Urinary Catheterization

• Catheterization may not be performed without a doctor’s order.
• It is considered an invasive procedure
• Why?
• Strict sterile technique must be maintained!

Indications
• Decompression of the bladder
• To provide better visualization during abdominal procedures
• To prevent trauma during abdominal procedures
• To promote healing following GU procedures
• Drainage of urine
• To prevent the overfilling of the bladder during lengthy procedures
• To measure urinary output
• To obtain a sterile specimen
• To relieve urinary retention
• To treat urinary incontinence
• Irrigation of the bladder
• Control of bleeding
• The balloon can be placed in the bladder neck following TURP to tampenade excised area

Considerations
• In surgical cases the catheter will be following induction of anesthesia
• Insertion of catheter may cause an infection and/or injury to the urethra & bladder
• Use the smallest size to drain the urine without leakage around the edges
• The Foley catheter is the most common style
• The balloon should be filled with water
• Saline breaks down the catheter material
• Air could cause an embolism
• 10cc of water is used to completely fill a 5cc balloon
• To compensate for the water that remains in the infiltration channel
• Urine is drained by gravity
• The catheter is attached to a urinary drainage bag
• It should be placed below the level of the bladder
• The catheter should be secured to the pts thigh to prevent tension and accidental removal
• Always check the patient post op to find out if they have a catheter
• If you move a pt with a catheter and you forget to check, it can be pulled out when you transfer them to the stretcher
Types of Catheters
• Red Rubber (straight) catheter
• For in and out application
• Not for continuous drainage

A. Conical-tip urethral catheters
B. Coudé hollow olive-tip catheter
E. Malecot self-retaining urethral catheter
F. Foley-type balloon catheter
G. Foley-type, three-way balloon catheter

Sizes of Catheters
• Range from 8 fr to 30 fr
• Use 8 fr to 12 fr for pediatrics
• 14 fr to 30 fr for adults
• The most common size used for adults is 16 fr
Procedure for Females
• Pt is placed in the frog-leg position
• If not already in lithotomy
• The catheter kit is placed between the legs and opened
• Apply gloves using the open technique
• Create the sterile field and place the fenestrated drape with the opening over the vulva
• Check the catheters balloon to make sure there are no leaks in the balloon and the valve works correctly
• Place the lubricate on the end of the catheter
• Open and pour the prep solution in to the tray provided
• With non dominant hand separate the labia majora and locate the urethral meatus
• If you remove your hand at any time during the procedure you will have to start over
• Using the disposable forceps with dominant hand pick up a cotton ball and dip into prep solution
• You will need three cotton balls for the whole procedure
• With the first cotton ball, cleanse laterally from clitoris to vaginal opening
• Discard cotton ball
• With the second cotton ball, cleanse the other side
• Discard cotton ball
• With the third cotton ball, cleanse directly down the middle
• Discard cotton ball
• Insert the catheter into the urethral opening approximately half the length of the catheter
• If you miss the urethra and it accidentally inserts into the vagina, another catheter must be used
• Wait until urine flows before you inflate the balloon
• Pull the catheter just until you feel resistance
• Secure the catheter to the pts leg

Electrosurgery
The Electrosurgical Unit - Surgery with Electricity
Introduction
Electrosurgery
Definition and Usage
• Electric current used to cut and/or coagulate tissue
• Used to cut fat, fascia, muscle, and internal organs
• Part of surgeon’s routine armamentarium
• Often referred to as the “Bovie”
Monopolar vs Bipolar
Monopolar Current

• Most frequently used type of cautery
• Requires a grounding pad
• Pencil-style handpiece is used
• May be activated with a foot control or hand switch
Bipolar Current
Used for minor procedures; plastic procedures; delicate procedures such as ophthalmic and neurosurgery
• Does not require a grounding pad
• Various types of forceps are used (one tip is the active electrode and the opposing tip is inactive)
• Foot pedal is used to activate
Flow of Current
Monopolar
current flows from the
1. Generator or electrosurgical unit (ESU) to the
2. Active electrode (cautery tip) through the
3. Patient’s tissue to the
4. Dispersive electrode (grounding pad) and back to the
5. ESU
Bipolar current flows from the
1. Generator or electrosurgical unit (ESU) to the
2. Active tip of the forceps through the
3. Patient’s tissue to the
4. Opposing forceps tip and back to the
5. ESU
Types of Monopolar Current
Coagulate
• Coagulate capillary and other small bleeding vessels
Cut
• Cut adipose tissue, fascia, internal organs
Blend
• Combination of cutting and coagulating current
• Not a strong coagulating current
• Effective on capillary bleeding
Monopolar Handpiece
• Handpiece (with cord attached) and tip are single-use disposable items
• Distal end of cord is passed to the circulator to be connected to the generator
• Coagulating current is activated with the distal handpiece button
• Cutting current is activated with the proximal handpiece button

