MODIFIED PRONE POSITION –for surgical procedures on the spine, the mattress on the operating bed is adjusted so the hips are over the break between the body and leg sections. A large, soft pillow is placed under the abdomen. The upper break of the operating bed is flexed, and the operating bed is tilted so the surgical area is horizontal.

TYPES:

1. KRASKE (JACKKNIFE) POSITION –the patient remains supine until anesthesized and is then turned onto his or her abdomen by rotation.

2. KNEE-CHEST POSITION –this position is used for sigmoidoscopy or culdoscopy. For this position , an extension is attached to the foot section.

LATERAL POSITION –the operating bed remains flat. The patient is anesthesized and intubated in the supine position and then turned to the unaffected side.

TYPES:

1. SIMS RECUMBENT POSITION –the patient lies on his or her left side with the upper leg flexed at the hip and knee.

2. KIDNEY POSITION –the flanked region is positioned over the kidney elevator on the operating bed when the patient is turned onto the unaffected side.

3. LATERAL JACKKNIFE POSITION –the patient is first placed in the lateral position, and then the operating bed is flexed at the level of the patient’s flank or lower ribs.

4. LATERAL CHEST (THORACOTOMY) POSITION –modifications of the lateral position are used for unilateral transthoracic procedures with a lateral approach.

5. ANTERIOR CHEST POSITION –the positioning is more supine than for the lateral chest position.

PHYSICAL PREPARATION AND DRAPING OF THE SURGICAL SITE

This determines specific procedures to be carried out before incision is made: -type of surgical procedure to be performed -the age and condition of the patient -preferences of the surgeon

URINARY CATHETERIZATION

The patient should void to empty the urinary bladder just before the transfer to the OR suite unless the procedure requires the bladder to be full. Women : 16 or 14 (fr) Men : 16 or 18 (fr)

PRINCIPLES OF PATIENT SKIN PREPARATION

Purpose: to render the surgical site as free as possible from transient and resident microorganisms, dirt, and skin oil so that incision can be made through the skin with minimal danger of infection from this source.

* Many surgeons prefer to have their bathe with antimicrobial soap the morning of the surgical procedure. * The perioperative nurse should assess the patient’s skin before, during and after the prepping process. * Abnormal skin irritation, infection, or abrasion on or near the surgical site might be a contraindication to the surgical procedure and is reported to the surgeon.

PREMILINARY PREPARATION OF THE PATIENT’S SKIN

HAIR REMOVAL –carried out per surgeon’s order, whether on the preoperative unit or in the OR as close to the scheduled time for surgical procedure as possible.

CLIPPERS –electric clippers with fine teeth cut hair close to the skin. Clipping can be done immediately before the surgical procedure or up to 24 hours preoperatively.

DEPILATORY CREAM –hair can be removed by chemical depilation before the patient comes to the OR suite. This should not be used around the eyes or genitalia. After the cream has remained on the skin for the required time, usually about 20 min, it is washed off. The hair comes off in the cream.

RAZOR –shaving should be performed as near the time of incision as possible if this method is used.

SKIN DEGREASING –it is used to enhance adhesion of ECG or other electrodes.

ANTISEPTIC SKIN CLEANSING FUNDAMENTALS

TWO-STEP PREPARATION –performed wearing sterile gloves

ONE-STEP PREPARATION –performed wearing non-sterile gloves

*SETUP & PROCEDURE FOR A TWO-STEP PREP

The sterile items being prepared:

*small table drape *sterile gloves *2 absorbent towels *2 or 3 small *cotton-tipped applicator *gauze sponges

The surgical site is bordered by sterile towels after donning the sterile gloves. The soapy antiseptic sponges are used to mechanically an chemically cleanse the skin in a circular motion from the incisional sit to the periphery. The paint-style antiseptic solution is applied in the same manner, using a circular motion from he incisional site to the periphery.

*SETUP & PROCEDURE FOR A ONE-STEP PREP

-is a self-contained unit that is constructed o a sponge applicator tip and chamber containg antiseptic solution.

Mechanical actions –stationary form it takes over the skin surface.

Chemical actions –the actual antiseptic agent in combination with an alcohol base.

PREPPING AREAS CONSIDERED CONTAMINATED

‘UMBILICUS : some surgeons prefer the umbilicus to be cleaned with cotton-tipped swabs before the main incision. `STOMA :should be isolated with a sterile clear plastic adhesive dressing to prevent fecal material from entering the wound.. `OTHER CONTAMINATED AREAS: the general rules of scrubbing the most contaminated area last with separate sponges applies. `FOREIGN SUBSTANCES –a none-irritating solvent should be used to cleanse the skin. `TRAUMATIC WOUNDS –the wound may be packed or covered with the sterile gauze while the area around it is thoroughly scrubbed and shaved if necessary. `AREAS PREPARED FOR GRAFTS –the donor site for a skin graft should be scrubbed with a colorless antiseptic agent so that surgeon can properly evaluate the vascularity of the graft postoperatively.

