Unit 6: patient prep and draping

Question 1

When is most of the heat lost in surgery

Answer 1

First 20 minutes

Question 2

When do you remove the hair of the animal

Answer 2

Clipping is performed in the induction area once the patient has been stabilized under anesthesia
Be sure you are comfortable with the patients level of anesthesia before you begin any manipulations

Question 3

What should you wear when clipping a patient

Answer 3

An old green scrub gown or lab coat is usually worn when the patient is being clipped

Question 4

How do you hold the clippers when shaving

Answer 4

Hold the clippers in a pencil grip
This grip permits the greatest amount of control and manoeuvrability
The clipper blade should lie flat on the patient’s skin for the closest clip

Question 5

How do you shave a patient

Answer 5

The hand not holding the clipper can tense the skin to encourage as easy a movement as possible for the clipper
Ensure that the area of hair clipped is neat, tidy and symmetric
Clippers need to be cleaned and oiled as directed on product directions
It is a general rule to clip more rather than less hair
In long haired animals, clip the hair that may fall onto the surgical area

Question 6

How much fur do you shave in surgery

Answer 6

The amount of hair to be removed depends on the surgery being performed
For general soft tissue surgery, a rule of thumb is to clip two clipper blade widths in every direction front eh proposed incision site
In orthopedic surgery, the patient is clipped more extensively ( the joint above to the joint below)
The limb needs to be clipped circumferentially to allow complete limb draping and manipulation

Question 7

Where do you not use clippers

Answer 7

On the scrotum as it causes clipper burn

Question 8

What should the shaved area include

Answer 8

Preoperative clipping and prepping need to include preparation for any ancillary procedures that may be done
Such as chest tubes or drains or placement of cautery pad

Question 9

What should you do after the fur has been shaved off

Answer 9

Vacuum off the hair while you are clipping, and thoroughly once you have completed the clipping procedure
The hair should be vacuumed from the animal as well as from the area around the animal

Question 10

When do you shave large animals for surgery

Answer 10

Determine the incision site
- Surgeons specifications
Standing bovine patients
- Clipped prior to entering surgery using a #40 blade
Equine
- Clipped once the animal has been anaesthetised in the induction area

Question 11

When can you cause clipper burn

Answer 11

Clipper blades are dull
Technique is harsh
Excessive pressure is used

Question 12

What should you look for on the clipper blades before use

Answer 12

Chipped or missing teeth
Rust
Anything else that may hinder their performance

Question 13

What are the downfalls of irritation caused by the clipper blade

Answer 13

Inhibit surgical site healing if over the surgical site
Promote bacterial growth leading to possible infection of the surgical site
Promote excessive licking which also comprises the healing process

Question 14

How and when do you clean clipper blades

Answer 14

Clipper blades should be cleaned and changed after each use
After using clippers spray with Clippercide
Remove all debris from clippers and blade with a brush
Remove the blade from the clipper
Place dirty blade and brush in to barbicide
Must be in barbicide for minimum of 10 minutes
When placing a new blade on clipper from the barbicide, wipe the blades dry with a cloth removing any excess liquid and spray with Clippercide

Question 15

Why do you express the bladder before surgery

Answer 15

The urinary bladder should be manually expressed prior to performing the surgical skin prep
This will help to prevent iatrogenic trauma to the bladder when the abdomen is entered
Bladder expression is necessary to prevent the patient from urinating during the surgical procedure
If they urinate during the procedure, they will soak the table linens as well as their fur and skin
Lying in urine for may period exposes the patient to the risk of urine scald
There is an increased risk of contamination of the surgical wound if urination occurs post operatively

Question 16

How do you express the bladder before surgery

Answer 16

The bladder can be expressed with the patient either in dorsal or lateral recumbency
Some type of receptacle, such as kidney bowl is used to collect the expressed urine
This is bode to avoid saturating the fur with urine or having the urine pool under the animal
Use gentle, constant pressure rather than a pulsating action when applying pressure to the urinary bladder

Question 17

What is the reason for a surgical scrub

Answer 17

The purpose is to render the skin as clean as possible to minimize the risk of wound infection
There are multiple options of antiseptics, rinsing agents, and applications that can be used to prepare the skin for surgery

Question 18

What are the antiseptic scrub products used for surgical site scrub

Answer 18

Providone iodine
Chlorhexidine gluconate

Question 19

What are the positives of Providone iodine as a surgical prep scrub

Answer 19

Bacterial, viricidal, fungistatic and fungicidal – residual effect
Relatively low tissue toxicity
Generally diluted 50:50 with water when used as a patient scrub

Question 20

What are the positives of chlorhexidine gluconate as a surgical prep scrub

Answer 20

Bactericidal action against 30 bacterial genera, viricidal and fungicidal – residual effect
Low tissue toxicity – except for mm
Generally used in a 60:40 dilution with water

