En - 2031 90 23963789 Nursingor All PDF
En - 2031 90 23963789 Nursingor All PDF
En - 2031 90 23963789 Nursingor All PDF
DEPARTMENT OF NURSING
OPERATING ROOM
Table of Contents
Section 1: Administrative
Page 1 of 16
King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1. 1 Vision
The King Khalid University Hospital Operating Room will be the healthcare leader
in the Middle East and be recognized around the world as a premier medical
institution dedicated for new surgical opportunities in education, research, training
and providing quality perioperative nursing care service.
1. 2 Miission Statement
The O.R. nursing staff supports the vision and mission of the hospital, surgery
department and Nursing Deparment by providing quality perioperative nursing
services.
Operating Room
The Operating Room Staff strongly believe that perioperative nursing service is a
dynamic behavioral and technical process directed towards provision of quality
patient care during surgical intervention. Our primary concern is to ensure a safe
physical environment, protection of patients and delivery of holistic perioperative
nursing care..
The O.R. staff are committed to improving their knowledge and skills through
personal professional developments in order to facilitate implementation of
scientific and technological advances in health care.
The Recovery Room Staff (Post Anesthesia care Unit) strongly believe that all efforts
should be directed towards provision of high quality of care for all those who have
undergone surgery and anesthesia. Concern is to ensure a safe physical
environment, protection of the patient’s airway and effective management of pain.
We also value personal and professional development of staff in order to be able to
give the best updated care possible.
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1.3 Values
c. Respect and collegiality: To treat our colleagues, co- workers and most specially
our patients with respect and dignity.
d. Collaboration and Teamwork: To cooperate and work with other members of the
surgical team and departments by fostering efficiency, professional and personal
growth.
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1. 4 Scope of Practice
The perioperative registered nurse is primarily accountable and responsible for the
process of nursing practice to patients who are facing an operative & invasive
procedure. The registered nurse shall assist the patient in meeting outcomes in order
to implement the nursing process effectively. The nurses who are engaged in the
practice of perioperative nursing shall be based on best practices and evidence
based information to continuously update knowledge & skills. The registered nurse
shall determine the range of practice by considering the care setting and the
resources available.
B. Scope of Services
The King Khalid University Hospital Operating Room with 17 theaters is an integral
agent in the total health care system, share and affirm the hospital’s goals of
continuous improvement in quality patient care, motivation in educational planning
and programs with the continuous interest and participation in medicine and
nursing research.
The O.R. provides elective surgical service every Saturday to Wednesday and 24
hour daily emergency services. We provide a wide scope of surgical services
including in- patient and out- patient surgical services.
We cover a wide range of specialties which are under the following different
departments and specialties.
Page 4 of 16
King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1. Department of Surgery:
a. Hepatobiliary Surgery
b. Colorectal Surgery
1.2 Urology
a. Adult
b. Pediatric
2. Department of Orthopedics
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
4. Department of Anesthesia
5. Department of Nursing
Page 6 of 16
King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1.4.2 Administration Services
The overall smooth running of the flow of events in the O.R. is the
responsibility of the O.R. Medical Director & ADON-O.R. The ADON-
O.R. should ensure full nursing staffing coverage for 24 hours
perioperative nursing services. The perioperative nursing care is
under the supervision of the ADON-O.R. who reports to the Director
of Nursing.
The HN-O.R. is responsible for the daily allocation of staff in the all
the theatres. The Cardiac HN is responsible for Cardiac theatres
staffing & HN-RR for Recovery Room (PACU) staffing.
A. CLIENTS
1. Surgical Patients
The KKUH Operating Room is an integral part in the total health care system,
and shares goals of quality assurance in patient care, motivation in education
planning and programs, and continuing interest and participation in science,
medicine and nursing research. Our clients are the surgical patients and the
effective functioning of the Operating Room and its team members is vital and
essential in our clients/patients' physical, mental, spiritual and social well being.
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
The perioperative nursing care should be rendered effectively and efficiently in
these 3 phases:
The delivery of nursing care in the Operating Room is functional team concept. The
nursing process is used in the Operating Room guided by the Operating Room
standards as adapted in the O.R. Policies and Procedure. The perioperative nurse
uses many interventions when caring for the patient having surgery, including
proper identification and collecting pertinent data using appropriate assessment
techniques to develop a plan of care for the theater are:
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1. The patient remains free from infection unrelated to preoperative
existing conditions.
2. The patient remains free from injury related to positioning,
extraneous object or chemical, physical or electrical hazard.
3. The post- operative patient relates positive physical and
psychological responses to the operative intervention experience.
The Operating Room also serves as a clinical setting for experience for students
from the King Saud University & other Colleges. The students in all grades or
levels of different fields are also our clients in O.R. for their clinical experiences
& surgical training but also share surgical services to our main clients, the
surgical patients. The framework of education is correlated with the university
health care programs and constantly forms likewise, a stimulus for continuing
education for the members of the Operating Room staff.
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
B. SUPPLIERS
The equipment and supplies needed in the O.R. are provided in the same process
of procurement like other departments are doing which is through the Medical
Supplies Department & Warehouse.
There are some equipment and supplies that are stock items and these can be
ordered through the Central Stores and Warehouse. The O.R. non- stock items
are purchased through the Department of Surgery and submitted to the Medical
Supplies for processing. The O.R. Medical Director, O.R. ADON & the O.R. Non-
Stock officer coordinate with each other with regards to the ordering of
equipment & supplies for O.R. use with the approval and signature of the
Chairman of the Department of Surgery. The surgeons coordinate with the O.R.
Medical Director ,ADON-O.R. and O.R. Non- Stock Officer for any preferred
new equipment/item needed in their surgeries wherein there is an attached
justification letter and minutes of their division meeting that such item is agreed
for purchase.
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1.6 Goals and Objectives:
1.6.1 Goals:
1.6.2 Objectives:
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1. 8 Staffing Plan / Pattern
A. Brief Description:
The Operating Room team is a coordinated, highly specialized multidisciplinary
group trained in the skills necessary to achieve the optimum effective surgical
service. An atmosphere of respect for each individual is necessary and vital because
of the close interactions and stressful circumstances which bring this team together
in the Operating Room setting.
The Nurse Educator of O.R. and the unit Education Coordinator coordinates with
ADON & HN's-O.R. in order to facilitate the orientation, competency verification,
quality care improvement and continuing education of the Operating Room Staff.
All operating room newly hired nursing staff receive a comprehensive core
orientation by nursing department of education and through the Mentor &
Preceptorship program. There is also specific orientation being done to newly hire
health care assistants (porters) and housekeeping staff which are based on their job
descriptions, adult learning methods and geared to individual learner depending on
experience.
There are 17 operating theatres in the hospital-11 theatres in Main O.R., 4 theatres
in Phase IV-O.R., 1 theatre in L.D.(O.B. Th.), Level 1 & 1 theatre in Ward 25-A,
B.U.-O.R.(closed temporarily)The newly constructed theatres Th.1 & Th.45 are
already opened for surgical services but this will depend on the availability of
anesthesia & O.R. staff coverage.
The O.R. will be staffed for the operation of the abovementioned number of theatres
from Sunday through Wednesday 7:30 am to 5:00 pm. The on-call teams will be
available from 5:00 pm to 8:00 a, Saturday through Wednesday and the weekends
and holidays-12 hours shift will be available for 24 hours emergency services.
The Operating Room is presently staffed with the following which are under
Department of Nursing:
1. O.R. = 70 nurses
2. PACU (RR) = 14 nurses
3. Cardiac = 12 nurses
4. Main O.R. & Phase IV-O.R. = 10 (HCA Porters)
The safe number of O.R. nursing staff assigned in each theatre is 3 O.R. staff
consisting one Charge Nurse and 2 Staff nurses. However, in Cardiac theatre and at
times in theatres with major & complicated cases, 4 staffs are allocated to maintain
safe & smooth flow of events. The charge nurse in each theatre is responsible and
accountable for the control and smooth flow of works in the theatre. During her
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
absence like vacation and sick leave, a senior O.R. staff nurse will cover. The Charge
Nurse should remain in his/her respective theatre with the O.R. R.N.s assigned in
order to assume responsibilities for all activities in the theatre. The HN/ Designee is
responsible for the daily allocation of all O.R. staff in all the theatres including the
O.R. Reception Area from Saturday to Wednesday except weekends and this is based
on patient requirements & staff expertise.
We are utilizing the 3 shifts method (9.5 hrs.per shift for weekdays) and 12 hrs.
shift ( 2 shifts) for Cardiac nurses and weekends for all staff at least once a month.
We have a 3rd team standby for on calls after 5:00 pm on weekdays from Saturday
to Wednesday and 24 hours on calls staff for weekends-Thursdays & Fridays.
Regarding overtime, this is considered as additional time worked if there are cases
done and time backs or compensations are given accordingly when O.R. is not busy
or depending upon the length of time the staff worked.
Shortage of Staff:
If there is shortage of staff, giving overtime to some staff can cover the shortage. The
transferring of responsibilities from one staff to another is the responsibility of HN
with the approval of ADON.
Holiday Planner:
The number of staff who can go for holidays depends upon this calculation: Number
of staff x 45 days divided by 354 days per year. Charge nurse & Acting Charge
Nurse in each theatre are allowed to overlap for one week and two weeks can be
allowed if justified with valid reasons. More staffs are scheduled to go on leaves
during summer holidays when work in O.R. is not heavy.
Sick Leaves:
There is one staff coverage in each phase of O.R. In Main O.R., - 2 Phases(Phase1 &
2) x 2 staff, Phase 3-RR x 1 staff & Phase IV-O.R. x 1 staff.
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
B. Staffing Pattern in the Operating Room:
Duration & area of coverage: All theatres with different specialty sessions except
Cardiac theatres- 3 shifts for 9.5 hours/per shift.
3. Night Shift: 11:30 pm to 8:00 am- 2 theatres for emergency coverage. One
or two twelve hours duty is scheduled for every evening duty staff to cover
time shortage depending upon the month of Hejira Calendar.
Total # of staff = 4 staff
CN x 1 & SN x 3 staff
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King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
For Recovery Room Staff
Duration of Coverage:
3 shifts of 9.5 hours x 5 days- Saturday to Wednesday
12 hours shift for weekends- Thursdays & Fridays
Total # of staff:
There is a Unit PDP conducted every Saturday from 8:00 am to 9:00 am, lectures from
nursing staff & surgeons and also additional in- service training from companies which is a
requirement of the Medical Supplies Dept. for commissioning & training purposes. In
addition for staff continuing education, Core PDP & Saudi Council CME courses are
conducted by the Nursing Department of Education. The Nurse Educator and Education
Coordinator are available as a resource person for any staff member who may identify a
learning need. Topics for planned in- services are chosen based on annual needs assessment
and current clinical issues. Documentation of competencies is mandatory for CPR, Fire
Safety, Infection Control, and IV & Medication Calculation which are assessed annually for
continuing education. Other in-service programs are also of great importance to the
following topics which are incorporated to the Unit PDP to refresh staff and orient novice
staff.
• Electrosurgical Generator Safety- Valleylab ESU & Ligasure, CUSA,
Harmonic Ultrasonic Generator 300, etc.
• In-Service Training for da Vinci Robotic Surgical System
• ORICS (O.R. I Technology)
• Stapling Devices-Open & Laparoscopic
• Laser Technologies-Yag, CO2, etc.
• Orthopedic Power Drills & others
• Medtronic Neuro Navigation system
• Zeiss Neuro Microscope and other microscopes
• Other O.R. Basic Equipment
Page 15 of 16
King Saud University
King Khalid University Hospital
DEPARTMENT OF NURSING
OPERATING ROOM
1. 9 Communication and Reporting within the Department:
The Operating Room of KKUH is a part of the Surgical Services. The O.R. cooperates
fully with Hospital Administration, Department of Surgery, Department of Anesthesia,
Department of Orthopedics, Department of O.B. - Gynae, Department of Nursing and
other departments like CSSD, Radiology, etc. in order to render safe, efficient and
quality care to surgical patients.