ANTISEPTIC SOLUTIONS

QUALITIES OF AN IDEAL ANTISEPTIC SKIN CLEANSING AGENT:

=it has broad-spectrum antimicrobial action and rapidly decreases the microbial count. =it can be quickly applied and remains effective against microorganisms. =it can be safely used without skin irritation or sensitivization. =it effectively remains active in the presence of alcohol, organic matter, soap, or detergent. =it should be non-flammable for use with laser, electrosurgical, or other high-energy devices.

CHLORHEXIDINE CLUCONATE –used as antiseptic skin cleansing soap preoperatively. IODINE AND IODOPHORS –it is used for wound care ALCOHOL –a 70% concentration with continuous contact for several minutes is satisfactory for skin antisepsis if the surgeon prefers a colorless solution that permits observation of true skin color. TRICLOSAN –is a broad spectrum antimicrobial agent. PARACHLOROMETAXYLENOL –has a bactericidal properties useful for skin antisespsis.

SKIN PREPAPRATION FOR SPECIFIC ANATOMIC AREAS

*HEAD AND NECK EYE : 1. The eyebrows are never shaved or removed unless the surgeon deems this essential. 2. The eyelashes may be trimmed, if ordered by the surgeon, with fine iris scissors coated with sterile water-soluble lubricant to catch the lashes. 3. The eyelids and preorbital areas are cleansed with nonirritating antiseptic agent. 4. The conjunctival sac is flushed with a nontoxic agent. EARS, FACE OR NOSE : 1. Skin surfaces should be cleansed at least to the hairline. 2. Cotton applicators are used for cleansing the nostrils and external ear canals. 3. Protect the eyes with a piece of sterile plastic sheeting. NECK : 1. One sterile towel is folded under the edge of the blanket or gown almost to the nipple line. 2. The area includes the neck laterally to the table line and up to the mandible, tops of the shoulders and chest almost to the nipple line. 3. Include the face of the eyes; shaved areas of the head, ears and posterior neck and the areas over shoulders. *CHEST AND TRUNK LATERAL THORACOABDOMINAL AREA 1. The gown is removed. 2. The arm is held up during the prep. 3. Beginning at the site of injection, the area may include the axilla, chest, and abdomen from the neck to the iliac crest CHEST AND BREAST 1. The anesthesia provider turns the patient’s face forward the unaffected side. 2. Our towel is folded under the blanket edge, just above the pubis. 3. The arm on the affected side is held up by grasping the hand raising the shoulder and axilla slightly from the operating bed. 4. The area includes the shoulder, upper arm down to the elbow, axilla, and chest wall to the table line and beyond the sternum to the opposite shoulder. SHOULDER 1. The anesthesia provider turns the patient’s face toward the opposite side. 2. A towel is placed under the shoulders and axilla. 3. The arm is held up by grasping the hand and elevating the shoulders slightly from the OR bed. RECTROPERINEAL AREA 1. With the patient in lithotomy position, a moisture-proof pad is placed under the buttocks and extends to the kick bucket that receives solutions and discarded sponges. 2. The area includes the pubis, external genitalia, perineum and anus, inner aspect of the thighs. 3. Begin the scrub over the pubic area, scrubbing downward over the genitalia and perineum. 4. The inner aspects of the upper third of both thighs are scrubbed with separate sponges working from groin to distal aspect of thigh. 5. The anus is prepped last. 6. The rectoperineal area is prepped before the abdomen, using a separate prep set and gloves if an abdominal approach is planned. VAGINA 1. Sponge forceps should be included on the preparation table for a vaginal prep, because a portion o prep is done internally.

