion Sterility assurance level (SAL): microorganism probability after sterilization
    • SALs differ according to various methods of sterilization
    • Surgical instruments must be sterilized to a SAL of 10^- 6
    • 10^-3: probability of 1 in one thousand (1:1000)
    • 10^-6: probability of 1 in one million (1:1000000)
    • A sterilizer must kill one million spores in half that standard programmed cycle (e.g., within 2 minutes of a 4 minute cycle) High-temp:
    • Steam: hot water vapor under pressure to increase its temperature
    • Dry heat: used to sterilized powders, oils, or petroleum products; rarely used in-hospital Low-temp:
    • Ethylene oxide (EtO): ether-smelling toxic gas
    • Hydrogen peroxide gas plasma or vapor: has largely replaced EtO due to toxicity
    • Ozone (O3): effective for liquids, air, and surfaces; works similar to how chlorine works in water, but has a stronger oxidation-reduction potential
    • Ionizing radiation (irradiation): used for bulk sterilization of foods, postal mail, medications, disposable medical supplies; rarely used in- hospital
    • Most common, most economical, and least toxic steril- ization method

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• Minimum temperature of steam for sterilization is 250°F
• Most sterilizers operate at 270- 275°F
• Steam must be placed under pressure of 15- 17 psi to reach 250°F and 27 psi to reach 270°F

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• Avoid condensation by not placing warm objects on cool surfaces

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• Standard cycle is 4 minutes; extended cycles may be 5, 8, or 15 minutes
• Instruments exposed to prions (i.e., Creutzfeldt- Jakob disease (CJD)) require an 18 minute cycle in a prevacuum sterilizer or 60 minutes in a gravity displacement sterilizer

26. Bowie-Dick Test - Evaluates the effectiveness of air removal in dynamic air removal autoclaves

• Requires specialized commercial paper with heat-sen- sitive ink
• Uniform ink patterns demonstrate a successful test
• Performed daily before first use of the day as recom- mended by the Association for the Advancement of Med- ical Instrumentation
• Alternative: the "daily air removal test"

27. Steam-Flush-Pres - Autoclave that uses the repeated sequence sure-Pulse Autoclave/Steril- izer
28. Immediate-Use Sterilization "steam-flush-pressure-pulse" to perform sterilization

• Does not create a vacuum by removing air
• Performance is not affected by air leaks
• Does not require Bowie-Dick or air removal testing
• Includes pressure pulses above atmosphere pressure to increase heat AKA: flash sterilization, or "just in time" sterilization
• Recommended for urgent clinical situation, not