The Operating Room is under supervision of the O.R. Medical Director who reports to
the Chairman of Surgical Dept. & O.R. Committee.
The O.R. ADON reports to Director of Nursing for nursing matters and to O.R.
Medical Director for all O.R. matters. All concerns and issues should be discussed
through channel of communication.
Minutes of the meeting are recorded and filed for further and future references.
Page 16 of 16
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 001
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
2.0 PURPOSE:
All OR Registered Nurses are responsible and accountable to ensure safe and
quality perioperative nursing care practice is carried out during the
immediate pre-operative, intra-operative and immediate post-operative
periods.
3.0 DEFINITIONS:
4.0 POLICY:
5.0 PROCEDURE:
5.2 Continuously update knowledge and skills
5.3 Determine the range of practice by considering the care setting and
the resources available.
5.4 Ensure the patient’s participation in health promotion, maintenance
and restoration
5.5 Develop policies and procedures in collaboration with associated
departments.
6.0 REFERENCE:
AORN
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
2.0 PURPOSE:
All OR Registered Nurses are responsible and accountable in providing the needs of
the surgical patients in a safe and cost effective manner
3.0 POLICY:
Perioperative Nursing Standards and Processes are practiced and carried out
continuously throughout the pre-operative, intra-operative and post-operative
periods.
4.0 PROCEDURES:
4.1 To ensure safe, high quality nursing care for the patient having an
operative or invasive procedure in this hospital
4.2 To assess, plan and implement optimum patient care.
4.3 To promote an atmosphere conducive to learning for all personnel
4.4 To maintain an ongoing performance improvement program that will assist
in the maintenance and improvement of patient care
4.5 To maintain a safe and controlled environment for patients, staff and
physicians
4.6 To provide efficient and cost the effective services.
5.0 REFERENCE:
AORN
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 003
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
2.0 PURPOSE:
3.0 POLICY:
3.1 The plan for nursing care prescribes nursing actions to achieve the
goals.
3.2 The plan for nursing care in the intraoperative setting reflects the
perioperative assessment, priorities for nursing action and a logical
sequence of nursing activity to attain stated goals, which are
individualized to the patient’s needs.
4.0 PROCEDURES:
4.8 Adherence to the principles of asepsis
4.9 Assurance of appropriate and properly functioning equipment and
supplies
5.0 REFERENCE:
AORN
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.O.R- 004
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
2.0 PURPOSE:
2.1 To ensure that all nursing staff are familiar with the safe evacuation routes
in removing patients in an orderly manner in the event of fire.
2.2 To ensure all patients and OR nurses are evacuated horizontally when
instructed to do so by senior officer and in extreme conditions if the fire has
engulfed the whole floor and parts of the building as well as fire fighting
equipments have been overwhelmed.
2.3 To ensure that all nursing staff should know how to handle and use fire
extinguishers.
3.0 POLICY:
All OR RN’s are responsible and accountable to ensure that all patients will be
evacuated from the OR in an orderly manner in the event of fire
4.0 PROCEDURE:
4.1 OR new nurses during their orientation period must learn about fire
prevention and preparedness, fire evacuation plan and must know the
locations where fire fighting equipments, smoke detectors, wall fire alarms;
fire doors are located.
4.2 All OR nurses should be conversant with the locations of fire fighting
equipments, wall fire alarms, smoke detectors, fire door etc.
4.3 In case of fire or smoke, the OR nurses who discovers it should activate the
wall fire alarm by pressing the center of the glass with a thumb and dial 953
giving the following information.
4.3.1 Description / Type of Fire / Smoke.
4.3.2 Location of Fire
¾ Level 2
NURS.O.R- 004 FIRE EVACUATION FOR SAFETY OF PATIENTS & STAFF IN OR Page 1 of 4
¾ Block 9 could be the theatre1, 2, 3, 4, 5, 6, 7 & Receiving Area
Block 6 could be for theatres 8, 9, 10 & 11 Recovery Room.
Block 24 (Phase IV-OR) could be for theatres 12, 13, 14 & 45
¾ Fire Zones for OR
Block 9 – Zone 71
Block 6 – Zone 66
Block 24 – Zone 58
4.3.3 Use appropriate fire fighting equipments to extinguish and control the
spread of fire if confident & safe to do so.
4.3.4 Ensure fire doors are closed to delay / limit the spread of fire.
4.3.5 Evacuation must be under the control of ADON, HN or designee who
makes the assignment / instruction.
4.3.6 At any given time, OR personnel must know that there are 3 categories
of patients in the OR.
Category I – Patients in the waiting / Holding Area
Category II – Patients already inside the theatres, anesthetized
and undergoing surgery.
Category III – Patients in the Recovery Room, recovering from
anesthesia after surgery.
4.3.7 All elective & emergency surgeries in progress should continue unless
there is a need to evacuate the area.
4.3.8 All patients in the RR and the Reception / Holding Area should be
evacuated first including all OR personnel not needed in the area.
4.3.9 If there is a fire in Block 6 & 9, the meeting area for patients and staff
will be in the Reception Area before evacuating horizontally to a safe
place in the same floor level, then vertically when instructed to do so as
fire fighting equipments have been overwhelmed.
4.3.9.1 In Block 9, there is an area without fire exit access and if
there is a big fire in the following theatres 3, 4, 5 and 6 + the
sterile Storage Room, all the staff and patients beyond this
point will be trapped but the key in fire prevention is the
responsibility of all staff to maintain a safe working
environment staff and patient will be evacuated to O.R.
reception area & hallway leading to Block 6 exit or SICU.
4.3.9.2 In Block 24, Phase IV – OR, patients and staff will be
evacuated through the 3 exits the double door leading to the
corridor then the corridor then the safe area Ward 21B and
the double door of Neuro Theatre leading to the old
Engineering Dept. or to R.R. any nearest vacant theatre and
double door leading to SICU.
4.3.10 With the senior person’s instruction, patients on OR tables undergoing
surgery should be stopped and their wounds should be packed with wet
NURS.O.R- 004 FIRE EVACUATION FOR SAFETY OF PATIENTS & STAFF IN OR Page 2 of 4
sterile lap sponges covered with sterile drapes and transferred in another
trolley with fire blanket while the anesthetists ventilates and oxygenates
the patients then wheeled to RR or nearest vacant theatre.
4.3.11 All surgical Team (Anesthetists, surgeons, nurses) working in the OR
should be responsible in transporting the patient to a safe place (RR) or
in another area if instructed to do so.
4.3.12 The anesthetist / anesthetist technician should shut off the flow of
oxygen / nitrous oxide and other medical gas but should maintain the
breathing of the patient with a valve mask respirator or ambu bag.
4.3.13 Disconnect all electrical powered equipment, any leads, lines or other
equipment that may be anchoring the patient to the area.
4.3.14 After a thorough check of the whole area, the ADON, HN or designee
should ensure no one is left and closed the fire door when leaving and
anyone not accounted for should be reported to the Fire Chief l
Department Head. An accurate count should be maintained to all
patients and staff members during evacuation.
4.3.15 No one to return to the area until the all clear and safe signal sign is
announced by the Fire Chief or from Hospital Administration.
4.4 All OR personnel are responsible to maintain a safe working environment at all
times by adhering to the following:
4.4.1 All OR nurses should attend the Unit Fire Safety Lecture at least once or
twice a year.
4.4.2 All OR nurses must ensure that the Fire Annual Assessment is updated
which is mandatory for the renewal of contact.
4.4.3 All OR personnel should participate in fire drills conducted for
preparedness in ensuring an effective and efficient response to a fire
occurrence in OR in a smooth and coordinated manner.
4.5 All OR personnel should know by heart these acronyms as response components
of the Fire Safety Plan.
4.5.1 Acronym RACE to follow in the event of fire
R – Rescue all patients in danger
A – Activate the wall fire alarm call 953
C – Confine the fire
E – Extinguish the fire and Evacuate if required
4.5.2 Acronym PASS on how to operate the fire extinguisher
P – Pull the pin
A – Aim the nozzle at the base of the fire
S – Squeeze the handle
S – Sweep the stream over the base of the fire.
NURS.O.R- 004 FIRE EVACUATION FOR SAFETY OF PATIENTS & STAFF IN OR Page 3 of 4
5.0 FORMS AND ATTACHMENTS:
O.R. Fire Evacuation Plan
6.0 REFERENCE:
6.1 AORN
6.2 Fire & Safety Training Manual
6.3 KKUH Fire Prevention Broad Policy Guideline
NURS.O.R- 004 FIRE EVACUATION FOR SAFETY OF PATIENTS & STAFF IN OR Page 4 of 4
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 005
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
2.0 PURPOSE:
2.1 To ensure that all O.R. Personnel should know the locations of all fire
fighting equipment including wall fire alarms and be able to activate,
handle and use them in the event of fire.
2.2 To ensure that all OR Personnel should know the locations of all fire
doors and that these serve as exits and should be clear and accessible
at all times; then be closed to limit fire in the event of fire.
3.0 POLICY:
All OR RN’s should be conversant with the locations of all the fire fighting
equipment in the Operating Room in the event of fire.
4.0 PROCEDURE:
4.1 All OR RN’s should be able to locate immediately all fire fighting
equipment, wall fire alarms, fire doors etc. in case of fire / smoke.
5. In front of Theatre 7
Wall Fire Alarm x1
5.0 REFERENCE:
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 006
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
2.0 PURPOSE:
To ensure that all patients and personnel are evacuated from the O.R. in an
orderly manner in the event of fire ensuring an effective and efficient
response
3.0 POLICY:
All OR Nurses are responsible and accountable to ensure that they are
familiar with the safe evacuation process and must know their individual
responsibilities in removing / evacuating patients in an orderly manner.
4.0 PROCEDURE:
4.1 Anesthetist
4.1.1 He is the leader of the team.
4.1.2 Responsible for the oxygenation and total physiological status
of the patient.
4.1.3 Responsible in shutting off the flow of O2, nitrous oxide and
other medical gasses but maintaining the breathing of the
patient with a valve to masks respirator / ambu bag.
4.1.4 Responsible in giving instructions when patient is ready to be
moved.
4.2.1 Ensures that all the necessary equipment needed like ambu bag,
portable monitor, etc. are available.
4.2.2 Remove ECG cables, pulse oximeter probe, BP cuff.
4.2.3 Disconnect the anesthesia machine, any leads, I.V.lines and other
equipment that may be anchoring the patient to the area.
4.3 Surgeon:
4.3.1 Packs the wound with wet lap sponges (wet with saline) and
secure it properly in placed.
4.3.2 Assists in the transfer and transport of the patient.
4.4 Scrub Nurse
4.4.1 Prepares the wound packing and hand it to surgeon.
4.4.2 Ensures that the wound pack (lap sponges soak with saline – not
dripping) is covered with sterile gauze dressings and secured
properly.
4.4.3 Removes all instruments and cables anchored to drapes.
4.4.4 Responsible in checking other tubing’s, catheters, etc. connected
to the patient.
4.4.5 Assists the surgical team in transferring the patient from the O.R.
table to another trolley if patient is evacuated out from O.R. or
patient is transported with the same O.R. table and is transferred
to another vacant theatre not affected with the fire.
4.5 Circulating Nurse:
4.5.1 Responsible for activating the fire alarm and informs H.N.
4.5.2 Assists the scrub nurse in packing the wound by ensuring the
security of the wound packing.