Tip of handpiece is
• Removable to facilitate use of various styles (blade, needle, loop, etc)
• Considered a “sharp” and must be handled and disposed as such
• A countable item in some facilities
Types of tips
• Blade - most frequently used; available in regular and long (for use in deep body cavities) lengths
• Ball - ball shape on end of tip; frequently used in throat procedures such as T&A
• Needle - ends in a sharp point; used in minor procedures, plastic, and delicate procedures
Cleaning of Tip
• To keep charred tissue from building up on cautery tip preventing effective flow of current
• Clean the tip using moist sponge or cautery scrapper
– Cautery scrapper: small square abrasive pad with adhesive backing placed on sterile field
• Knife blade NOT recommended, but is often used
Grounding Pad and Placement
• Technical names - inactive or dispersive electrode
• Single-use disposable item
• Available in various sizes ranging from adult to infant
• Prelubricated with conducting gel
• Position patient; then place the pad
• Place pad as close as possible to the operative site
• Do not remove and reposition pad
– Loss of conducting gel
– New pad must be placed
• Pad should cover as large of area as possible
• Extremity - place on area of largest circumference
• Do not place on area with excessive scar tissue
• Do not place over area with excessive hair
– May have to shave the area
• Do not place over bony prominences
• Do not place over or near metal implants
• Do not allow skin prep fluids to pool around or under the pad
• Place on clean, dry skin
• Pad must uniformly adhere to patient’s skin
– No tunneling effect or air pockets
– Edges cannot curl up
• No part of the patient’s body can touch a metal surface such as OR table
– Electric current is attracted to metal
– Current will seek the path of least resistance to complete the circuit
– Body part touching metal will be severely burned
• Awake patient
– Warn patient of placement due to cold and sticky nature of conducting gel so that the patient is not startled
Principles Associated with
Cauterizing Tissue
• ESU produces “buzzing” sound when activated
• Surgeon may ask the assistant to “buzz” a clamp or forceps to coagulate tissue within
– Surgeon holds tissue or vessel with forceps or clamp
– Assistant touches instrument with electrocautery (“Bovie”) tip
– Current travels down instrument to cauterize tissue or vessel
Precautions when “buzzing”
• Do not activate cautery prior to application to instrument to avoid “arcing” of current
• Place cautery tip below fingers of surgeon
– Current can penetrate surgical gloves and cause pin point 3rd degree burn
• Be sure that the instrument grasping the tissue is not touching other tissue
• Be sure that the instrument grasping the tissue is not touching other metal instruments such as a retractor








Documentation
Documentation
Circulator records all information on patient’s intraoperative record
• Location of grounding pad
• Condition of patient’s skin pre- and postoperatively
• Power settings for cutting and coagulating currents
• ESU hospital identification number
Safety Principles

• Initial skin incision is be made with the scalpel
– Bovie will char and scar the skin
• Keep handpiece protected when not in use to prevent accidental activation
– Place in plastic protective holster that can be attached to the drapes
– Keep out of team member’s way to avoid leaning on it

General safety rule
• Start with lowest power settings of current that accomplish the job
• Adjust the current at the surgeon’s request

Clue to equipment malfunction
• Surgeon has repeated request for more power
Avoid inhaling plume (smoke)
• Not yet proven; could be harmful
• Could contain bits of vaporized tissue that could be mutagenic and/or carcinogenic
• Plume is irritating to the respiratory tract
• Oxygen and Nitrous Oxide Used
– Do not use cautery in the mouth, around the head, or in pleural cavity in the presence of oxygen and nitrous oxide
– Nitrous oxide supports combustion
• Metal jewelry removed from patient
• Only moist sponges used in presence of ESU
• ECG Electrodes
– Place electrodes as far away from operative site as possible
– Place grounding pad as far away from ECG electrodes as possible
– Electrical current can be attracted to ECG electrodes and cause severe burns
• ESU can disrupt the operation of implanted cardiac pacemaker
• Alcohol used for skin prep
– Alcohol must be allowed to dry before draping the patient
– If not allowed to dry, fumes can build up under the drapes and possibly ignite when cautery is used
Reasons for Malfunction of ESU

• Improper placement of grounding pad
• Less that full contact of grounding pad with skin surface
• ESU machine malfunction
• Frayed cord

Physical Environment and Safety Standards
By Javier Espinales, CST
Physical Environment and Safety Standards
• Objectives:
• 1. Identify and describe hazards to the patient in the operative department.
• 2. Identify support services that work with the OR team in the care of the patient.
• 3. Discuss the type of air-handling system required in the OR and the temperature and humidity required to maintain a sterile field.
• 4. Identify cleaning procedures, traffic patterns, and routines in the operative environment.
Physical Environment and Safety Standards
• 5. Identify the design types of the OR.
• 6. Identify hospital departments that relate to surgical services.
• 7. Discuss the working environment of the OR.
• 8. Identify the physical components of the OR.
Physical Design of the OR Suites
• Location – Usually in an area near critical care and supporting departments.
• Principles in design.
– Exclusion of contamination from outside the suite.
– Separation from clean and contaminated areas.
Areas of the Operating Room
• Central Core Race Track Plan
• Central Core Peripheral Corridor
• Central Core Hotel Plan
• Central Core Cluster Combination
Physical Design of the OR Suites
• Ventilation System
– Should provide clean air and remove airborne contamination
– Air exchange should be 20 air changes per hour
– HEPA filters capable of removing bacteria
Physical Design of the OR Suites
• Vestibular/Exchange Area
– Unrestricted Area
– Semirestricted Area
– Restricted Area
Peripheral Support Areas
• Preoperative Check-in Unit
• Preoperative Holding Area
• Induction Room
• Post Anesthesia Care Unit (PACU)
• Dressing Rooms and Lounges
• Control Desk
Peripheral Support Areas
• Anesthesia Work Room
• Housekeeping
• General workroom
• Storage
• Sterile Supply Room
• Instrument Room
Peripheral Support Areas
• Laboratory Dept
• Radiology Dept
• Pathology Dept
• Environmental Services
• Central Sterile Supply and Processing
Operating Room
• Usually 20’ x 20’ x 10’
• Larger rooms 20’ x 30’ x 10
– Larger pieces of equipment; Microscopes, C-arms,
Video equipment.
Operating Room
• Substerile Room
– Saves time and steps
– It allows better care of equipment
– Usually contains a warmer, Flash/washer sterilizer
Operating Room
• Inside the room
– Temperature and Humidity
• Temp between 65 F and 75 F
• Humidity between 50% and 55%
– Floors - most common seamless vinyl
– Walls and Ceilings
Physical Components of the OR
• Equipment
• Electrical outlets
• Suction outlets
• Gas outlets
• Lights
• Viewing box
Standard OR Furniture
• O.R. Table
Standard OR Furniture