2. With the patient in lithotomy position, a moisture proof pad is placed under the buttocks and extends to the kick bucket that receives solutions and discarded sponges. 3. A towel is folded under the edge of the blanket above the pubis. 4. Urinary catheterization is performed if indicated. 5. The external area includes the pubis, vulva, labia, perineum, anus and adjacent area, including inner aspects of the upper third of thighs. 6. Begin over the pubic area scrubbing downward over the vulva and perineum. 7. The vagina and cervix are cleansed with sponges on the sponge forceps or disposable sponge sticks. 8. After thoroughly cleansing the vagina, wipe out with a dry sponge. 9. The anus is prepped last. *EXTREMITIES 1. A moisture-proof pad should be placed on the operating bed under an extremity. 2. A full extremity prep may e done in 2 stages. 3. Caution must be taken to prevent solution from pooling under a tourniquet. UPPER ARM 1. A towel is placed under the shoulder and axilla. 2. The arm is held up by grasping the hand and elevating the shoulder slightly from the OR bed. 3. The area includes the entire circumference of the arm to the wrist, the axilla and over the shoulder and scapula. ELBOW AND FOREARM 1. A towel is placed under the shoulder and axilla. 2the arm is held up by grasping the hand. 3. The area includes the entire arm from the shoulder and axilla to and including the hand. HAND 1. Towels may be omitted. 2. The arm must be held up by a gloved person supporting it above the elbow so that entire circumference can be scrubbed. 3. The area includes the hand and arm to 3 inches (7.5) above the elbow. HIP 1. One towel is placed under the thigh on the OR bed. 2. The leg on the affected side is held up by supporting it just below the knee. 3. The area includes the abdomen on the affected side, the thigh to the knee, the buttocks to the table line, the groin and the pubis. THIGH 1. One towel is placed under the thigh on the OR bed. 2. The leg is held up by supporting the foot and ankle. 3. The area includes the entire circumference of the thigh and leg to the ankle, over the hip and buttocks to the table line, the groin and pubis. KNEE AND LOWER LEG 1. A towel is placed over the groin. 2. The leg is held up by supporting it at the foot. 3. The area includes the entire circumference of the leg and extends from the foot to the upper part of the thigh. ANKLE AND FOOT 1. Towels are omitted. 2. The foot is held up by supporting the leg at the knee. 3. The area includes the foot and entire circumference of the lower leg to the knee.

DOCUMENTATION INCLUDES: 1. The condition of the skin around the surgical site and placement sites of any electrodes. 2. Hair removal, if done. 3. Antiseptic solutions, fat solvents, irrigating solutions, and any other agents used. 4. The skin area prepped and skin reaction, if any. 5. The name of the person who did the prep.

DRAPING – the procedure of covering the patient and surrounding areas with a sterile barrier to

create and maintain an adequate sterile field. CRITERIA TO BE MET: 1. Blood- and fluid-resistant to keep drapes dry and prevent migration of microorganisms. 2. Lint-free to reduce airborne contaminants and sheding into the surgical site. 3. Antistatic eliminate risk of a spark from the static electricity. 4. Sufficiently porous to eliminate heat buildup so as to maintain an isothermic environment appropriate for the patient’s body temperature. 5. Drapable to fit around contours of the patient, furniture, and equipment. 6. Dull, nonglaring to minimize color distortion from reflected light. 7. Free of toxic ingredients. 8. Flame-resistant to self-extiguish rapidly on removal of an ignition source.

DRAPING MATERIALS

*SELF-ADHERING SHEETING (sterile, waterproof, antistatic, and transparent or translucent plastic sheeting may be applied to dry skin.) INCISE DRAPE –the entire clear plastic drape has an adhesive that is applied to the skin. TOWEL DRAPE –the plastic sheeting has a band of adhesive along the edge. It will remain fixed on the skin without towel clips. APERTURE DRAPE –adhesives surrounds a fenestration in the plastic sheeting. This secures the drape to the skin around the surgical site, such as an eye or ear. ADVANTAGES OF SELF-ADHERING DRAPE MATERIAL * resident microbial florae from skin pores, sebaceous glands, and hair follicles cannot migrate laterally to the incision. * microorganism do not penetrate through the impermeable material. * landmarks and skin tones are visible through the transparent plastic. * inert adhesive holds drapes securely, eliminating the need for towel clips and possible puncture of the patient’s skin. * plastic sheeting conforms to the body contours and has elasticity to stretch without breaking its adhesion to skin. THIS MATERIAL IS USED IN THE FOLLOWING MANNER: 1. The usual skin preparation is done. 2. The scrubbed area must be dry. 3. Transparent plastic material is applied firmly to the skin, with the initial contact along the proposed line of incision. 4. Regular fabric drapes are applied over the plastic sheeting unless plastic is incorporated into the fenestrated area of the drape.

NONWOVEN FABRIC DISPOSABLE DRAPES (are compressed layers of synthetic fibers combined with cellulose and bonded together chemically or mechanically without knitting, tufting, or weaving)

ADVANTAGES: 1. Moisture-repellant. 2. Lightweight, yet strong enough to resist tears. 3. Lint-free unless cellulose fibers are torn or cut. 4. Antistatic and flame-retardant for OR use. 5. Prepackaged and sterilized by manufacturer, which eliminates washing, mending, folding, and sterilizing processes. LASER-RESISTANT DRAPES -nonwoven drapes that contain cellulose ignite and burn easily. THERMAL DRAPE –an aluminium-coated plastic body cover reflects radiant body heat back to the patient to reduce intraoperative heat loss.