4.5.3 Removes all instruments away from the patient.
4.5.4 Put or switch off any equipment not needed.
4.5.5 Responsible in bringing the necessary patient’s documents
(patient’s blue & yellow files, etc.) during evacuation.
4.6 Head Nurse
4.6.1 Informs ADON or Supervisor (during evening, nite & weekends)
and asks for further instructions.
4.6.2 Gives instructions to staff regarding the process of evacuation.
4.6.3 Responsible in checking the theatre before leaving.
4.6.4 Ensures no one is left and close all fire doors when leaving and
anyone not accounted for should be reported to the Fire Chief &
ADON-OR.
4.7 ADON
4.7.1 Informs DON & O.R. Medical Director
4.7.2 Coordinates with Nursing Administration and Fire Chief for
further instructions.
4.7.3 Gives further instruction to HN & staff for the smooth and
coordinates manner of evacuation.
4.7.4 Ensures that all O.R. Nurses should participate in fire drills and
fire lectures & fire update.
4.7.5 Ensures that the staff’s Fire Annual Assessment is updated which
is mandatory for the renewal of contract.
4.8 Staff who discovers the fire should initiate the following safety actions in
case of fire:
4.8.1 Rescue all those in danger first and activate the fire alarm by
pressing the center of the glass with a thumb to break the glass.
4.8.2 Dial 953 and give the following information:
4.8.2.1 Identify yourself.
4.8.2.2 Fire area: level,, block & zone #
4.8.2.3 Description of fire.
4.8.3 Inform the head nurse
4.8.4 Try to extinguish the fire, if you are confident, capable and if it is
safe to do so.
4.8.5 Always make sure that there is an exit behind you when you are
trying to extinguish the fire.
4.8.6 Evacuate if necessary to area of safety.3
5.0 REFERENCE:
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 007
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
2.0 PURPOSE:
2.1 To respond quickly in a well coordinated manner during a disaster whether
internal or external.
2.2 To ensure all staff are being oriented to the department’s disaster plan and to
familiarize themselves with the procedures to follow when a possible
disaster is notified as standby or when a disaster is confirmed.
2.3 To ensure preparedness by coordinating and following the commanding
officer for further instructions once an emergency disaster is confirmed.
2.4 To ensure an up to date list of names of all OR-RR staff with their addresses,
telephone / mobile numbers that should be available in the nursing
department and in the OR office for the purpose of contacting them when in
dire need of manpower during a disaster.
3.0 DEFINITIONS:
Disaster Preparedness – is the preparation of our health care facilities and health
care workforce in the O.R. in order to cope with emergency situations so as not to
disrupt the delivery of health care services in the event of emergency / disaster.
4.0 POLICY:
5.0 PROCEDURE
5.1 O.R. new nurses during their orientation period must learn about the
emergency plan in case of a disaster whether internal or external.
5.2 A command call should be received from DEM and Nursing Department thru
Supervisor on duty or ADON if she is already informed to initiate necessary
actions for the preparation of OR in order to receive victims in an orderly
manner by ensuring adequate staffing and equipment / supplies to be needed.
5.3 Coordinate with the Nursing Dept. and other departments i.e. DEM, Anesthesia
Dept., Surgery Dept., CSSD, Blood Bank, Wards and delegate responsibilities to
OR staff for the proper preparation of theatres.
5.4 ADON / Designee should find out how many victims / patients may require
surgery in order to know how many OR staff needed to be called when a
disaster is confirmed during the normal working hours, the ADON / designee
should inform HN to notify all surgeons who are presently operating at the time
and the elective lists should be stopped but to finish the cases already in progress
and then the theatres should be prepared to receive the emergency disaster
cases. All empty theatres should be used first.
5.5 When a disaster is confirmed during the outside working hours (evening and
night shift and weekends) the following procedures should be followed:
5.5.1 If no operation is in progress the OR Charge Nurse /designee of the shift
should inform ADON and call the other staff needed.
5.5.2 If there are operations in progress, the OR Charge nurse / designee of
the shift should ask the Nursing Supervisor on duty to inform ADON and
to call other OR staff needed.
5.5.3 The OR Staff living in Diriyah Housing should be contacted first as they
can come immediately to the hospital.
5.5.4 OR Staff Disaster Coordinators from each housing and OR staff live out
Coordinators are responsible to contact the rest of the OR staff needed
and coordinate with the Nursing Supervisor /ADON / Designee for their
transport.
5.6 Staff from other departments is not allowed to be deployed to work in the
theatres during a disaster as they don’t have OR experiences.
5.7 Once the number of cases requiring surgery is assessed and confirmed for
surgery; the ADON / designee should decide how many staff are required to do
shifts to cover all the theatres with disaster cases.
5.8 Extra hours worked by the OR staff during a disaster should be recorded and
compensated.
6.0 REFERENCE:
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 008
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
3.0 DEFINITIONS:
4.0 POLICY:
All HN/CN/Designee must ensure that all elective cases must be booked a day prior
to surgery and the O.R. list (O.R. Theatre Schedule) must be submitted in the O.R.
office on time.
5.0 PROCEDURE
5.1 All scheduled elective cases for surgery must be written legibly in the O.R.
Theatre Schedule form and must be received in the O.R. office by 2:30pm
(1430hrs).
5.2 The O.R. list must be submitted by the Senior Registrar / Registrar / Resident
or Intern and must be checked by Head Nurse / Designee for any
clarifications.
5.3 The O.R. lists must be entered in the computer by O.R. Secretary and must be
checked again by the HN / Designee.
5.4 The O.R. printed list must be circulated to all departments for preoperative
preparations and screening.
5.5 The allocated anesthetist must collect the duplicate copy of written O.R. list
or printed copy for his preoperative screening of patients.
5.6 All original handwritten O.R. lists must be filled and kept in the O.R. office
for future references.
5.7 The Senior Registrar / Registrar / Resident or Intern must inform the
Anesthetist for any additional cases and any changes in the sequence of the
list after submission to the O.R. for typing.
5.8 The list must commence at 8:00am (0800 hrs) and must conclude at
4:30pm (1630hrs) or depending upon the length of time the last case in
each theatre finishes.
5.9 Any list starting at 7:30am (0730hrs) or earlier than 8:00am (0800hrs)
must be communicated to the anesthetists allocated in that particular
theatre.
5.10 All O.R. lists for Saturdays must be scheduled to start 9:00am (0900hrs) to
enable all O.R. staff to attend their weekly one hour Unit Professional
Development Program, equipment in-service training, unit meetings and
CSSD / O.R. Staff Meeting, Nursing Quality Improvement Meeting.
5.11 Anesthetists are instructed not to anesthetize major cases after 3:00pm
(15:00hrs) and minor cases at 3:30pm (15:30 hrs.).
6.0 REFERENCE:
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 009
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
1.1 All OR RN’s
1.2 O.R. Porters
2.0 PURPOSE:
2.1 To ensure smooth running of all theatres.
2.2 To ensure no delays of all elective surgeries.
3.0 POLICY:
All OR RN’s and Porters are responsible and accountable: To ensure safe sending of
patients for elective surgery from Ward or other department, to ensure the
scheduled time of surgery is being followed.
4.0 PROCEDURE:
4.1 The evening or night shifts RR nurses should prepare the “OR Patient Call
Slips Forms” by writing clearly the theatre number, dates in Arabic and
Gregorian calendars, patient’s name, patient’s hospital number, ward
number, and the surgery performed
4.2 The O.R. Patient Call Slip should be signed by the OR nurse with the time
when patient was sent for.
4.3 The OR Receiving Nurses are responsible in sending the “Patient Call Slips”
for all first cases in the theatres at least 30 minutes before the scheduled
time for surgery.
4.4 The OR receiving nurse should hand over the patients call slips to the OR
porters and then the porters should bring the patient to the OR with the
ward nurses for proper endorsement.
4.5 No patient should be brought to OR unless the patients call slip is being sent
from OR with the porter except in extreme emergencies.
4.6 The succeeding / subsequent cases should be responsibilities of the charge
nurses in each theater when to send and it they are busy she should call the
OR receiving nurse to send for their next patient.
4.7 The OR receiving nurse should ensure that the patient call slip is handed
over to the porter or should ensure that every call slip hanged at the external
door of the Reception Area is taken by the porter in order to avoid delay of
collecting the patient from the ward / other department.
4.8 Any problem that is causing the delay in sending the patient to OR from the
ward / other department, the ward nurse should inform the OR Head
Nurses that the necessary actions should be taken accordingly by informing
concerned anesthetist and surgeon.
6.0 REFERENCE:
6.1 KKUH Broad Policy & Procedures
6.2 Old O.R. Policies & Procedures
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 010
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
2.1 For effective organization and booking of emergency cases.
2.2 For efficient running of the Operating Room.
2.3 To maximize the theatre time and provide quality perioperative
service.
3.0 DEFINITIONS:
3.1 Emergency Cases: Cases that threatens the life or welfare of a patient.
3.2 Booking of emergency cases must be categorized as follows:
3.3 Category I: Life Threatening, extreme emergencies and cases that
need to be done within 2 hours.
3.4 Category II: Emergency cases to be done within 6-12 hours.
3.5 Category III: Emergency cases to be done within 12-24 hours.
4.0 POLICY:
5.0 PROCEDURE:
5.3 The Surgeon must inform the Anesthetist on-call regarding the
patient and not the O.R. Nursing Staff.
5.4 All emergency cases must be done as soon as the theatre becomes
available. No emergency cases must be booked for later time or on
the day before surgery.
5.5 If a surgeon decides that his / her case must be done first before any
of the other scheduled cases, then, he must personally contact and
get the approval of the other consultant surgeons whose cases have
already been booked, otherwise the service must follow first come
first serve basis. All staff must cooperate to ensure the smooth
running of the emergency services available.
5.6 When patient is category I Emergency, the anesthetist on call is
authorized to start the case immediately in any available theatre
during working hours.
5.7 In the event of all theatres being occupied and there is a life
threatening case needing immediate surgery, the elective surgery list
must be suspended to accommodate the emergency case if the
emergency theatre is already occupied. It will be preferable to do this
in the same specialty however it could be any room where the
surgery is near completion.
5.8 Emergency services staffing are normally available for two rooms
only, “A&E and OB-Gyne”. A third room will only be made available
for cases which cannot be delayed and will be decided by the
Consultant Surgeon on-call and must get the approval of the
Consultant Anesthetist on-call.
5.9 The Anesthesia Department must be informed about the emergency
case if there is any difficulty in locating the Anesthetist on–call
during the working hours from 0730 hrs. to 1630 hrs.
5.10 The O.R. Nursing staff must not get involved in deciding the priority
of any emergency cases.
5.11 The telephone # 7-1026 in the O.R. office must be reserved for
booking emergency cases and must not be used for any personal
calls. All medical staff must use this phone # to communicate to O.R.
staff and they must respond to it quickly.
6.0 REFERENCE:
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 011
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
1.1 All OR RN’s
1.2 All OR Porters
2.0 PURPOSE:
2.1 To ensure effective organization and smooth running of emergency theatre.
2.2 To ensure prompt actions to emergency cases.
3.0 POLICY:
All patients for emergency surgery should be dealt with immediately most
especially extreme emergencies and life threatening.
4.0 PROCEDURE:
4.1 Upon receiving the emergency list of operation, the OR Receiving Area nurse
prepares the “patient call slip” by writing clearly the patient’s name, hospital
#, ward #, Arabic & Gregorian.
4.2 The HN or Charge Nurse or designee should inform the anesthesia
technician and the OR nurses assigned for emergency to prepare the theatre
accordingly.
4.3 Emergency cases are categorized into 3 categories:
4.3.1 Category I – Life threatening, extreme emergencies and cases that
need to be done within 2 hours.