Question 21

What are the common rinsing agents for a surgical site prep

Answer 21

70% isopropyl alcohol
Sterile water or saline

Question 22

What are the positives and negatives of isopropyl alcohol as a rinsing agent

Answer 22

Effective against most G- bacteria
Coagulates proteins, so contraindicated on open wounds and mm
Enhances residual properties of chlorhexidine
Rapid evaporating – can contribute to patient hypothermia
Do not use if electrocautery will be used intraoperatively

Question 23

When do you use water as a rinsing agent

Answer 23

Removes detergent but has no antimicrobial properties
Used to prep open wounds, compound fractures, or mm where alcohol is contraindicated

Question 24

What do you use to get the antiseptic onto the animal

Answer 24

Gauze sponge
- Most common
Cotton balls/cotton tipped applicators
- Particle only when prepping small areas
Spray bottles
- Appropriate only for application of final paint solution
- Can be messy

Question 25

What do you do for a male dog going into a abdominal surgery

Answer 25

This step is required when the prepuce will be in the draped surgical field and is performed prior to beginning the surgical site prep After the hair has been removed from the prepuce, the sheath must be flushed to remove potential contamination as follows Combine 1mL of Povidone-iodine solution with 9mL of water Insert syringe tip into the prepuce and inject 5mL of solution Pinch the prepuce around the syringe tip before removing the syringe Gently massage the solution in the prepuce Place a towel over the end of the prepuce to absorb the solution Release the pinch hold on the prepuce Repeat the process with the remaining 5mL of solution

Question 26

How and when do you use the target pattern for scrubbing

Answer 26

Most common pattern Resembles a bullseye Primarily used for abdominal, thoracic, and neurological procedures

Question 27

How do you scrub the surgical site for orthopaedic surgery

Answer 27

Used for orthopedic procedures Added step of covering foot with an exam glove Caution to avoid creating a tourniquet with the tape holding the exam glove in place

Question 28

How do you prep the surgical site for a perianal surgery

Answer 28

Pattern is 3 separate target patterns performed in a specific sequence A purse string suture is placed in the anus before the preparation is began to prevent the evacuation of fecal material onto the surgical site during the procedure Caution is needed to avoid puncturing the anal glands As the surgical tech, you are responsible to ensure that the suture is removed after the procedure

Question 29

What are common chemical related reactions seen

Answer 29

Reactions to prepping products generally manifest as plaques or wheals Certain breads (labs or shar pei’s) tend to be more prone to these reaction Povidone-iodine tends to cause more reaction than chlorhexidine If a patient has a chemical related reaction, it should be recorded in their medical record

Question 30

What is different between the final and initial surgical site prep

Answer 30

Performed in surgical room once the patient has been properly positioned and secured to the surgery table Same procedure except that it is performed in a sterile manner Wear gloves (open glove technique) and use a sterile prep set up Solutions (“Paint”) are the final step in surgical site preparation

Question 31

What is the final Paint step in the surgical site preperation

Answer 31

Differs from scrub in that it doesn't contain a detergent Efficacy improves if allowed to air dry prior to draping If using a spray bottle as an applicator– the first squirt should be directed into the kick bucket to “clean” the nozzle of debris and bacteria Providien-iodine Tends to have a stronger concentration of iodine that the scrub Chlorhexidine gluconate 0.2% concentration

Question 32

What are the supplies needed when prepping a LA surgical site

Answer 32

Bucket of tap water Scrub brush Plastic container Scrub soap Spray solution (Povidone-iodine or chlorhexidine gluconate) Alcohol

Question 33

How do you scrub a LA patient

Answer 33

The operative site is scrubbed with the scrub soap and a brush then rinsed with water after each scrub until the site is clean using the target pattern A small container is used to dip into the bucket of water The brush is rinsed off after each scrub by pouring water over the brush from the small container The brush should not be rinsed in the bucket as that water is to remain clean for further prepping Three more preps are done using the scrub soap, rinsing with alcohol between each scrub Make sure you are rinsing the brush with water between each scrub Alcohol is poured onto the operative site beginning at the incision site and working towards the contaminated area Sterile prep done in the surgical suite Alcohol may be poured over the operative site rather than wiped using sterile gauze sponge Finally, the paint solution is sprayed onto the operative site to complete the sterile prep

Question 34

How do you know if a surgical scrub is good enough for a LA patient

Answer 34

Cleanliness of the patient's skin is determined by drawing an alcohol-soaked gauze over the area The gauze is then examined for debris or hair If any is seen, the site is rescrubbed This is continued until the alcohol soaked gauze appears clean

Question 35

When is heat lost during surgery

Answer 35

Surgical site is shaved Surgical site is cleaned using water then followed by alcohol - quickly cooling the skin Anesthetic gas is carried by cold O2 due to compression of the O2 in the tank Administration of the room temp fluids Opened body cavity exposing internal organs to room temp air Patient lying on a metal table/grate