WOVEN TEXTILE FABRICS (the thread count and finish of woven natural fibers determine the integrity and porosity of reusable fabrics.)

THE FOLLOWING POINTS SHOUL BE CONSIDERED: 1. Materials must be steam-penetrable and must withstand multiple sterilization cycles. 2. When packaged for sterilization, drapes must be properly folded and arranged in sequence of use. 3. Materials must be free from holes and tears. 4. Drapes should be sufficiently impermeable to prevent moisture from soaking through them. 5. Reusable fabrics must maintain barrier qualities multiple launderings.

STYLE/TYPE OF DRAPES

TOWELS –disposable or reusable sterile towels may be used to outline the surgical site after prepping the skin. They are usually packaged in group of four and can be secured with nonperforating towel clips. FENESTRATED SHEETS –the drape sheet has an opening that is placed to expose the anatomic area where the incision will be made. BASIC STYLES:

LAPAROTOMY SHEET/ LAP SHEET THYROID SHEET CHEST SHEET HIP SHEET PERINEAL SHEET LAPAROSCOPY SHEET SEPARATE SHEETS –used for these purposes, leaving exposed only the small surgical area. SPLIT SHEET MINOR SHEET MEDIUM SHEET SINGLE SHEET LEGGINGS STOCKINETTE –used to cover the extremity

PRINCIPLES OF DRAPING:

1. Place drapes on a dry area. 2. Allow sufficient time to permit careful application. 3. Allow sufficient space to observe sterile technique. 4. Handle drapes as little as possible. 5. Never reach across the operating bed to drape the opposite side; go around it. 6. Take towels and towel clips, if used, to the side of the operating bed from which the surgeon is going to apply them before handing them to him or her. 7. Carry folded drapes to the OR bed. 8. In unfolding a sheet from the prepped area toward the foot or head of the OR bed, protect the gloved hand by enclosing it in a turned-back cuff of sheet provided for this purpose. 9. If a drape becomes contaminated, do not handle it further. 10. A towel clip that has been fastened through a drape has its points contaminated. 11. If a hole is found after it is laid down, the hole must be covered with another piece of draping material or the entire drape discarded. 12. A hair found on a drape must be removed, and the area must be covered immediately.

PROCEDURES FOR DRAPING

**LAPAROTOMY –an incision through the abdominal wall into the abdominal cavity.

HEAD: 1. The surgeon places four towels around the head and secures them with towel clips or affixes them in a place with sutures or skin staples. 2. Hand one end of a fan-folded medium sheet to the assistant. 3. Place a fenestrated sheet with the opening over the exposed skin area of the head. FACE: 1. The surgeon places a drape under the head while the circulator or assistant elevates the head.

2. Hand up three additional towels and for towels clips. 3. Place a medium sheet just below the site. 4. A fenestrated drape may be placed to compete draping. 5. Cover the remainder of the foot of the OR bed. EYE: 1. The surgeon places two towels and a medium sheet under the head while the circulator holds the head up, as described for a face drape. 2. Hand up four towels and towel clips to isolate the affected eye. 3. Cover the patient and remainder of the operating bed below the surgical area with a single sheet. EAR: the head will be turned toward the unaffected side. CHEST & BREAST: 1. Place a minor sheet on an armboard, under the patient’s arm, extending the sheet under the side of the chest and shoulder. 2. The patient’s body is draped with a sterile medium sheet. 3. Hand up towels and towel clips. 4. Apply a breast sheet so that axilla is exposed or anticipated axillary dissection. SHOULDER: 1. Place medium sheets over the chest and under the arm. 2. Place a minor sheet under the shoulder and side of the chest. 3. The surgeon outlines the surgical site with towels and secures them with clips. 4. Place a minor sheet over the patient’s chest, covering the neck. 5. Wrap the arm in a minor sheet or encase it in sterile stockinette. 6. Place a medium sheet above the area, and secure these sheets together with towel clips. 7. A laparotomy or breast sheet may be used.

DRAPING OF EQUIPMENT

PNEUMATIC TOURNIQUET-used to control bleeding during surgical procedures on the upper and lower extremities. NONSTERILE TOURNIQUET CUFF –placed around the extremity before skin preparation and is covered by draping material.

FOLLOWING APPLIES TO DRAPING EQUIPMENT: 1. Tailored disposable clear plastic drapes are available to cover such equipment.

2. If x-ray films are to be taken during surgical procedure, a casette holder may be placed on the OR bed, under the mattress, before the patient is positioned, prepped and draped.

3. Cords, cables, attachments, and tubing that are not sterile are inserted into sterile plastic sleeves before they are placed on the sterile field.

PLASTIC ISOLATOR -a clear plastic shield on one side of or completely over the OR bed. -may be used to exclude microorganisms from the environment immediately surrounding the patient.