4.3.2 Category II – Emergency cases to be done within 6-12 hours.
4.3.3 Category III – Emergency cases to be done within 12-24 hrs.
4.4 The O.R. nursing staff should not get involved in deciding the priority of any
emergency cases.
4.5 The O.R. staff should only send for the patient after final agreement by both
anesthetist and surgeon-on-calls as to which case should be done first.
4.6 The HN or CN or designee should inform the anesthetist & surgeon-on-calls
if any problem that may be causing the delay in sending the patient.
4.7 The HN or CN or designee should bleep the anesthetist & surgeon-on-calls
before sending for the patient and both of them should agree to send for the
patient.
4.8 The HN or CN or designee should send for the “patient call slip” to the ward
with the O.R. porter by writing the time when patient is sent and signing the
call slip.
4.9 The ward Nurse should not bring the patient to O.R. unless the “patient call
slip” has been sent with the porter except in extreme emergency wherein
patient comes directly from DEM. In such case, the “patient call slip” will be
signed in O.R. by DEM nurses accompanying the patient and will bring with
them the request for O.R. Schedule.
4.10 The OR-RR receiving nurse should indicate the time when patient sent for
and time when patient is received direct form DEM.
5.0 REFERENCE:
Old OR Policy & Procedure
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 012
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
To ensure effective and safe transfer of patients from DEM to Operating
Room
3.0 POLICY:
All OR RN’s and DEM RN’s are responsible and accountable to ensure that
only FOR LIFE THREATENING CASES, EXTREME EMERGENCIES AND IN A
DISASTER SITUATION, patients can be brought directly to the O.R. from
Department of Emergency Medicine (DEM).
4.0 PROCEDURE:
4.1 The admitting / treating surgical team must discuss the case with the
on-call anesthetist that he / she agreed to do the case.
4.2 The admitting / treating surgical team must also arrange with the Blood
Bank for emergency blood required for the patient.
4.3 The O.R. nurse in-charge must be informed by admitting / treating
surgical team to prepare the room accordingly.
4.4 The DEM nurse must inform O.R. Nurse in Charge that the patient is
ready to be sent for O. R
4.5 The admitting / treating surgical team and anesthetist on-call must
accompany the patient to O.R. with the DEM nurses.
4.6 No patient’s valuables are to be sent with the patient to the O.R. The
Department of Emergency Medicine nurses are responsible for the
transferring of the patient’s valuables to the Admission Department.
6.0 REFERENCE:
KKUH Broad Policy and Procedure
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 013
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 Conditions:
All OR RN’s, Ward RN’s
2.0 Purpose:
To ensure safe and effective patient transfer from ward to O.R.
3.0 Policy:
3.1 All OR RN are responsible and accountable to ensure that:
3.1.1 All patients undergoing surgical procedures must be provided with a
safe, dignified and quality pre-operative care.
3.1.2 The correct patients information and criteria should be ensured and
met before surgery.
3.1.3 Receiving the right patient with the right diagnosis and right side of
operation prevents operating on the wrong patient and wrong site of
operation.
4.0 Procedure:
4.1 The receiving OR nurse welcomes the patient and introduces herself to the
patient.
4.2 The patient must be endorsed by the accompanying ward nurse to the
receiving OR nurse using the pre-operative checklist provided in the
patient’s blue file.
4.3 The following relevant points must be rigorously checked.
4.3.1 Identify patient by ID band on the right wrist against patient notes
and verbal confirmation if this is possible. For pediatric patient, ID
bands are placed in the right wrist and one in the ankle.
4.3.2 Ensure that all documentations, care plans, fluid and electrolyte
balance chart, medications and other relevant information regarding
the patient are endorsed.
NURS.OR- 013 RECEIVING OF PT. FOR SURGICAL PROCEDURES FROM WARDS & OTHER DEPT. Page 1 of 3
4.3.3 Check X-rays, MRI, Ultrasound results, Laboratory investigation
results, patient’s observation file, yellow file etc. are endorsed to the
receiving OR nurse.
4.3.4 Ensure that there is complete, signed and valid consent both written
in Arabic & English and also indicating the correct surgical
procedure, site of operation and it should be up to date.
4.3.5 The surgical operation site that is shaved (depending upon the type
of surgery), cleaned and clearly marked should be endorsed properly
to the receiving OR nurse.
4.3.6 The skin integrity must be endorsed and checked for any skin lesions,
allergies, infectious skin disease, pressure sores, scars etc.
4.3.7 Ensure that patient’s bladder is emptied and if drainage bag is in situ
then it should be emptied.
4.3.8 Ensure that there are no jewelries, ornaments and external prosthesis
on patients and if jewelries can’t be removed then it should be
secured properly with something that covers the skin and must be
endorsed to the receiving OR nurse.
4.3.9 Check that all IV lines should be endorsed properly with the
following important points.
4.3.10 Type of infusion, site of infusion, rate of infusion, IV pump in use,
medications incorporated in the piggy bag, the amount remaining
and IV with insulin therapy must be on IV pump.
4.3.11 For blood transfusion: type of blood, number of units given,
remaining units and cross-matched blood.
4.3.12 Pre-medications given and other medications required during the
surgical procedure must be endorsed to the receiving OR nurse.
4.3.13 Ensure that the patient must be on NPO as per surgical procedure to
be done and must be endorsed to the receiving OR nurse.
4.3.14 If the patient is an infected case, it should be notified before surgery
in advance and indicated in the submitted OR list of surgeons.
4.3.15 Ensure that the patient is in proper theatre attire and hair should be
fully covered with an OR cap most especially female patients and
undergarment should be removed depending upon the procedure.
4.4 Following the endorsement of the patient from wards to receiving OR nurse,
the patient is moved to the waiting / holding are in a safe and dignified
manner.
4.5 Patient must be covered properly and should not be exposed unnecessarily at
all times in the waiting / holding area.
4.6 Patient should be observed at all times and provide reassurance when there
is a delay of the surgical procedure by informing the patient at least every
15 minutes regarding the situation inside the theatre.
4.7 The patient should not be disturbed by any undue noise and a quiet
environment should be maintained at all times.
NURS.OR- 013 RECEIVING OF PT. FOR SURGICAL PROCEDURES FROM WARDS & OTHER DEPT. Page 2 of 3
4.8 The brakes of the trolley should be locked and the side rails are up all the
times.
4.9 All patients should be individually separated by cubicle curtains to ensure
dignity and privacy.
4.10 Female patient should not be in close proximity to male patients where this
is possible.
4.11 Mothers are asked and encouraged to stay with their children in the
receiving area but should be observed by the OR receiving nurse every now
and then.
6.0 REFERENCE:
6.1 Alexander’s Care of Patient in Surgery by Jane Rothrock
6.2 KKUH Broad Policy Guidelines
NURS.OR- 013 RECEIVING OF PT. FOR SURGICAL PROCEDURES FROM WARDS & OTHER DEPT. Page 3 of 3
KING SAUD UNIVERSITY
King Khalid University Hospital
You are requested to review the attached document(s) as there could be an effect or impact upon your
department if the action is initiated. Please sign if you concur (agree) with the document, date and
forward to the next person on the list. If you do not agree with the document, please provide an
explanation and send your written comments to the sender (initiating) department.
Concur Non-concur *
Concur Non-concur *
Concur Non-concur *
Concur Non-concur *
Concur Non-concur *
Concur Non-concur *
Concur Non-concur *
Concur Non-concur *
Concur Non-concur *
* Non-concurrence must forward written comments to the originating department/person.
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 014
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
OR RN’s
2.0 PURPOSE:
2.1 To ensure that the surgical consent is complete, signed and valid.
2.2 To ensure surgery for the right patient and with the right side.
2.3 To promote and ensure the utilization of ethical processes of surgery that is
competent and legal.
3.0 POLICY:
3.1 All OR RN’s are responsible and accountable to ensure that:
3.1.1 Patient above 15 years have signed for the surgical consent.
3.1.2 If the patient is below 15 years the consent should be signed by the
next kin: father, mother, guardian or any immediate family member.
3.1.3 High risk consent must be signed by 2 consultants.
4.0 PROCEDURE
4.1 OR receiving nurse must ensure that the surgical consent is signed and up to
date in both English and Heijra Calendars.
4.2 OR Receiving nurse must ensure that the correct surgical procedure is clearly
indicated and written legibly in both Arabic and English.
4.3 OR Receiving nurse must ensure that the right surgical procedure and the site of
surgery is clearly specified in the surgical consent form. The operation site must
be clearly marked and the ward nurse should endorse to the OR receiving nurse.
4.4 OR Receiving nurse must ensure that the surgical consent is witnessed by 2
witnesses; the doctor who explained the procedure and who has the consent and
any nursing staff or HCA.
4.5 If the patient is conscious and alert; OR Receiving nurse must confirm with
patient who signed the consent.
4.6 If the patient is unconscious, the OR Receiving nurse must ask with endorsing
Ward nurse in order to confirm who signed for the surgical consent.
4.7 In case of extreme emergency with the inability of patient to sign for the
surgical consent and the unavailability of the next of kin, two consultants can
sign for the surgical consent (it could be one surgical consultant and one
anesthesia consultant or other consultants or doctors as appropriate for the
department.
4.8 Patients with high risk consent must be clearly endorsed by the ward nurse to
the OR Receiving nurse.
6.0 Reference:
6.1 KKUH Broad Policy & Procedure
6.2 O.R. old Policies & Procedures
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 015
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
1.1 All OR RN’s
1.2 All OR Porters
2.0 PURPOSE:
2.1 To maintain the patient’s dignity at all times.
2.1.1 During transportation to & from the ward.
2.1.2 In the waiting area (O.R. Reception Area)
2.1.3 During transportation from the Reception Area to the Theatre.
2.1.4 Inside the theatre during surgery.
2.1.5 During transportation from theatre to R.R.
3.0 POLICY:
3.1 All OR RN’s are responsible and accountable to ensure:
3.1.1 Patient’s dignity is maintained at all times.
3.1.2 Patient’s psychological and cultural needs are met.
4.0 PROCEDURE:
4.1 All patients for surgery must be dressed in the designed O.R. surgical
apparel with O.R. cap / head cover.
4.2 Female patient must be fully covered including their face during
transportation to and from the O.R.
4.3 Female O.R. Nurse must always be present with female patients.
Female patient must not be left unattended unless she is with a female
anesthesia technician.
4.4 No physical examination of patient must be done in the waiting area.
4.5 All medical staff and O.R. personnel must ensure that patients are not
exposed unnecessarily during physical examination, positioning and skin
prepping in the theatres.
4.6 The presence of male O.R. and medical personnel in the theatres must be
limited to those whose presence is absolutely necessary for female patient
until anaesthetized. Male Anesthesia technician must be allowed inside
the theatre prior to induction.
4.7 The rest of the male medical team and students must be allowed inside
the theatre after the female patient is completely draped.
4.8 The Charge Nurse must have the authority to limit the number of male
personnel entering the theatre during surgery on female patients.
4.9 Conversation and noise inside the theatres must be kept into a minimum.
There must be no comments made regarding patients in both O.R. & R.R.
4.10 Male and female patients must be kept separate in the Reception Area /
Recovery Room when possible.
4.11 Once female patient has recovered from anesthesia and she is fully
conscious, her face must be covered when she is transferred back to the
ward.
5.0 REFERENCE:
5.1 KKUH Broad Policy Guidelines
5.2 AORN Best Practice Guidelines
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 016
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. RN’s
2.0 PURPOSE:
To ensure safe transfer and transport of surgical patients in O.R.
3.0 POLICY:
All OR RN are responsible and accountable to ensure safe transfer and transport of
surgical patients using a roller or without.