• Mayo Stand
Standard OR Furniture
• Back table
Standard OR Furniture
• Ring stand
Standard OR Furniture
• Kick buckets
• Linen hamper
Hazards in the OR
• Safe environment
– Equipment must be properly handled and operated properly.
– ST’s must be educated and trained on safety measures.
– Surgical team must have knowledge of the possible hazards and how to keep everyone safe.
Hazards in the OR
• Physical: noise, ionizing radiation, electricity, injury to body, fire, explosion
• Biologic: laser/electrosurgical plume, pathogens , latex sensitivity, sharps injury
• Chemical: disinfecting agents, waste anesthetic gas, vapors and fumes
Physical Hazards
• Surgical Lights – non glare
• Noise in the OR
• Proper posture and body mechanics
• Electrical hazards
• Radiation
Fire Hazards
• Fire/explosion can result from:
– Source of ignition
• Spark from metal hitting metal
– Oxygen
– Flammable materials
• Gas, vapor, liquid (ethyl alcohol)
Biological Hazards
• Universal precautions – defined in 1985
• Standard precautions – defined in 1996
• Causes
– Needles in needle holders
– Suturing
– Manual tissue retraction
– Needle on the field
Biological Hazards
– Dropping needle/blade on a foot
– Reaching for falling items
– Placing sharps into sharps containers
Biological Hazards
• Preventions for possible sticks
– Have a sharps management plan
– Neutral zone
– Appropriately place sharps containers
– Never recapped needles
– Sharps on the mayo stand should be kept in a central area.
– Load needles prior to use
Biological Hazards
• Hazardous waste disposal
– Infectious waste disposed in a red bags
• Follow local policy
• Management for exposure
– Needle stick squeeze wound, then clean
– Exposure to oral or nasal flushed with water
– Eyes flushed with water or saline
Biological Hazards
• Laser plume
– Use a smoke evacuator or use the suction tip to the regular suction canister.
• Latex allergy
– To patient and staff
– Two types
• External and systemic
Chemical Hazards
• Waste Anesthetic Gases
• Methyl Methacrylate – Bone cement, liquid and power components.
• Formalin
• EtO
• Glutaraldehyde

Special Populations
By Tracey Carpenter
Pediatric Patients
• Ages between birth and 12 years of age
– Neonates- the first 28 days of life
– Infant- 1 to 18 months
– Toddler- 18 to 30 months
– Preschooler- 30 months to 5 years
– School Age- 6 to 12 years
Communication
• Fearful of separation from family and
• Unfamiliar surroundings
– Unknown people all covered up
– Can only see eyes
• Lack of understanding and communicative skills

Calming Fears
• Allow child to bring a favorite toy with them
• Don’t have too many people in the room
• Stay quiet and calm
– Why
• Anesthesia and circulator are only ones to interact with pt
– Accept if child becomes combative
– Restrain only to prevent the child from hurting themselves
Intra-operative Considerations
• Temperature
– Less fat, poor thermal insulation
– Monitored either with skin or rectal thermometers
• Shock
– Septic shock
• due to infection
– Hypovolemic
• due to dehydration and bleeding
Birth Trauma
• *Cord compression
• Broken clavicle
• Facial paralysis
• *Placental abruption
Obese Patients
• 100 lbs or more over ideal weight
• Increased morbidity and mortality due to:

Considerations
• Transportation
– Some must be transported on their hospital bed into the OR
– Sometimes two OR beds must be used
– Sometimes (seldom) the operation must be done on the hospital bed
– Extra personnel needed to transport for saftey
Respect
• Pts are usually self conscious
• Keep negative comments to yourself
• Keep exposure to a minimum
Anesthesia Complications
• May need a cut down for venous access
• Difficult intubation due to lack of movement in the neck
• Poor ventilation
• Need for more anesthetic agents
Intra-operative Considerations
• Need for longer instrumentation
• Longer surgical time due to lack of exposure
• As with all surgical procedures counts must be accurate
– There is more of a chance that something could be left behind in deep incisions
Post-operative Considerations
• Longer healing time
– Adipose tissue in the obese has decreased blood supply
• Increased likelihood of wound infection
• Wound dehiscence
• Pulmonary embolism
• Post operative asphyxia due to sleep apnea
• Leaks at anastomosis sites……