Question 36

What are the temps that are indications of hypothermia

Answer 36

Thermal hemostasis is achieved by modulating the flow of blood to organs, viscera and skin via vasoconstriction or vasodilation Most patients lose body heat while they are anaesthetised Mild hypothermia – body temp no lower than 36*C– is expected and usually well tolerated by the patient A body temp below 34*C is worrisome and can affect the patients recovery adversely Small patients are at the greatest risk due to their small body surface to mass ratio Most what loss occurs within the first 20 min of general anaesthesia

Question 37

Ways to maintain patients body temp

Answer 37

Circulating warm water pad Warm air convector Heating coils Microwave heat pad Plastic bottle of heated uncooked rice Warm IV fluids - Can warm bag or run the line through a bowl of warm water of fluid warmer before passing into patient Plastic bubble wrap around extremities and head

Question 38

Where are warming devices placed

Answer 38

Placed away from surgical site May need to be in place before the patient is moved into surgery Inflatable warming devices must remain turned off until the patient is draped

Question 39

How are electrocautery plates placed

Answer 39

Need to be in direct contact with patient at all times Poor contact affects function

Question 40

Patient positioning factors

Answer 40

Surgical approach Surgery to be performed In orthopedics, affected leg often suspended form an overhead support of IV stand Draping technique Number of surgeries

Question 41

How do you maintain patient position

Answer 41

Tape Sandbags Vacuum bags Ties

Question 42

When do you place a sterile drape

Answer 42

Sterile drape placement Placed after site prep is completed Provides and impervious barrier

Question 43

What supplies are needed for draping

Answer 43

Quarter drapes Towel clamps Single large drape

Question 44

What are drapes and gowns made of

Answer 44

Made of paper or cloth Need to be folded in a consistent manner There are specifically designed drapes for specific procedures

Question 45

How do you quarter drape

Answer 45

Open away from table The top of the drape is folded away from you Corners are rolled outwards to warp around palms and minimize risk of contamination of gloves Float the drape over patient - do not drag over the patient The drape is placed close to the incision site

Question 46

How do you secure a quarter drape

Answer 46

Penetrating towel clamps are used to secure the drapes to the patient and to each other Once placed, towel clamps and drapes can not be moved

Question 47

What are the final drapes used

Answer 47

Large final drape - Covers patient and surgical table Placing the drape is a sterile procedure - 1-2 people - Add fenestrations if needed after draping

Question 48

What are some additional drapes sometimes used

Answer 48

Attached to the incision - Sticky drapes Placed near the incision - Stockinettes Sterile field contamination - Add sterile drapes - Replace garments

Question 49

What is the hanging limb draping technique and how do you do it

Answer 49

Place a stockinette and secure to the patient with tape Use tape to secure the distal end of the limb to the IV pole Place quarter drapes sound the base of the limb A sterile drape is applied to the distal limb to allow manipulation of the foot Sterile outer layer of a self adherent wrap is placed over the distal limb A fenestrated drape is placed over the quarter drapes

Question 50

How do you prep equine skin for surgery

Answer 50

Sometimes difficult to clip before anaesthesia Clipping done with electric razor in surgical suite Hair cooled with portable vacuum After initial skin prep, 3-5 surgical scrubs are performed Spray with chlorhexidine solution Prepuce sheath packed with gauze and sutured with a purse string suture

Question 51

What is the purpose to drape a LA for abdominal surgery

Answer 51

To minimize contamination of the sterile surgical site

Question 52

What drapes are need to an equine abdominal surgery

Answer 52

Aseptic prep Aseptic gowns and gloves Requires at least 2 people

Question 53

How do you drape a horse for abdominal surgery

Answer 53

Step 1 - Begins after anesthetic prep - Sterile stockinette or leg drapes over hindlimbs - Hand towels placed on a four quarter fashion around the incision site Step 2 - Large laparotomy drape - Individuals are positioned on opposite sides of the patient, carefully unfolding the large drape over the horse - Unfold with a backward step - Then unfold longitudinally Step 3 - Towel clamps to secure drape - Cover exposed clamps with gauze sponge - Adhesive, impervious drape over incision site - Adhesive tape

Question 54

What do you need for LA orthopedic surgery

Answer 54

Electrocautery plate - Placed beneath patient - Connect cords Imperious plastic drapes - Contain an adhesive - Placed over the surgical site - They reduce strike through contamination

Question 55

How do you drape for LA orthopedic surgery

Answer 55

Step 1 - Limb prep (done in lateral recumbency) - Suspend the limb from an IV pole - Aseptic prep is performed - The proximal area of the limb is draped Step 2 - Remove limb form IV pole - Grasp limb ( over the non prepped area) - Place a sterile surgical glove or towel over hoof - Placement of the fenestrated drape - The limb is fed through the fenestration - The drape is placed and secured with towel clamps

Question 56

When do the common sterility breaks happen

Answer 56

During draping surgical/instrument table setup Remember: the back of the surgical gown is not sterile Hands Keep hands above waist and below shoulders