4.0 PROCEDURE
4.1 Raise the OR table one or two (1-2) inches higher than the surgical stretcher, to
prevent back strain. Ensure surgical stretcher is locked into place. Use the lift
that was placed under the patient pre-op. The lift sheet should be placed to
extend from above the patient’s elbows to below the buttocks. If the lift is soiled
or wet, i.e., Betadine, blood it must be changed.
4.2 The Anesthetist / Anesthesia Technician will support the patient’s head and
neck. OR circulating nurse on both side of the patient and the patient’s feet.
4.3 Grasp the sheet close to the patient’s body.
4.4 The Anesthetist / Anesthesia Technician will coordinate the transfer. OR
personnel on both side of the patient will ensure the OR table and trolley do not
move.
4.5 Once the patient is moved to the surgical trolley, raise both side rails, lock in
place. Cover patient with a warm blanket. Place safety strap across the patient’s
legs above the knees.
4.6 Position any IV’s, Foley bag or drainage bags onto the trolley for transportation.
4.7 Raise head of bed, per Anesthetist request.
4.8 Anesthetist and Circulating RN will take patient to R.R. or ICU.
5.0 REFERENCE:
Alexander’s Care of Patient in Surgery by Jane Rothrock. 12th Edition.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 DEFINITIONS:
Surgical Attire – Non – sterile apparel designated for the OR practice setting
that includes 2 piece pant suits, head covering, O.R. clogs, mask and other
protective cover.
3.0 PURPOSE:
3.1 Surgical attire provides a barrier between personnel and between
patient and patient and personnel, through which contamination
may pass.
3.2 Surgical attire also provides protection for personnel against
exposure to infectious microorganisms and hazardous materials.
4.0 POLICY:
All nursing staff who enter the semi-restricted and restricted areas of the
Operating Room’s surgical theatres should wear freshly laundered
surgical attire or scrub suit intended for use only within the surgical areas.
5.0 PROCEDURE
5.1 All nursing personnel entering semi-restricted and restricted areas of the
surgical suite shall be in operating room attire.
5.1.1 Operating Room attire consists of standard reusable woven fabric
or single-use non woven scrubs and surgical hat or hood. All
attire show be low-linting.
5.1.2 OR attire which is soiled or wet shall be changed.
5.1.3 All reusable attire shall be laundered after each use, by a laundry
facility approved and monitored by the hospital.
5.1.4 OR attire shall be stored in an enclosed cupboard.
5.1.5 A cover gown or lab coat is to be worn whenever leaving the
surgical suite.
5.2 All head and facial hair is to be covered while in the restricted areas of
the surgical suite.
5.2.1 The surgical hat or hood is to be clean, free of lint and confine the
hair. The surgical hat or hood is changed daily. Reusable hats or
hoods shall be laundered after each use, by the laundry facility
approved and monitored by the hospital.
5.3 All nursing personnel entering the restricted area of the surgical suite
are to wear closed-toe and heeled non-fabric shoes. Clogs of fabric-
constructed shoes are prohibited.
5.3.1 Shoe covers shall be worn if it is anticipated that splashes or spills
will occur.
5.3.2 When shoe covers are worn, they are to be changed whenever
torn, soiled or wet. Shoe covers are to be removed whenever
leaving the surgical suite.
5.4 Nursing staff who are not “scrubbing in” shall wear long sleeved jackets.
Jackets are to remain closed (buttoned).
5.5 All Nursing Services personnel shall wear high filtration masks in the
surgical suites.
5.5.1 Masks shall be worn at all times in the surgical suites and the
other areas where open sterile supplies or scrubbed personnel are
located. Masks shall cover the nose and mouth and shall be
discarded whenever removed.
5.6 Face shields or goggles/glasses shall be worn when splashing or spraying
is anticipated.
5.6.1 Face shields/goggles/glasses that become contaminated shall be
disposed of or decontaminated, as appropriate
5.7 Personal jewelry worn in the surgical suites shall be limited to the
following:
5.7.1 Watch
5.7.2 Bracelets – none
5.7.3 Necklace – one (1) small single chain
5.7.4 Earrings – small studs; all other earrings worn are to be
contaminated within a cap at all times
5.7.5 Rings – wedding set only or one (1) ring per band.
5.8 All Jewelry (rings and watches) is to be removed prior to hand washing/
scrubbing; all other jewelry shall be totally confined within scrub attire
or removed
5.9 Fingernails should be kept short (less than one-quarter (¼) inch in
length) and well maintained. No artificial fingernails or extenders.
6.0 REFERENCE:
Association of Perioperative Registered Nurses (AORN), Perioperative
Standards and Recommended Practices, 2008 Edition.
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 018
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
Applicable to all O.R. RN’s
2.0 PURPOSE:
2.1 To document all nursing activities performed which is legally and
professionally important for clear communication as well as collaboration
with the surgical team and for continuity of care.
2.2 To encode in the HIS Theatre Management Menu foe statistics purposes.
3.0 POLICY:
All OR RN’s should be responsible and accountable for the completion of
perioperative documentation which is essential for the continuity of goal directed
care and for comparing achieved patient outcomes to expected patient outcomes.
4.0 Procedure
4.1 The circulating RN will accurately document all care given to the patient from
the time the patient arrives in the operating room to the time of transfer to the
PACU or patient care unit.
4.2 The Circulating RN will verify and document the following information:
4.2.1 Preoperative diagnosis prior to surgery
4.2.2 Preoperative patient assessment
4.2.3 Patient skin condition on arrival and discharge
4.2.4 Disposition of glasses, dentures, hearing aids, etc. i.e. patient direct to
O.R.
4.2.5 Postoperative diagnosis after completion of procedure
4.2.6 Surgical procedure performed
4.2.7 Procedure/ site identified by the surgical team before incision (time
out)
6.0 REFERENCE:
AORN Standards Recommended Practices and Guidelines 2008 Edition.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
NOTE:
Nursing Operative Data (N.O.D.) - Data entered / encoded to theatre management menu
(HIS) Nurse, logbook, statistic etc. can be retrieved through HIS.
1.0 CONDITIONS:
OR HIS Nurse.
2.0 PURPOSE:
To ensure maintenance of the Surgical Logbook.
3.0 DEFINITIONS:
Logbook: All the patient information operative procedure written and other
important data written in the NOD is encoded in the HIS.
4.0 POLICY:
4.1 OR HIS Nurse is responsible and accountable to ensure that a copy of the
operative record of all procedures done in the operating room or done in
another area of the hospital by Surgical Services personnel will be
maintained in the Surgical Logbook.
5.0 PROCEDURE:
5.1 The following information will be included for all procedures:
5.1.1 Medical record number
5.1.2 Patient name
5.1.3 Sex of patient
5.1.4 Date of birth
5.1.5 Surgeon
5.1.6 Assistant surgeon, if present
7.0 REFERENCE:
7.1 International Code of Disease ICD – 9-CM
7.2 KKUH Computer Department Guidelines
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. and R.R. RN’s
2.0 DEFINITION:
2.1 Controlled Drugs – regulated by law with regard to possession and
use of drugs.
2.2 Controlled drugs are the following:
2.2.1 Fentanyl
2.2.2 Sufentanyl
2.2.3 Morphine
2.2.4 Pethidine
2.2.5 Hydromorphone Hydrochloride, etc
3.0 POLICY:
All OR RN’s and RR Nurses are responsible and accountable to ensure safety
of Controlled Drugs inside the O.R. Department.
4.0 PROCEDURE:
4.1 Scheduled drugs shall be locked within a secured area. (Drug Room near
Dumb Waiter)
4.2 Only authorized personnel shall be given access to locked areas.
(HN/CN/Designee)
4.3 Access to operating room theatres shall be strictly limited to authorized
individuals. (O.R. nurses, anesthetists, technicians)
4.4 Non-controlled medications on top of or in an anesthesia cart located in
an opening room suite or in a labor and delivery suite must be secured.
The areas are considered secured when these areas are staffed and staffs
are actively providing patient care.
5.0 REFERENCE:
5.1 Comprehensive Drug Abuse Prevention and Control Act of 1970
5.2 CMS Hospital Conditions of Participation Final Rule, Effective January
26, 2007, Section 482.25
5.3 American Society of Hospital Pharmacists, Technical Assistance
Bulletin on Hospital Drug Distribution and Control, American
Journal of Hospital Pharmacy,1980;37:1097-103,
http://www.ashp.org/s_ashp/bin.asp?CID=6&DID=5463&doc=file.
pdf
5.4 Security of Medications in the Operating Room, American Society of
Anesthesiologists Position Statement, Approved by the ASA Executive
Committee,October2003,
http://www.asahq.org/clinical/LockedCartPolicyFinalOct2003.pdf
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. RN’s
2.0 PURPOSE:
2.1 T o ensure patient’s safety all counts must be performed in all procedures in
order to account for all items and to lessen the potential for patient’s injury
as a result of any retained foreign body.
2.2 To count accurately throughout the surgical procedure thereby, the surgical
team should consider its importance in order to minimize the risks of
retention of items which they can be held liable.
2.3 To define all items to be counted not only on the 3 categories like sponges,
sharps instruments, etc but also during the times when counts must be done
and when documentation is required.
3.0 DEFINITIONS:
3.1 Instruments – are surgical tools – for cutting, dissecting, grasping, holding,
retracting & suturing.
3.2 Sharps – are items with edges or points capable of cutting or puncturing. i.e.
suture needles, scalpel blades, hypodermic needles, electro-surgical needles
and blades.
3.3 Sponges – soft goods (gauze pads; cottonoids, peanuts, dissectors, tonsil and
laparotomy sponges).
4.0 POLICY:
All OR RN’s are responsible and accountable to ensure the following:
4.1 Count Policy Guidelines should be applied effectively in counting swabs,
instruments, needles, peanuts, loops nylon tapes, bulldogs, blades etc.
4.2 Counts must always be done with a second person and NEVER BY THE SCRUB
NURSE ALONE. The scrub and the circulating nurse should count all items in
unison and aloud. Counting should not be interrupted.
Minimum count for any operative procedures must be three:
NURS.OR- 021 ITEM COUNTS Page 1 of 5
4.2.1 Before the beginning or start of operation as a baseline.
4.2.2 Before any closure begins.
4.2.3 When skin closure is begun.
However the scrub nurse is entitled to do as many counts where he / she thinks
is required.
4.3 If any uncertainty exists about a count, it should be repeated.
4.4 The circulating nurse should immediately record the count for each type of item
on the count board.
4.5 If additional sponges, instruments, sharps, or other items are dispensed during
the procedure, they are similarly counted and the circulating nurse must record
the quantity added.
4.6 The name of the circulating nurse should be recorded in the NOD as soon as
each count is completed.
4.7 Additional counts should be performed whenever there is a change / relief in
scrub nurse.
4.8 Once items are counted, linen or trash bags should not be removed from the
theatre until the procedure is completed and the patient is taken out of the
theatre.
4.9 Additional counts should always be undertaken before a cavity within a cavity is
closed. Ex. when uterus is closed in caesarian sections.
4.10 X-ray detectable sponges / swabs should never be used for dressing to avoid the
appearance of a retained item or post-op x-ray studies.
4.11 Used needles should be kept in a needle pad or container to facilitate counting
and to ensure their containments on the table.
4.12 Count Procedures must be the same standard practice in every theatre
irrespective of sub-specialty.
5.0 PROCEDURE:
5.1 Instruments are checked by the scrub nurse with instruments checklist in the
tray and the circulating nurse will record any discrepancies and report to CSSD
technicians / supervisor immediately. The scrub nurse must sign the packing
list at the end of the operation.
5.2 Swabs are counted by the scrub nurse and circulating nurse. Each type and size
of sponge should be kept separate from the other types. The circulating nurse
who did the count must be the one to record it on the board.