Geriatrics
• The term geriatric is taken from the Greek word yeros, which means old.
• People over the age of 65 are considered elderly
• Elderly people may maintain their functional capabilities throughout their life time.
• The main influence on aging depend on their genetic, environment, and lifestyle
Geriatrics
• Gerontology - is the study of all aspects in aging to include, physiologic, psychologic, economic, and sociologic problems and consideration of the aging person.
• Life expectancy has increased with major advancements in the study of the disease process, prevention and treatment
Geriatrics
• The US Dept. of Health and Human Services indicate that a person born in;
– 1954 expect to live to 68 years of age
– 1988 expect to live to 74 years of age
– By 2030, 1 in 10 will be older than 85 years of age with only 41% of the population below the age of 35
– The median age will be 40 y/o
– With the increase life expectancy and decrease in mortality the largest patient population will be geriatrics
Geriatrics
• As the life expectancy increase so does the rate of comorbidity.
• Comorbidity – the existence of two or more disease process in a single pt
– ie a pt with coronary artery disease, may also have osteoporosis, may also be hypertensive and be diabetic.
• Comorbidity is also a major consideration in the attainment of expected outcome.
Geriatrics
• Aging is viewed from many perspectives, some positive & some negative
• The positive aspects are;
– Maturity & wealth of knowledge
• The negative aspects are:
– Debilitation
– Pervading weakness & dependence at the end of their life
Geriatrics
• Major organ systems affected by the aging process:
– Central Nervous System
– Musculoskeletal System
– Cardiovascular System
• Other systems include:
– Gastrointestinal Endocrine
– Genitourinary Integumentary
Geriatric Surgery
• The surgical team needs to be aware of the physical, psychological, and social status of the geriatric pt.
Surgical Considerations
• Ease with bruising or laceration
• Loss of mobility in joints
• Ease of fx’s and strains
• Lack of ability to tolerate episodes of hypoxia
• Potential lack of understanding
Geriatric Surgery
• The normal changes of the aging process present the surgical team with a wide variety of needs
– Protecting the pt’s skin and joints
– Temperature loss
– Fluid dynamics
– Cardiovascular response
Geriatric Surgery
• Questions to ask yourself
– Is the room temp OK?
– Is there sufficient padding on the OR bed?
– How is the pt’s skin condition?
– How flexible is the pt?
– What is the mental status of the pt?
– What specific complications are most likely with this pt’s?
Trauma
• #1 health care issue in the world
• About 160,000 Americans die each year from trauma
• Difficult to diagnose and treat because most trauma victims have multiple types of injuries
• When working with a trauma team the ST must be ready to do almost every type of surgery
Trauma Centers
• Level I
– Meets all needs required for trauma patients on a 24 hour basis
• Level II
– Can treat seriously ill and injured pts but not to the extent of Level I
• Level III & IV
– Usually a community or rural hospital. Trauma pts are stabilized and transported to a Level I
Types of Trauma

Blunt
&
Penetrating

Blunt Trauma
• Skin is usually unbroken
• Injury to the underlying tissues and organs
• Makes diagnosis difficult
• Examples include:
– Car accidents, falls, battery and sports injuries
Penetrating Trauma
• When a foreign object passes through tissue
• The most common are bullets and knives
• Extent of injury depends on the size and type of foreign object and how many tissues and/or organs that are affected
Penetrating objects
• Should never be removed in the until in the operating room
• The object acts as a tampenade for bleeding
• If it is removed before in an area that can take care of this then the patient may die from subsequent bleeding
Questions?

Standards of Conduct
Chapter 2
Legal Aspects of Health Care
• Laws, standards, and guidelines
• Patient is an autonomous individual
• Concepts related to legal aspects of medicine
Traditional Principles
Doctrine of Borrowed Servant
• The one controlling or directing the employee has greater responsibility than the one paying the employee
• Surgeon is liable for any negligent act committed in their presence
• Captain of the Ship doctrine
Doctrine of Personal Liability
• Each person is responsible for his or her own tortuous conduct
• Others may be liable as well
• Physicians assure the medical professional will take responsibility for an action
Intentional Torts
• Assualt
– an act that causes another person to fear that they will be touched in an offensive manner w/o consent
• Battery
– the actual act of harmful contact w/o consent
• Defamation
– slander (oral) or libel (written) - reputation or good name
Intentional Torts
• False Imprisonment
– Illegal detention w/o consent
• Intentional Infliction of Emotional Distress
– Disparaging remarks
• Invasion of Privacy
– Disclosure of private information
Unintentional Torts
• Individuals make mistakes
• Most common type of patient indiscretions by OR personnel include
– Negligence: breach of duty
– Malpractice: wrongful conduct
Errors That Can Occur
• Patient misidentification
• Incorrect procedure
• Foreign bodies left in patient
• Patient burns
• Falls or positioning errors
• Improper handling of specimen
• Incorrect drugs or administration
Errors (continued)
• Harm secondary to use of defective equipment/instruments
• Loss of or damage to patient’s property
• Harm secondary to a major break in sterile technique
• Exceeding authority or accepted functions
• Abandonment of a patient
Consent for Surgery
• Permission being given for an action
• Granting party must have authority
• Voluntary and informed act
• Nonconsensual touching = battery

