AORN PeriOp 101 Exam Hemostasis, Sponges, & Drains/Endoscopic and MIS/Wound Closure/Wound, Exams of Nursing

Download AORN PeriOp 101 Exam Hemostasis, Sponges, & Drains/Endoscopic and MIS/Wound Closure/Wound and more Exams Nursing in PDF only on Docsity! AORN PeriOp 101 Exam Hemostasis, Sponges, & Drains/Endoscopic and MIS/Wound Closure/Wound Healing/Perioperative Safety: Introduction 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 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 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 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 What precaution should be taken when microfibrillar collagen is used as a hemostatic agent intraoperatively? - Avoid using it with an autologous blood salvage unit Drains that allow for passive drainage of fluid from the body: - Penrose and T-tube Benefits of a standardized count procedure: - 1. Assists accuracy 2. Assists efficiency 3. Human error studies have shown that many errors result from deviation Type of dressing used to prevent drying of the wound and increase the proliferation of epithelial cells: - Occlusive 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. pledget - non-absorbable suture used when there is a possibility of sutures tearing through tissue. common uses of a pledget - vascular closure, septal repair, myocardial closure, heart valve suturing, hepatic repair ligature aka "tie" - strand of material tied around a vessel to occlude the lumen a nd prevent bleeding transfixion suture - type of ligature = crisscross stitch placed to control bleeding from a tissue surface or small vessel when it is tied bone wax - mixture of beeswax, isopropyl palmitate and a softening agent, which provides a mechanical tamponade effect to stop oozing from cut bone surfaces. common uses of bone wax - orthopedic and neurosurgical procedures and on the sternum during heart procedures mechanical hemostasis methods - bone wax ligature pledget clamps sutures staples sponges direct pressure chemical hemostasis methods: pharmacological - epinephrine standby mode always set your endoscopic light source parameters - according to the manufacturer's instructions (IFU) position the insufflator - at the level of the patient's heart or higher *to prevent intra-abdominal fluids or gases from contaminating the device periumbilical - region of the patient's abdomen traditionally used to establish pneumoperitoneum for laparoscopic surgery CO2 is the gas used for abdominal insufflation because it is - rapidly eliminated 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 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 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!!! reduces the risk of systemic hemodynamic changes - maintaining intra-abdominal pressure at the lowest level necessary to achieve pneumoperitoneum parameters of insufflator CO2 pressure are set according to - 1. manufacturer's instructions for use (IFU) 2. surgeon's preference flush the insufflator and insufflation tubing with the selected gas before - the tubing is connected to the cannula 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. thermal burns in MIS/endoscopic procedures - can result from breaks in the insulation of instrument cords because they allow electrical current to escape previous incisions may alter - trocar insertion technique 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 an additional consent - the circulating RN should always get _____ covering the possibility of an open procedure prior to a MIS/endoscopic procedure the circulating RN should always consider the risk of hypothermia - during MIS/endoscopic procedures d/t the use of fluids for irrigation or distention 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. safety straps and a foot board - should be used to keep patient from slipping while in the Trendelenburg or reverse Trendelenburg position 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 patients having MIS/endoscopic procedures are at risk for - 1. hypothermia 2. hypervolemia 3. hyponatremia IV, irrigation, hyponatremia, hypervolemia - Achieving correct fluid management for the patient during MIS/endoscopic procedures includes monitoring overload of _____ and _____ fluids, to avoid _____ and _____. 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. an electrical current transfer through intact insulation - capacitive coupling a responsibility of the scrub person ahead of laparoscopic procedure - checking and tightening any screws on endoscopic instruments docking and undocking the robot - should NOT be interrupted for any other activities diameter - a designation of "4-0" on a suture package indicates the suture material's memory - capacity of a suture to regain former shape after being reformed elasticity - ability to regain original form and length after being stretched knot tensile strength - when knotted, the force in pounds, which the suture can withstand before it breaks capillarity - ability to soak up fluid along a strand linear staples - type of staplers used in the alimentary tract and in thoracic procedures alimentary tract - digestive tract surgical stainless steel - non-absorbable = used for abdominal wall closure or sternum, respiratory tract, orthopedics and neurosurgery 316L-SS low-carbon iron allow wire - surgical stainless steel sutures plain catgut = treated w/aldehyde to strengthen -creating a very small path that heals quickly *ligaments/tendons, skin, nasal & oral cavities, and pharynx reverse cutting point needle - triangular shape with cutting edges on OUTER curvature *fascia, ligaments, tendon sheath, nasal & oral cavities, and oral mucosa 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 trocar point needle - has 3 cutting edges at the very tip - used to penetrate tough tissues at the time of insertion - when the body reacts to the suture material skin adhesive - involves the use of liquid polymers micro point needle - reverse cutting used for the eye precision point needle - routinely used for plastic/cosmetic procedures ex: Prolene & Surgilene 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 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 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 point in the healing process when most wound disruptions occur - during neovascularization in the early proliferation phase (Phase 2) 2-10 days thyroidectomy - Class 1: Clean colon resection (colectomy) - Class 2: Clean-contaminated open or fresh traumatic wound - Class 3: Contaminated ruptured appendix - Class 4: Dirty prolonged high doses of steroids preoperatively delay - collagen formation suppress, contraction, collagen - Steroids _____ the inflammatory response but delay _____ and _____ synthesis. The CDC's Classification of Surgical Wounds system is intended to - monitor postoperative infections and suggest steps to take to reduce these infections 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 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 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 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 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 methods of producing hemostasis - 1. administer blood 2. apply pressure 3. use electrocautery 4. use topical hemostatic agents 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 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 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