5.3 Needles, nylon tapes, blades, loops, peanuts, tonsil swabs, kitners, patties,
bulldogs, screws must be treated the same and recorded on the board by the
circulating nurse who did the count.
5.4 All swabs 4x4, 30x30, 45x45, peanuts, tonsil swabs, patties during an operation
must be translucent and never be out and used for any other purpose.
5.5 If a package of sponges is dispensed to the field with incorrect quantity or
number of sponges it should be handed off the field in its entirety, not to be
included in the bagged, labeled, and isolated counts but to be given to the Head
Nurse for Quality Control purposes.
5.6 During surgery the scrub nurse should discard soiled sponges into a plastic
lined bucket. The circulating nurse must separate and place it around the edge
of the kick bucket.
All the rest of the items: needles, blades, nylon tapes etc. are counted as one of each. Once
the required numbers of each different swab are in the kick buckets, the circulating nurse
must count them with the scrub nurse. There must be no extra or other type of swab in
the kick bucket during the count.
5.7 The checked swabs must be tied together, put in plastic bag kept in one place in
the theatre until the end of the operation. The counted and bagged swabs must
be crossed off and initial of the nurse who did the check must be on both the
bag and the board.
5.8 No items must be removed from the theatre during the operation unless the
scrub nurse is aware and has given his / her approval.
5.9 The scrub nurse should inform the circulating nurse for any swab kept inside
the cavity while the operation is going on and should be written on the board
and cross off when the swab is removed to avoid discrepancies during the
counting. The scrub nurse must always be aware of the number of swabs and
instruments in the operating field at all times.
5.10 As the first layer of closure is begun, the scrub nurse and the circulating nurse
should start the count consecutively, proceeding from the sterile field to the
back table and then to the bagged sponges off the field. The scrub nurse should
inform the surgeons of the results of the count.
5.11 If any item which is part of the count is missing the surgeon must be informed
immediately. A thorough search for the item must be carried out.
5.12 The surgeon has to re-examine the wound and if still not found, the patient
must be x-rayed to exclude the possibility of the item being inside the wound.
5.13 The HN / designee at the time must be informed immediately and if the item is
still unaccounted for, an incident form should be completed by all staff nurses
working in the room. This must be recorded in the nursing operative data.
5.14 Change of scrub nurse must be done only in exceptional circumstances and not
as a routine; the relieving scrub nurse must do a complete count with the
circulating nurse. All items must be accounted for before the change of scrub
nurse takes place. Surgeon should be informed when a change of scrub nurse
will commence.
5.15 Discrepancy in the count must be recorded in the Nursing Operative Data.
Counts must be done during all procedures, however listed below are the
operating procedures where it is not absolutely necessary to do a final count:
5.15.1 Closed endoscopic procedures
5.15.1.1 Cystoscopy / Urethroscopy
5.15.1.2 TURP
5.15.1.3 Insertion / Removal of DJ and Ureteric catheter
5.15.1.4 Arthroscopy only
5.15.1.5 Bronchoscopy only
5.15.1.6 Gastroscopy only
5.15.1.7 Sigmoidoscopy only
5.15.2 Procedures where there is superficial incision / no incision
5.15.2.1 Circumcision
5.15.2.2 Repair of Hypospadias
5.15.2.3 Skin Grafting
5.15.2.4 Dermabrasion
5.15.2.5 Removal of Sutures
5.15.2.6 IV Cutdown only
5.15.2.7 Liposuction
5.15.2.8 Operation on Ear Lobe / Lip/ Eyelids
5.16 In procedures that may require the use of high volume of needles, the scrub
nurse can count any filled needle pad with the circulating nurse and hand it off
the field. The circulating nurse should then bag, sign and label it with the
number of needles contained.
5.17 Broken needles and cut nylon tapes during the procedure must be accounted for
in their entirety.
5.18 Raytec gauze (lap sponges) used for wound packing.
When the surgeon has to leave raytec gauze (lap sponge) to pack thewound for
hemostasis, it must be clearly documented in the nursing operative data,
specially the type and number of gauze (lap sponge) left inside the wound. The
surgeon has to sign the NOD (Nursing Operative Data) and the person-in-
charge of the operating room must be informed. The ICU /Ward nurse must
also be informed during the handover of the patient.
7.0 REFERENCE:
7.1 AORN RECOMMENDED PRACTICES
7.2 Pocket Guide to the Operating Room by Maxine A. Goldberg
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 022
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe & proper preservation, documentation & reporting of physical proofs
or evidences.
3.0 DEFINITIONS:
Physical evidence, i.e., bullets, fragments and drugs
4.0 POLICY:
All OR RN’s are responsible and accountable to ensure a chain of custody is
established for physical evidence so that it may be used by law enforcement
agencies.
5.0 PROCEDURE:
5.1 The scrub nurse will pass the evidence to the Circulating RN.
5.2 Do not handle bullets in metal instruments is possible. Metal instruments will
scratch the bullet.
5.3 Place bullet in non-metal specimen container after removal from the patient.
5.4 Submit bullets to law enforcement per local and state regulations.
5.5 Patient’s personal belongings (ongoing criminal investigation:
5.5.1 Place all patient items in a paper bag for those cases that are involved in
an ongoing criminal investigation.
5.5.2 Label belongings with patient’s identification information.
5.5.3 Clothing removed from a patient shall be cut along the seams around
bullet hole(s) or stab wound hole(s).
6.0 REFERENCE:
Pocket Guide to the Operating Room by Maxine A. Goldman
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. Personnel entering the theatres and Restricted Areas, All O.R. Registered
Nurses, Surgeons, Anesthetists, Technicians, etc
2.0 PURPOSE:
2.1 To ensure safe and effective procedure for establishing and maintaining a
sterile field in which surgery can be performed safely.
2.2 To prevent contamination of the open wound, isolate the surgical site from
the surrounding unsterile environment, and create a sterile field. Should be
opened, dispersed and transferred by methods that maintain sterility and
integrity. Ex. Wrapped edges should be secured when presented to a sterile.
3.0 POLICY:
All OR Registered Nurses are responsible and accountable in ensuring proper
adherence to the principles of Aseptic technique eliminates or minimizes modes and
sources of contamination hereby prevent surgical site infection.
4.0 PROCEDURE:
4.1 Items used within a sterile field should be sterile.
Rationale:
All materials is in contact with the wound and used within the sterile field must
be sterile. Sterilization provides the highest level of assurance that an item is
devoid of viable microbes.
4.2 All items presented to the sterile field should be checked for proper packaging,
processing, moisture, seal integrity, package integrity, expiry date and the
appearance of sterilization chemical indicator.
Rationale:
The inspection of packaging helps ensure that only sterile items are presented
to the sterile field. Items of doubtful sterility must be considered
unsterile.
Rationale:
When opening sterile supplies, circulating nurse should open the wrapper flap
farthest away from the first and the nearest wrapper last, to prevent
contamination by passing as unsterile arm over a sterile item.
4.3.1 Items should not be tossed onto a sterile field because they may roll off
the edges and become contaminated, displace other items or penetrate
the drape.
Rationale:
Good judgment must be used when presenting items to the scrubbed
person or by placing them securely on the sterile field.
4.4 All scrubbed personnel should wear sterile gowns, and gloves.
Rationale:
Sterile gowns established a barrier that minimizes the passage of
microorganisms between sterile and non-sterile areas.
4.5 Sterile gowns should be considered sterile in front from chest to the level of the
sterile filed, and the sleeves should be considered unsterile from 2 inches above
the elbow to the stockinet cuff.
Rationale:
The cuff should be considered unsterile because it tends to collect moisture
and it is not an effective bacterial barriers.
Areas of the gown considered unsterile are the following:
4.5.1 neckline
4.5.2 shoulders
4.5.3 under the arm
4.5.4 back
4.6 Sterile drapes are used to create a sterile field.
Rationale:
Sterile surgical drapes establish aseptic barriers minimizing the passage of
microorganisms from non-sterile to sterile area. Sterile drapes should be placed
on the patient and equipment to be included in the sterile field leaving
the incisional site expose.
4.6.1 Sterile drapes should be handled by scrubbed personnel only and
handled as a little as possible.
Rationale:
The movement of sterile drapes from clean to dirty areas helps prevent
contamination.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. RN’s
2.0 PURPOSE:
To ensure the disinfections of hands and arms of the O.R. Nurses
3.0 DEFINITIONS:
3.1 Skin – is a major potential source of microbial contamination in the
surgical environment.
3.2 Surgical Hand Antisepsis – refers to the antiseptic hand rub or wash
performed before donning sterile scrub attire to eliminate transient
bacteria.
3.3 Antiseptic Agent – Anti microbial substance applied to the skin to
reduce the number of microbial flora.
4.0 POLICY:
All OR Surgical Scrub Team should disinfect their hands and forearms
and then, don on sterile gown and gloves prior to performance of any
surgical procedures.
5.0 PROCEDURE:
5.1 All surgical scrubs should be 5 minutes scrubs.
5.2 Remove all jewelries on your hands and wrists. Fold the sleeves above the
elbow.
5.3 Turn water on and adjust for the temperature and make sure the water
does not splash. (Note: New Scrub ware sink has automatic sensor.
5.4 Wet arms to elbow thoroughly and always hold hands above the level of
the elbow and away from the body so that contaminated water cannot
run from elbows to hands, the hands being the cleanest.
6.0 REFERENCE:
6.1 AORN Recommended Practice Guidelines No. 8 Edition
6.2 KKUH, Infection Control Manual
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. Scrub Nurses
2.0 PURPOSE:
To ensure maintenance of a sterile field by covering areas of the body and
clothing with a sterile barrier
3.0 POLICY:
All OR scrub nurses after performing theatre Surgical Hand Scrubbing should
done on sterile gown and gloves prior to performance of any surgical
procedure.
4.0 PROCEDURE:
4.1 Open the sterile gown and glove package on designated flat surface in
prescribed manner.
4.2 With your hands above the level your waist, approach the table where
gown and gloves have been prepared and pick up the sterile towel
touching only the sterile towel and step back. Allow the towel to fall
open.
4.3 Start with one end of the towel, dry one hand and arm stopping 2 inches
above the elbow. Note: When drying hands, do not go over areas already
dried.
4.4 Invert the towel and with the other end, dry the other hand and arm,
bend forward slightly to prevent any part of the towel from coming in
contact with your scrub suit.
4.5 When both hands and arms are dry, discard the towel properly.
4.6 For unassisted Gowning. Grasp the pre-fold sterile gown by the neckline
with both hands and step back from the table into an unobstructed area.
4.7 Hold the folded gown with the inside toward you, locate the neckline of
the gown and hold the gown with both hands allowing the gown to
unfold infront of you.
5.0 REFERENCE:
Alexander’s Care of Patient in Surgery by Jane Rothrock. 12th Edition.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. scrub nurses who scrub and assist for the surgery
2.0 PURPOSE:
To ensure safe and effective assistance to another member of the sterile team don
sterile gown and gloves prior to the start of a procedure.
3.0 POLICY:
Other members of surgical scrub team should be assisted by the scrubbed person
(usually scrub nurse) in gowning and gloving prior to the performance of any surgical
procedures.
4.0 PROCEDURE:
4.1 Gowning Another Member of the Surgical Scrub Team
4.1.1 Open the sterile towel and hand it across the palm of the team member
being gowned.
4.1.2 Unfold the gown carefully, hold at the neck pad so that the inside the
gown faces the wearer.
4.1.3 Keep gloved hands covered by the outside gown shoulders; place the
gown on the arms of the wearer, as he or she slips into the sleeves of the
gown and push up toward the shoulders.
4.1.4 Release the gown at shoulder height and adjust the sleeves in preparation
for assisted open gloving.