Consent for Surgery
• Express
– Direct verbal or written statement granting permission for treatment
• Implied
– Manifested by action or inaction of silence that assumes consent has been authorized
Written Informed Consent
• Physician’s responsibility:
– Information must be given in understandable language
– There can be no coercion or intimidation of the patient
– The proposed surgical procedure or treatment must be explained
– Potential complications must be explained
Written Informed Consent
• Potential risks and benefits must be explained
• Alternative therapies and their risks and benefits must be explained
Written Informed Consent
• A proper consent form should contained the following:
– Patient’s legal name
– Surgeon’s name
– Procedure to be performed
– Patient’s legal signature
– Signature of witness(es)
– Date and time of signatures
Who Can Give Informed Consent
• Competent adult
• Parent or legal guardian of a minor
• Guardian in case of physical inability or legal incompetence
• Temporary guardian
• Hospital administrator
• Courts
Consents
• Witnesses for a consent signature
– Physician/surgeon
– Registered nurse
– Other hospital employee
• Once given a consent can be taken away
Documentation
• Placing information into a patient’s medical record (chart)
• Combined account of interaction between the patient and health care providers
Documentation
• Hospitals are mandated to report certain items to other authorities:
– Disease of the neonate
– Child abuse
– Elder abuse
– Communicable diseases
– Births and deaths
Documentation
• Any suspicious deaths
• Any known criminal acts
• Professional misconduct
• Incident reports
Additional Information
• Advanced directives
– Rights of self-determination
• Ethical and moral issues
– Concepts of right and wrong
• Bioethics
– Study of ethical implications of biological research and applications in medicine
Patient’s Bill of Rights
• Adopted by American Hospital Association 1972 and revised in Oct 1992
• Requires collaboration between
– Patients
– Physicians
– Other health care professionals
• Establishes patient as consumer of health care
Patient’s Bill of Rights
• Hospital must respect the pt’s rights and role in health care decision making
• Hospital must be sensitive to culture, racial, linguistic, religious, age, gender, and other differences including disability
Ethics
• Surgical technologists will be exposed to many issues that may create discomfort
• Decide what type of situations you cannot participate in and act upon your decision
• Respect other viewpoints
Ethics
• Elective sterilization
• Fertilization procedures
• Elective abortion
• Human experimentation
• Animal experimentation
• Organ donation/transplantation
• Quality vs. quantity of life
• Substance abuse
• Gender reassignment
• HIV and AIDS pts
• Newborns w/severe disability
• Good Samaritan law
• Assisted suicide
• Genetic engineering
• Refusal of treatment
• Termination of care & right to die
Surgical Conscience
• Personal moral authority to accept responsibility
• Committed to maintaining confidentiality
• Nondiscriminatory treatment
• Personal values, feelings, and principles are secondary
Surgical Conscience
• Basis
– If you or someone else in the case breaks sterile technique, admit it or acknowledge it
– If someone says that you have broken sterile technique, take them at their word
– Above all: do not argue, do not give excuses

The Surgical Patient
By Javier Espinales, CST
The STSR and the Surgical Patient
­ The ST’s contact with the patient occurs preoperatively, intraoperatively and postoperatively.
­ No matter what role the ST is playing you must be aware of the pt, other team members, surrounding environment, and care and safety issues.
The STSR and the Surgical Patient
­ Every health care employee is morally obligated.
­ No one is excused.
Physical, Psychological, Social, and Spiritual needs of the PT
­ For a pt to go through surgical intervention, the physical, psychological, social and spiritual are major events for them.
­ The pt may presume good care – but the pt inner self may haunt them before and after surgery.
Physical, Psychological, Social, and Spiritual needs of the PT
­ The pt has a life before surgery and the question remains after.
­ The health care professional needs to care for the pt well being or they need to find another profession.
Causes for Surgical Intervention
­ All surgical pt’s have one thing in common – they rather not be there.
­ Most have surgery due to trauma, disease, genetic factor that can only be corrected by surgery.
Prioritizing Needs
­ Maslow’s Hierarchy
– Physiological Needs
– Safety Needs
– Love and Belonging Needs
– Esteem Needs
– Self-actualization
Prioritizing Needs
­ Guidelines and Constraints
– The OR team must recognize the pt’s physical needs but the team has to also understand that the pt has certain rights to refuse surgery.
What can an ST do?
­ Help establish an environment that communicates care and concern.
– Discuss with the circulator if there are any issues with the pt that you need to know.
– Plan simple actions for the pt
– Introduce yourself professionally
– If the pt ask what you do, explain in simple language.
Cultural and Religious Influences
­ Every culture has different beliefs.
­ You must be aware that different pts react differently due to their beliefs.
Patients Bill of Rights
­ American Hospital Association – adopted the Patients Bill of rights in 1972.
­ These assumptions are for the protection of the patient.
­ The bill was later reinforced with The Patient Self-Determination Act of 1990
– It says that each patient has the right under state law to make decisions concerning his/her care, including the right to refuse treatment.
Consent for Surgery
­ JCAHO’s definition – A person who receives health services from a health care provider and who gives consent for the provider to provide those services.
­ To perform surgery without consent is liable to be charged with battery.
Consent for Surgery
­ Consent
­ Battery
­ Expressed
­ Implied
­ Informed Consent
Principles of Documentation
­ Surgical records that will also go into the pt’s record
– Informed consent, surgical procedure
– Anesthetic procedure – response to anesthesia and post anesthetic care
­ As far as the OR Nurse
– Pt’s condition before, during and after the case
Principles of Documentation
– Time of initiation and termination of case
– Proper counts, implants, drains, dressings and so on
– Specimen/lab report
Principles of Documentation
­ Mandated reportable items to proper authority
– Disease of Neonate
– Child Abuse
– Elder Abuse
– Communicable disease
– Births and Deaths
Principles of Documentation
– Any suspicious death
– Any known criminal acts
– Professional misconduct
– Incident reports
Legal and Ethical Considerations
­ AST Code of Ethics
Legal and Ethical Considerations
­ Bioethical Situations
– Elective Sterilizations
– Fertilization Procedures
– Abortion
– Human Experimentation
– HIV and Other Infections
Legal and Ethical Considerations
– Animal Experimentation
– Organ donation/transplant
– Quality of life
– Euthanasia
– Right to Die
– Death and Dying
Legal and Ethical Considerations
­ Possible mistakes in the OR
– PT mis-ID
– Performing incorrect procedures
– Foreign bodies left in the pt
– Burns by ESU
– Falls or positioning mistakes
Etc, etc.

