Posted by: Kimberly Prinsen RN, MSN
When I think of the role of a circulating nurse in the Operating Room I’m struck by both the complexity of the work and the privilege of providing care for patients at a time when they are most vulnerable…when the patient cannot be their own advocate due to the effects of anesthesia. It is at this moment when the nurse becomes the eyes, ears, and voice for the patient.
The nurse is entrusted to know how to care for the patient, to understand, guide and deliver this care with competence throughout the patient’s perioperative journey. Care needs to be specific to and focused only on the patient being cared for.
One patient … one unique perioperative journey.
So how do you, as a circulating nurse, make certain you deliver the care each patient needs? How is it made unique to the patient? Let me use surgical skin prep to illustrate. We know the surgical skin prep is a critical step in reducing the risk of a surgical site infection for patients undergoing surgery. Because all commonly used patient skin preps meet the FDA criteria for immediate microbial kill and persistent antimicrobial activity, it’s important to look at other factors that may affect performance when choosing a prep for each surgical patient. The circulating nurse is responsible for knowing the fundamentals of selecting and appropriately applying the surgical skin prep.
Manufacturers provide instruction for use which include application method, contraindications and warnings for their surgical skin prep products. This is the best resource for learning about the surgical skin prep products used in your facility. Here are 7 basic considerations to personalize the prep selection for your patient:
1. Does your patient have allergies and sensitivities?
Check for patient allergies or sensitivities to the ingredients contained in the surgical skin preparation products used in your institution
2. Is your patient less than two months of age?
Certain skin preps are not recommended for patients under two months of age due to the risk of excessive skin irritation or absorption of the active ingredient.
3. What is the surgical procedure site?
If it is near the eyes: alcohol-based preps would not be appropriate nor would chlorhexidine gluconate (CHG) products due to the risk of corneal damage.
If it is near the ears: alcohol-based preps would not be appropriate nor would CHG products due to the risk of ototoxicity /potential deafnessIf prep includes mucous membranes: no alcohol-based products should be used. CHG products should be used with caution
If the skin is not intact: alcohol-based preps should not be used.
If the site includes a lumbar puncture or contact with the meninges: CHG preps would not be appropriate due to the risk of neurotoxicity.
4. What challenges will your surgical site face?Does the procedure involve large amounts of fluids (e.g. blood and/or saline)? If so, select a prep that is resistant to being washed off when challenged with irrigation solution, blood or sponges that come in contact with the prepped skin. You want a prep that will continue to work throughout the procedure into the post procedure phase.
5. Does the procedure involve the use of an incise drape? Select a prep that enhances drape adhesion so that once you create that sterile field with an incise drape there is a reduced incidence of drape lift.
6. Does the procedure involve prepping a large surface area or include prepping an area of high microbial counts (e.g. groin, toes, axilla, fingernails, skin folds, etc.)?
When using a single use applicator it is important to select the appropriate size for the location you are prepping. Single use applicators specify the coverage area on the package insert. More than one applicator may be required. Using a single use applicator to cover an area greater then specified area can impact the efficacy of the prep.
Conversely, using a larger volume of prep than is needed for a small area increases the potential for pooling of solution which poses a risk for skin irritation and fire if the pooled solution or solution-soaked materials are not removed after the prep is complete.
7.Are you using a prep that contains alcohol? If so, to reduce the risk of fire, you should adhere to the specified dry times. The minimum dry time for a prep containing alcohol is 3 minutes on hairless skin and up to an hour in hair. Following dry time ensures prep efficacy, patient safety and minimizes skin irritation.
When you know the answers to these questions and have selected the appropriate prep for your patient and their procedure, the next step will be to apply the prep. To provide your patient with quality care, it is important to understand and follow the Instructions for Use (IFU) specific to the chosen prep.
Here are 4 factors to consider:
The application method for a surgical skin prep is critical for the prep to achieve its efficacy.
Instructions for use (IFU) are based on the product application used during testing to meet the FDA efficacy requirements. Even if the skin antiseptic active ingredients are the same between manufacturers, the application methods utilized for their clinical studies and the resultant efficacy findings may vary based on product formulation and applicator design. Application methods range from being painted on, scrubbed on, or applied in gentle back- and- forth stokes.
Application can vary in terms of contact time. For example; solutions that combine alcohol and another active ingredient (e.g. iodine povacrylex or CHG) kill bacteria more quickly and therefore generally have shorter application times than those that do not contain alcohol.
Application time may vary dependent upon intended use. For example, prior to surgery, prior to inserting a vascular catheter or prior to performing an injection. If the application times are different, the different times and indications must be identified on the product label or in the IFU. Application time may vary depending on the site being prepped.
For example, the prep times for a CHG/alcohol antiseptic are different depending on the prep site. If you are prepping a dry site (e.g. back, abdomen, leg) your application time will be 30 seconds. If the site you’re prepping is considered a moist site (e.g. axilla, groin) the antiseptic needs to be applied to the skin for 2 minutes. As you can see, even one of the most seemingly routine tasks in preparing your patient for surgery is anything but routine.
The ability of the circulating nurse to customize the care for each patient is critical to keeping the patient safe throughout the perioperative journey. Be that advocate: be their eyes, their ears, their voice!