4.1.5 The circulator assists with the gowning procedure by pulling the gown
onto the shoulders from the inside of the gown and securing the back of
the gown by fasteners at the neck and waist from the inside.
4.1.6 Gloving Another Member of the Surgical Scrub Team
4.1.7 Pick up the right glove, grasp it firmly with fingers under the everted
cuff and present it so that the thumb and palm are facing the wearer.
Announce the hand to be gloved.
4.1.8 Stretch the cuff sufficiency to allow hand access while protecting your
gloved hand and apply resistance while the wearer pushes hand into the
glove.
4.1.9 Release the cuff.
4.1.10 Present the left glove in the same manner. The wearer assists by
stretching the cuff with the index finger of his or her gloved hand.
4.1.11 Apply resistance as needed; then release the cuff.
4.1.12 Offer a damp towel to remove powder from gloves, and discard towel
after use.
5.0 REFERENCE:
5.1 Alexander’s Care of Patient in Surgery by Jane Rothrock. 12th Edition
5.2 Pocket Guide to the Operating Room by Maxine A. Goldman
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 027
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
1.1 All O.R. RN’s (Circulating & Scrub Nurses)
1.2 All Surgical Areas RN’s
2.0 PURPOSE:
2.1 To ensure skin is prepared aseptically before the operation or any
invasive procedures.
2.2 To reduce the risk of surgical site infection by removing transient
microorganisms.
3.0 DEFINITIONS: .
Antiseptic – is a product with antimicrobial activity capable of producing
antisepsis.
4.0 POLICY:
All OR Nurses are responsible and accountable to ensure that the surgical site &
surrounding areas should be clean and free from soil, debris and transient
microbes before applying antiseptic agent.
5.0 PROCEDURE
5.1 The patient’s surgical site shall be assessed for moles, warts, rashes or other
conditions prior to skin preparation and will be documented.
5.2 Hair Removal:
5.2.1 Hair at the surgical site shall be removed only if it will interfere with
the procedure.
5.2.2 Only Personnel trained and skilled in skin preparation techniques
shall prepare the surgical site.
5.2.3 Hair removal shall be completed as close to the surgery time as
possible.
5.2.4 Razors shall NOT be used in this hospital except for some cases.
5.2.5 Patients shall not be instructed NOT to self –shave pre-operatively.
5.2.6 Hair removal shall not be performed in the surgical suite to prevent
contaminating the surgical site and surgical field except for the
following conditions:
Based on practice in Neuro Theatre, the male patient is shaved which
is done inside the theatre.
For some GS surgeons new protocol in shaving can be done inside the
theatre.
5.2.7 An electric clipper, with disposable or reusable head, or a depilatory
cream if available may be used for shave preps. Disinfect reusable
shaver heads between patients.
5.2.8 Nursing Staff shall be trained on the correct use of clippers.
Note: If patient’s hair is removed for head surgery, save the patient’s hair,
placing it in a bag labeled with the patient’s information. The hair
will be returned to the patient/family upon discharge.
5.3 Skin Cleansing and Surgical Prep:
5.3.1 Skin cleansing shall be done before the surgical skin prep.
5.3.1.1 The patient shall clean the area by showering, shampooing
or washing the surgical site area with an antiseptic agent
the night before the procedure, if able.
5.3.1.2 The surgical team may wash the surgical area, prior to
prepping the skin with an antiseptic agent
5.3.2 An antimicrobial agent with a broad-spectrum germicide action will
be used for the surgical prep.
5.3.3 The surgical skin prep (with the antimicrobial agent) will be
performed using sterile supplies, i.e., sterile gloves, sterile 4x4s,
sterile sponge stick, sterile towels.
5.3.4 Always begin the skin prep from the surgery site, continuing to the
periphery. Discard all prep sponges once the sponge reaches the
periphery of the surgical area.
5.3.5 Areas of high microbial counts, i.e., pubis, open wounds, shall be
prepped last.
5.4 Skin preparation for contaminated area differs. If possible, contaminated
areas are sealed off with a towel or sponge, while remaining skin areas are
scrubbed. The most contaminated area is scrubbed last with separate sponges
which are discarded after one-time use.
The following areas within the operative area are considered contaminated:
5.4.1 Umbilicus
5.4.2 Stoma
5.4.3 Draining of sinuses
5.4.4 Skin Ulcers
5.4.5 Vagina
5.4.6 Anus
5.4.7 Traumatic wounds
Note:
GS protocol for patient’s undergoing abdominal procedure, cleaning
of umbilicus is done in the ward and to be double checked inside the
theatre before skin surgical prepping is done.
5.5 Do not allow prep solution to pool around or underneath the patient or
under any equipment on the patient, i.e., electrodes, electro-surgical unit
grounding pad.
5.6 Allow prep solutions ample contact time before applying the sterile drapes.
(This helps achieve optimal effect of the prep solution).
5.7 If using flammable antiseptic prep solutions, allow time for complete
evaporation of the solution before draping, to decrease the risk of fire.
5.8 Do not allow flammable prep solutions to be absorbed into the drapes that
are in direct contact with the patient.
5.9 As part of the “time out” procedure, the surgical team shall ensure that:
5.9.1 The surgical site is dry before draping and before the use of the
electosurgical unit, cautery and/or laser.
5.9.2 There is no pooling of the prep solution around the patient.
6.0 REFERENCE:
6.1 Association of periOperative Registered Nurses (AORN), Perioperative
Standards and Recommended Practices, 2008 Edition
6.2 CMS, Memorandum: Use of Alcohol-Based Skin Preparations in
Anesthetizing Locations, January 12, 2007
6.3 CDC, Guideline for Surgical Site Infection, 1999
KING SAUD UNIVERSITY
King Khalid University Hospital
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Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 028
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
2.1 To ensure proper disposition of specimens taken from patient during and
after surgery.
2.2 To ensure all specimens collected are sent to specific laboratories for study in
which some results may be important for proper diagnosis and treatment of
patient’s disease.
3.0 POLICY:
3.1 All OR RN’s are responsible and accountable to ensure the following:
3.1.1 All fresh and dry specimens must be sent to the laboratory
immediately with the correct laboratory form completed by the
surgeon. O.R. circulating nurse in the theatre must enter the
specimen in the specimen registry book and then, send it to the
laboratory.
3.1.2 O.R. nurses must ensure that all instructions given by surgeons
regarding specimens collected are understood clearly, labeled
legibly in the specimen container and documented properly in the
NOD (Nursing Operative Data).
3.1.3 O.R. nurses assigned in the Reception Area are responsible in recording
all the specimens in the Specimen Book and sending them to the
respective laboratories.
3.1.4 Specimens sent to the laboratory must be recorded in the correct
specimen book in according to the type of specimen i.e. fresh
specimens, frozen sections, microbiology, cytology etc. Specimens must
be sorted accordingly.
3.1.5 The O.R. Reception Nurse and the O.R. porter must both write their
complete names and sign the specimen book.
3.1.6 The laboratory Receiving Technician must write his / her complete
name and sign the Specimen book after receiving the specimens.
4.0 PROCEDURE:
4.1 HISTOPATHOLOGY
4.1.1 O.R. nurses must discuss and follow instructions of surgeons regarding
specimens for histopathology and must be recorded in the NOD
(Nursing Operative Data).
4.1.2 The scrub nurse must ask permission from surgeon before passing any
specimens off from the sterile field to the Circulating Nurse.
4.1.3 The Circulating Nurse must receive the specimen in an appropriate
size specimen container and pour 10% Neutral Buffered Formalin by
asking first the surgeon.
4.1.4 Each specimen must be placed in a separate container and labeled with
the patient’s name, patient’s record #, date, time, surgeons name and
the type of specimen. Each specimen must be labeled in sequence by
indicating the number in the specimen container and the laboratory
request form. i.e. Specimen # 1, Specimen # 2.
4.1.5 Small specimens or small biopsies must have a fixing volume about
x10 the specimen size and about x5 for larger specimen / biopsies.
4.1.6 Larger specimens must not be forced into the container as this causes
poor fixation and distortion of tissue morphology but it must be placed
in an appropriate size container.
6.0 REFERENCE:
KKUH Laboratory Specimen Manual
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. Registered Nurses, All Housekeeping Staff
2.0 PURPOSE:
2.1 To ensure a clean environment for surgical patients.
2.2 To minimize health care workers and patients exposure to potentially
infectious microorganisms.
3.0 POLICY:
All OR RN’s are responsible and accountable to ensure the following:
3.1 To maintain and provide an optimum aseptic environment inside the
theaters.
3.2 Every morning before theatres are used, all OR lights, OR tables,
equipment and furniture surfaces, exposed shelves and kick buckets are
wiped down with damp cloth using disinfectant solution.
3.3 Terminal as well as cleaning of the theatres in between cases are the
responsibilities of the OR housekeeping staff with the supervision of the
OR nursing staff.
3.4 All walls in the Operating theatres are to be washed down, floors to be
scrubbed and high cleaning to be done weekly during Thursdays and
Fridays.
3.5 No delicate equipment and inside the cupboards are to be cleaned by
housekeeping.
4.0 PROCEDURE
4.1 Prior to first scheduled procedure of the day:
4.2 Inspect and check theatre for cleanliness and orderliness for any visible dust,
dried blood and / or debris.
4.3 Damp dust as necessary all countertops of all equipments and furniture
using surface disinfectant.
4.4 During The Procedure:
5.0 REFERENCE:
5.1 Old OR Policies and Procedures
5.2 Infection Control Manual
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Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 030
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
To ensure patient safety by providing scopes and scope instrumentation sets that
have been properly sterilized or disinfected according to the KKUH Infection Control
Department during endoscopic procedures.
3.0 POLICY:
3.1 The O.R. Nursing Staff and other nursing staff assigned in different
specialties using scope sets are responsible and accountable to ensure pre-
cleaning of the scopes and other instrumentation before sending to CSSD for
sterilization.
3.2 Rigid scopes must be cleaned and processed according to the Infection
Control Policy Guidelines.
3.3 Clean flexible scopes are to be hanged in the scope cabinet or kept in the
scope case.
4.0 PROCEDURE:
4.1 RIGID SCOPES
4.1.1 After each case separate all assembled components of scopes then, clean,
flush the scopes with soap and water by using brush.
4.1.2 Soak in Cidex for at least 30 minutes for the next case.
4.1.3 Rinse thoroughly with sterile water and flush all the channels with
sterile water using a bladder syringe.
4.1.4 Dry it with 30 x 30 lap sponge and keep it ready for use in the sterile
trolley.
4.1.5 At the end of the day or after all the cases, clean and flush the scopes
with soap and water with the use of the cleaning brush.
4.1.6 Blow and dry the scopes with medical air and then, pack and send to
CSSD for sterilization.
4.1.7 For infected cases, rinse the scope in running water then; soak in Cidex
for one hour. Rinse again and clean with soap and water using the
cleaning brush. Blow, dry and pack then, send to CSSD for reprocessing.
5.0 REFERENCE:
5.1 Old O.R. Policies and Procedures
5.2 Alexander’s Care of Patient in Surgery by Jane Rothrock
5.3 Pocket Guide to the Operating Room by Maxine A. Goldman
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 031
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
2.1 To ensure all used instruments in infected cases are returned to
CSSD.
2.2 To avoid missing and lost of instruments.
2.3 To ensure proper communication & endorsement of infected
instruments to CSSD for the prevention of transmission of
microorganisms.
3.0 POLICY:
3.1 All OR Registered Nurses are responsible and accountable:
3.1.1 To ensure that count of instruments is done before, during
and after an infected surgery.
4.0 PROCEDURES:
4.1 To report any missing and broken instrument immediately to CSSD
staff assigned in the OR and document it in the instrument set
packing list’s remarks portion.