Health Care Facilities
Javier Espinales, CST
Health Care Facilities
• Traditionally hospitals provided all the care
• Since the 1990’s you now have facilities;
– Wellness care and education
– Home health care
– Follow up care
Health Care Facilities
• All surgeries use to be in one building
• There were few specialty hospitals
• You now have ;
– Traditional OR’s
– Free standing ambulatory
– Surgical facilities
– Free standing specialty centers
– Dr’s offices and clinics
– L&D units
Health Care Facilities
• Several types of hospitals;
– Nonprofit (Not-for-profit)
– Proprietary (For profit)
– Tax supported
Health Care Facilities
• Nonprofit (Not-for-profit) – acute-care hospitals – nontaxable
• Owned by
– Community
– Church
– Other organization
• Profits put back into maintenance and improvements
• Can be supported by tax revenues
Health Care Facilities
• Proprietary (for profit) – investor-owned hospitals
– Owned and operated individual or corporation
– Profits returned to investors
– Profits are taxable
Health Care Facilities
• Surgeries can be performed in more than one setting in the hospital
– Traditional OR’s
– Outpatient surgery
– L&D
– Pediatric surgery
Health Care Facilities
• Free standing ambulatory surgical facility – separate from a hospital
• HMO – Health Maintenance Organization
– Insurer
– Provider of medical services
• Clinics – for specific procedures
• Vets provide surgical services
Hospital Organization
Hospital Organization
• Surgeon’s
– Medical doctors
– Doctors of Osteopathy
– Podiatry
• Board certified in their specialty
Hospital Organization
– RN’s
• GN – Graduate Nurses
• LPN/PVN – Licensed practical /vocational nurses
• ADN - Associate Degree Nurse
• BSN – Bachelor’s Science Nursing
• Master’s and PhD’s
• CNOR
• CRNFA
Hospital Organization
• Anesthesia staff
– Anesthesiologists – MD’s/DO
– Anesthetists – nurses CRNA
– Anesthesiologist assistant – AA
– Anesthesia technician
• PA’s – Physician Assistants – role usually as a surgical assistant
Hospital Organization
• Other personnel working in the OR
– X-ray tech
– Perfussionist
– Cell saver tech
– Bioelectrical tech
– Lab tech
– Ortho tech
– Ophthalmic tech
– Dental tech
Hospital Departments and Interdepartmental Communication
• Direct Patient Care Departments
– Nursing Care Units
– Diagnostic Imaging
– Medical Laboratory
– Pharmacy
– Physical/Occupational Therapy
Hospital Departments and Interdepartmental Communication
• Indirect Patient Care Department
– Administration
– Maintenance
– Biomedical
– Housekeeping
– Food Service
– Purchasing/Central Services
– Medical Records
Financial Considerations and Reimbursement
• Surgery is expensive
• Some surgeons provide free care
• Insurances – designate contractual relationship and mutual benefit that exist when one party or entity agrees to pay another for a specific loss or condition.
Financial Considerations and Reimbursement
• Most health care coverage are provided by HMO’s or PPO’s (Preferred Provider Organization)
– All seek to control cost through contractual arrangements
– Limit payments to agreed-on amounts
Financial Considerations and Reimbursement
• Medicare – administered by the Fed. Gov. Through the Centers for Medicare and Medicaid Services (CMS)
– Reimbursements to hospitals and physicians
– 65 y/o & older qualify
– People eligible for Social Security disability payments for at least 2 years
– Certain workers & families who require kidney dialysis or transplantation
Financial Considerations and Reimbursement
• Medicaid is a government assistance funded jointly by Fed. Gov. and State Gov.

• Provide for low-income persons who can not afford medical insurance

• Surgical Technologist and other staff personnel must control cost
Organization Related to Hospitals, Health Care, and Surgical Services
• Governmental
– Dept. of Health and Human Services (DHHS)
• Public Health Services (PHS)
• Centers for Medicaid & Medicare Services formally known as Health Care Financing Administration (HCFA)
• Social Security Administration (SSA)
• World Health Organization (WHO) UN division
Organization Related to Hospitals, Health Care, and Surgical Services
– Various state, county, and city department groups

• Private Volunteer Agencies
– American Cancer Society
– American Diabetes Association
– American Heart Association
– American Red Cross
Organization Related to Hospitals, Health Care, and Surgical Services
• Accrediting Agencies
– Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – An independent, nonprofit national organization
Organization Related to Hospitals, Health Care, and Surgical Services
• Professional Associations
– American College of Surgeons (ACS) – dedicated to improvement of surgical care by elevating standards of surgical education and pratices
– Association of Surgical Technologist (AST)
– Association of Operating Room Nurses (AORN)

Health Care Facilities
Javier Espinales, CST
Health Care Facilities
• Traditionally hospitals provided all the care
• Since the 1990’s you now have facilities;
– Wellness care and education
– Home health care
– Follow up care
Health Care Facilities
• All surgeries use to be in one building
• There were few specialty hospitals
• You now have ;
– Traditional OR’s
– Free standing ambulatory
– Surgical facilities
– Free standing specialty centers
– Dr’s offices and clinics
– L&D units
Health Care Facilities
• Several types of hospitals;
– Nonprofit (Not-for-profit)
– Proprietary (For profit)
– Tax supported
Health Care Facilities
• Nonprofit (Not-for-profit) – acute-care hospitals – nontaxable
• Owned by
– Community
– Church
– Other organization
• Profits put back into maintenance and improvements
• Can be supported by tax revenues
Health Care Facilities
• Proprietary (for profit) – investor-owned hospitals
– Owned and operated individual or corporation
– Profits returned to investors
– Profits are taxable
Health Care Facilities
• Surgeries can be performed in more than one setting in the hospital
– Traditional OR’s
– Outpatient surgery
– L&D
– Pediatric surgery
Health Care Facilities
• Free standing ambulatory surgical facility – separate from a hospital
• HMO – Health Maintenance Organization
– Insurer
– Provider of medical services
• Clinics – for specific procedures
• Vets provide surgical services
Hospital Organization
Hospital Organization
• Surgeon’s
– Medical doctors
– Doctors of Osteopathy
– Podiatry
• Board certified in their specialty
Hospital Organization
– RN’s
• GN – Graduate Nurses
• LPN/PVN – Licensed practical /vocational nurses
• ADN - Associate Degree Nurse
• BSN – Bachelor’s Science Nursing
• Master’s and PhD’s
• CNOR
• CRNFA
Hospital Organization
• Anesthesia staff
– Anesthesiologists – MD’s/DO
– Anesthetists – nurses CRNA
– Anesthesiologist assistant – AA
– Anesthesia technician
• PA’s – Physician Assistants – role usually as a surgical assistant
Hospital Organization
• Other personnel working in the OR
– X-ray tech
– Perfussionist
– Cell saver tech
– Bioelectrical tech
– Lab tech
– Ortho tech
– Ophthalmic tech
– Dental tech
Hospital Departments and Interdepartmental Communication
• Direct Patient Care Departments
– Nursing Care Units
– Diagnostic Imaging
– Medical Laboratory
– Pharmacy
– Physical/Occupational Therapy
Hospital Departments and Interdepartmental Communication
• Indirect Patient Care Department
– Administration
– Maintenance
– Biomedical
– Housekeeping
– Food Service
– Purchasing/Central Services
– Medical Records
Financial Considerations and Reimbursement
• Surgery is expensive
• Some surgeons provide free care
• Insurances – designate contractual relationship and mutual benefit that exist when one party or entity agrees to pay another for a specific loss or condition.
Financial Considerations and Reimbursement
• Most health care coverage are provided by HMO’s or PPO’s (Preferred Provider Organization)
– All seek to control cost through contractual arrangements
– Limit payments to agreed-on amounts
Financial Considerations and Reimbursement
• Medicare – administered by the Fed. Gov. Through the Centers for Medicare and Medicaid Services (CMS)
– Reimbursements to hospitals and physicians
– 65 y/o & older qualify
– People eligible for Social Security disability payments for at least 2 years
– Certain workers & families who require kidney dialysis or transplantation
Financial Considerations and Reimbursement
• Medicaid is a government assistance funded jointly by Fed. Gov. and State Gov.

• Provide for low-income persons who can not afford medical insurance

• Surgical Technologist and other staff personnel must control cost
Organization Related to Hospitals, Health Care, and Surgical Services
• Governmental
– Dept. of Health and Human Services (DHHS)
• Public Health Services (PHS)
• Centers for Medicaid & Medicare Services formally known as Health Care Financing Administration (HCFA)
• Social Security Administration (SSA)
• World Health Organization (WHO) UN division
Organization Related to Hospitals, Health Care, and Surgical Services
– Various state, county, and city department groups

• Private Volunteer Agencies
– American Cancer Society
– American Diabetes Association
– American Heart Association
– American Red Cross
Organization Related to Hospitals, Health Care, and Surgical Services
• Accrediting Agencies
– Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – An independent, nonprofit national organization
Organization Related to Hospitals, Health Care, and Surgical Services
• Professional Associations
– American College of Surgeons (ACS) – dedicated to improvement of surgical care by elevating standards of surgical education and pratices
– Association of Surgical Technologist (AST)
– Association of Operating Room Nurses (AORN)

Personal and Professional Relationships
n The calling
n JCAHO (Joint Commission of Accredited Hospitals Association) calls the surgical technologist an educated and trained individual in health care services.
n “The goal of a surgical technology program is not to get someone a job but to make one a surgical technologist.”
Surgical Technologist’s Lifestyle
n Little of the population know about us.
n Great knowledge about the human body.
n Involved in surgical procedures that the world thinks is either gross or miraculous.
n Our world is alien to non health care workers.
Surgical Technologist’s Lifestyle
n Weight of moral, legal, and professional obligations is ours to bear.
n Psychological events and outcomes.
n Excellence is always expected.
Surgical Technologist’s Lifestyle
n Duty and Obligation is our standard
n Accountability extends beyond the OR and interacts with one’s personal life.
Surgical Technologist’s Lifestyle
n Family inconvenience due to call.
n Social life put on hold due to call.
n Greater obligation for the care of your body from communicable disease.
n Details of personal information you cannot share with family and friends.
Surgical Technologist’s Lifestyle
n Many people don’t want to know about our exciting world.
n Isolation from the population may result due to the nature of the OR.
Surgical Technologist as a Professional
n Professional relations begin with competency and commitment at the workplace.
n “Enhancing the profession to ensure quality patient care.”
Surgical Technologist as a Professional
n Certification
n CAAHEP Accredited Schools
n LCC-ST
n CST – CST/CFA
n Specialty Practice and Employment
Surgical Technologist as a Professional
n Desirable Attributes for Success
n Care and Empathy
n Comprehend and convey
n Respect for Others
n Accept people as they are
n Emotional Self-Control
n Honesty and Ethical Behavior
n Admits error
Surgical Technologist as a Professional
n Desirable Attributes for Success (cont.)
n Manual Dexterity
n Organizational Skills
n Concentration
n Constant focused attention
n Possible short and long term problems
n Stress Hunger (hypoglycemia)
n Illness Lack of sleep
n Exhaustion Substance abuse
n Lack of interest or burnout
Surgical Technologist as a Professional
n Desirable Attributes for Success (cont.)
n Problem-Solving Skills
n Prioritizes activities
n Calmly seeks solution to any and all problems
n Uses time wisely
n Assesses own ability
n Demonstrates flexibility
n Selects the best alternative to achieve positive results
n Analyzes results and accepts feedback
Surgical Technologist as a Professional
n Sense of Humor
n “Humor when expressed appropriately, can create ease and relaxation.”
Surgical Technologist as a Professional
n Scope of Practice and State Jurisdiction
n Written hospital policy
n State nursing practice acts
n State medical boards
n State business and professional codes
n Dept of Health and Human Services
n JCAHO
Surgical Technologist as a Professional
n Unlicensed Surgical Technologist may not practice nursing.
n Activities that require nursing assessment and judgment
n Physical, psychological, and social assessment that require nursing judgment, referral, or intervention
n Design a nursing plan involving care and evaluation
n Administration of medication by any route
Surgical Technologist as a Professional
n Role of the Surgical Technologist
n STSR
n Assisting Circulator
n Circulator
n Preoperative
n Intraoperative
n Postoperative
Surgical Technologist as a Professional
n Continuing education is important to the ST for two reasons:
n Continued personal development and improved patient safety.
n Continuing certification requires demonstration of continuing education.
n Community service is another feature of professional responsibility.
Surgical Technologist as a Professional
n The Surgical Technologist as a Preceptor
Homework
n Read Chapter 2
n Key Terms – workbook
n Due by next class

History of Surgery
Tracey Carpenter
Introduction
• The ability to perform surgery depends on:
– Anatomical information
– Control of pain
– Control of infections
• We have been studying the human body for over 6000 year

• Advances were made in three areas contributing to the progression in the field of surgery.
– Anatomical and physiological knowledge
– Factors affecting the understanding of microbiology
– Development in anesthesia

• Advances in medical science were not linear
• Some were philosophical and others were practical

• Practical issues also influenced medical science.
– Type of experience in anatomical dissection
• – actual vs literary
– Level of chemical knowledge for physiology
Time Line
• 4000 BC Cuneiform Tablets from Nineveh are the earliest found documentation to give anatomical descriptions
• 2500 BC Imhotep wrote an early book on surgery
• 2000 BC
– Code of Hammurabi – medical practice
– Moses – Desert rule of cleanliness
Time Line
• 1500 BC Vedas (Hindu) – Correlated sweet smell of urine with a specific disease
• 1000 BC
– Homer – Provides us a view of military medicine through his writings

• 500 BC Aristotle – Established early scientific mindset
• Herophilos – Father of anatomy; Developed the Doctrine of the Pulse
• Nei Ching – Chinese writing on acupuncture

• Year Zero
– Celsus – Described the signs of inflammation
– Galen – First great anatomist; went unchallenged for 1500 years
• 500 AD – Alexander describe the pump like action of the heart
Historical Fact
• 1200 – 1300
– Surgeons and barbers belong to the same guild, until 1540 when the barbers agreed to confine their practice to dentistry.
– The combined groups were dissolved in 1745 and by 1899 the Royal College of Surgeons of London were chartered.
Time Line
• 1400 AD – Linacre - translated Galen (from year zero) from Greek to Latin
• 1500 AD – Pare - Greatest Surgeon of the 16th century.
– Ligated arteries after amputations
– Cauterized with hot irons and oil
Time Line – cont.
• 1500 AD (cont.)
– Versalius – Father of modern anatomy.
• Challenged Galen openly and correctly
• Performed dissections himself on human cadavers
• Created illustrations for permanent records

• 1850 AD –
– Pasteur – Father of Microbiology
• Pasteurization
– Lister – Developed antiseptic surgical technique
– Billroth – Responsible for advances in surgical procedures, ie Gastrectomy
Time Line
• Halsted – Developed meticulous wound closure
– He also developed the practice of using sterilized rubber gloves for surgical procedures
• Roentgen – Developed the X-ray machine
• 1900 – Cushing – Father of neurosurgery
Time Line
• Lord Berkeley George Moynihan (1865 – 1936)“Surgery has been made safe for the patient; we must now make the patient safe for surgery.”
• Surgery can not be considered safe all the time
• Patient outcome are not always predictable

• “Surgery as we know today is a 20th century phenomenon
Time Line
• 1950
– Cooley –
• Perfected the heart-lung machine.
• Performed 1st heart transplant
• 1st total artificial heart implant
– Debakey – Developed 1st ventricular assist pump
Time Line
• 1980 – Technological revolution began. Endoscopic surgery becomes routine.
• 1990 – Computers age changes surgery.
– Stereotactic surgery
– Virtual reality
– Robotic surgery
Modern Surgery
• Surgery combines the total care of an illness with an intervention (invasive or noninvasive) aspect of treatment.
– Surgical specialization
– Sophisticated diagnostic and imagining techniques
– Minimally invasive equipment
– Collaboration of caregivers and industry
Surgical Categories
• Emergent
• Urgent
• Elective
• Optional
Surgical Specialties
• General Surgery
• OB/GYN
• Orthopedics
• Cardiothoracic
• Peripheral Vascular
• Neurosurgery
• Genitourinary
• Oral & Maxillofacial
• Plastic & Reconstructive
Homework
• Chapter 1
– Read the chapter
– Workbook - Key Terms
• Due by next class