4.2 To ensure proper handling of infected instruments during surgery.
4.3 To ensure that all infected instruments are counted correctly before
surgery ends by both scrub & circulating nurses and inform CSSD
staff for any discrepancy.
4.4 To prepare the necessary barriers to be used in handling the infected
instruments – ex. Face mask with shields, extra gloves, sticker
indicator and orange plastic bag.
4.5 To ensure that all used infected instruments are opened and soaked
in little amount of water, sharps and pointed instruments are in
4.8 Inform CSSD staff that infected instruments are ready for handling
over/endorsement.
4.9 Endorse and account all used infected instruments properly to CSSD staff
if possible and the scrub nurse should sign the packing list.
4.10 Once all infected instruments are brought to CSSD by CSSD staff, the
instruments should be checked and counted immediately and then
inform the scrub nurse for the completeness or any missing instrument.
If there is any missing instrument and not found, the scrub nurse should
be responsible in replacing the instruments but failure of the CSSD staff
to inform the scrub nurse regarding the missing / lost instrument, after
2 hours the CSSD staff should be responsible for the replacement new
5.0 REFERENCE:
OR Old Policy and Procedures and Practice Guidelines
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. Registered Nurses
2.0 PURPOSE:
To ensure safe handling of used suction liners and used suction canisters containing
greater than 20 ml of any liquid, blood or blood products which are considered
potentially infectious waste.
3.0 POLICY:
All OR RN’s are responsible and accountable to ensure proper disposal of used
suction liners and cleaning of used suction canisters.
4.0 PROCEDURE:
4.1 Don personal protective equipment (PPE) or barriers when dealing with
used suction liners.
4.2 Add adequate amount of gelling agent to the suction liner and ensure that all
outlets of the liner should be safely closed.
Note: The dosage of gelling powder depends on the composition
of the fluid. Guide values should be noted with the following
before adding gelling agent:
Fluid / H2O – approximate – 6g / liter
Isotonic Solution / NaCL – 20g / Liter
Blood / Secretions – 6g / liter
4.3 Disconnect used suction liner from canister and discard in the designated
orange plastic bag.
4.4 Clean immediately if any accidental spillage occurs by using hypo chlorite
powder.
4.5 Replace new suction liner to suction canister and secure all caps to suction ports
and connections.
NURS.OR- 032 DISPOSAL OF USED SUCTION LINERS # CLEANING OF USED SUCTION CANISTER Page 1 of 2
4.6 Clean used suction canisters at the end of day with disinfectant solution.
5.0 REFERENCE:
5.1 KKUH Infection Control Guidelines
5.2 Gelling Agent Literature
NURS.OR- 032 DISPOSAL OF USED SUCTION LINERS # CLEANING OF USED SUCTION CANISTER Page 2 of 2
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 033
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
1.1 All OR RN’s
1.2 CSSD Staff
2.0 PURPOSE:
2.1 To maintain accurate inventory of equipment / instruments in the OR /
CSSD.
2.2 To ensure equipment / instruments are in proper order.
2.3 To ensure effective organization and quality service rendered for
patients.
3.0 POLICY:
The OR Nursing Staff should ensure that the necessary documents are produced
and processed for any borrowing / lending of equipment / instruments and
supplies.
4.0 PROCEDURES:
4.1 Borrowing or lending of equipment / instruments to the two other
hospitals company & individuals.
4.1.1 No equipment / instruments must be given to hospital, company
and individuals without any written supporting documents.
4.1.2 A special request from must be completed by borrower and names
must be written and signed legibly.
4.1.3 Request must be approved by the Hospital Administration and the
Chairman of the Department of Surgery.
4.1.4 Any equipment from the OR must be checked with the borrower
to ensure it is in working order before handing over to the
borrower.
4.1.5 Instruments must be borrowed from CSSD and not from the OR. If
the instrument is in the O.R., the O.R. staff must send it to CSSD
through the dumb waiter and borrower must collect it from
CSSD. The CSSD staff must check the instrument to ensure
intactness and sterility before giving to the borrower.
4.1.6 Any damage / broken equipment / instrument must be repaired
or replaced by borrower and an incident report must be written.
4.2 Borrowing of equipment / instruments within the hospital. (Internally).
4.2.1 Any equipment / instruments borrowed from OR / CSSD must be
checked with borrower to ensure it is in proper working order
before handing over to the borrower.
4.2.2 All instruments must be borrowed from CSSD and must be
documented in their loan book.
4.2.3 Any damage / broken equipment must be repaired or replaced by
borrower and an incident report must be written.
4.3 Receiving Equipment / Instruments / Products from Company or
individual for loan, trial or evaluation and for evaluation and for
patient’s use.
4.3.1 All requests must be communicated to the Director of |Medical
Supplies Department for approval through the Chairman of the
Department of Surgery.
4.3.2 All equipment / instruments / products must be delivered via
warehouse with supporting documents.
4.3.3 Equipment must be checked by Biomedical Engineering Department.
4.3.4 End user must receive the items / instruments / equipment.
4.3.5 Reusable instruments – must be received by Director of CSSD /
or O.R. ADON and then inform Surgeon.
4.3.6 Equipment / Disposable items must be received by OR ADON
and then inform surgeon.
4.3.7 The company’s representative must inform the Medical Supply
Department and Biomedical Engineering Department that he is
already collecting / retrieving the loan equipment / instruments with
the supporting documents.
4.3.8 O.R. ADON / HN / Designee must ensure that the Company’s
representative has signed that he already received the loan equipment
/ instruments intact and in working order with the presence of
Biomed Engineering Staff.
4.4 Providing Technical Training and Support by Company’s Product
Specialist to requesting surgeons for any product / instruments /
equipment to be used during surgery / symposium.
4.4.1 For instruments / equipment – this must be communicated to the
Department of surgery, Medical Supplies Department, CSSD and
Biomedical Engineering Department.
4.4.2 The HN / Designee must be aware of the presence of any product
specialists inside the O.R. and identify the surgeons to whom they
are conducting the technical training and support.
4.4.3 An approved permission from Engineering Department should be
given to O.R. HN before entering operating room.
4.5 Providing Service to other hospitals or individuals.
Example: Items for sterilization:
4.5.1 A letter of request must be written by individual or hospital’s
representative and the reasons why it is required must be
indicated.
4.5.2 Providing service must be approved by Hospital Administration.
4.5.3 The individual surgeons / hospital representative must go directly
to CSSD and not to O.R. for sterilization of items.
4.5.4 The approval letter is valid for In-service only.
4.5.5 For personal instruments brought by surgeons to be used in O.R.
there must be an approval letter from the Chairman of the
Department of surgery and final approval from Director of CSSD.
4.6 All instruments must be borrowed and returned via CSSD only.
6.0 Reference:
6.1 OR Policy & Procedure
6.2 Policies Supplies Protocol
6.3 CSSD Policy and Procedure
KING SAUD UNIVERSITY
King Khalid University Hospital
You are requested to review the attached document(s) as there could be an effect or impact
upon your department if the action is initiated. Please sign if you concur (agree) with the
document, date and forward to the next person on the list. If you do not agree with the
document, please provide an explanation and send your written comments to the sender
(initiating) department.
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NURS.OR- 033 JOINT POLICY OR –CSSD Page 4 of 4
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 034
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
1.1 All OR RN’s
1.2 All OR Personnel
2.0 PURPOSE:
2.1 To avoid damage equipment cables, plugs and sockets
2.2 To avoid patients and personnel electrocutions.
2.3 To avoid power supply outage.
3.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure adherence to
safety precautions for handling electrical plug.
4.0 PROCEDURE:
4.1 Disconnect electrical equipment from wall socket outlet, do not pull the cables
or cords instead hold the plug firmly and pull it. If you cannot reach the plug,
use a stool or ladder to be able to remove the plug properly.
4.2 Do not lay the equipment cable on the floor to avoid stepping or removing carts
on it.
4.3 Do not use excessive force to insert the plug into the wall socket if it is difficult
to insert, call the maintenance.
4.4 Do not use two pin plugs and extension cords inside hospital premises which
are strictly prohibited.
4.5 Report to Bio-medical Engineering and Maintenance Dept. for immediate repair
to any defective or broken equipment, switches, plugs, sockets, trunks covers,
cables or exposed wiring. Hospital members are not allowed to do repair to .
4.6 Do not ever use surgical tapes to repair broken electrical plugs and cables. These
are conductive media and can cause electrical leakage. Instead report to
Maintenance Dept. for repair.
4.7 Do not over roll the equipment cord around its classics to avoid internal damage
of the electrical wires.
5.0 REFERENCE:
5.1 KKUH Broad Policy & Procedure
5.2 Pocket Guide to the Operating Room by Maxine A. Goldman
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 035
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
To ensure optimum safety of the surgical patient during surgery, it is the
responsibility of all personnel to prevent the cause of electro-surgical burns and
other electrical hazards.
3.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure optimum safety
of the surgical patient during surgery.
4.0 PROCEDURE:
4.1 Assess or check conditions of skin before application of the grounding pas.
4.2 Apply the grounding pad or inactive electrode properly to the patient by placing
it on fleshy, non-hairy and should be close to the surgical site as possible.
4.3 Check patient and machine cable connections if done properly.
4.4 Keep the active electrode (electro-surgical pencil) in a holder or quiver when
not in use and don’t leave it lying on the drapes.
4.5 Ensure unit is grounded in according to the manufacturer’s grounding
instructions.
4.6 Follow electrical safety guidelines always and in the event of malfunction, report
or call Biomedical Engineering Department immediately.
5.0 REFERENCE:
AORN Recommended Practices
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s.
2.0 PURPOSE:
To ensure proper storage of extra skins taken from patient after skin grafting and for
utilization as needed whether in O.R. or in the wards.
3.0 POLICY:
All OR RN’s are responsible and accountable to ensure that extra skin for skin
grafting is being stored in O.R. fridge and the maximum length of time that we can
keep the skin in the fridge is 3 weeks. After 3 weeks of storage, the skin will be
discarded.
4.0 PROCEDURE:
4.1 The skin is taken mostly on the thigh region of the patient depending upon the
patient’s condition and is used for grafting purposes.
4.2 Extra skin is automatically for storage and the O.R. scrub nurse must spread it
on moistened plain gauze but not totally soaked with saline and then roll the
plain gauze with the skin and placed it in a completely labeled sterile specimen
container.
4.3 The specimen container must be labeled with patient details such as name of the
patient, hospital number, surgeon and it is very important to put the exact date
of storage inorder to determine the correct expiry date of the skin.
4.4 The O.R. nurse must store the skin in the fridge in Theatre 11 Anesthesia room
by placing it properly inside the fridge that can be visible.
4.5 The O.R. nurses assigned in Theatre 11 (Plastic) are responsible for the regular
checking of the expiry date of the stored skin.
4.6 All expired stored skin must be discarded properly.
NURS.OR- 036 PROPER STORAGE OF EXTRA SKIN FOR SKIN GRAFTING Page 1 of 2
4.7 If skin is needed in the ward, the ward nurse must notify the O.R. HN / CN /
designee and give the details of the patient. The O.R. nurse must find the correct
skin from the fridge and give it to the ward nurse.
5.0 REFERENCE:
5.1 Alexander’s Care of Patient in Surgery, 12th Edition by Jane C. Rothrock
5.2 Plastic Surgeon’s Preferences
NURS.OR- 036 PROPER STORAGE OF EXTRA SKIN FOR SKIN GRAFTING Page 2 of 2
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 037
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All OR RN’s
2.0 PURPOSE:
To ensure proper handling of patient died in O.R.
3.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure that:
3.1 A resting period of one hour after the patient is certified as dead
should be observed.
3.2 Surgeon should certify the patient as dead and complete the death
notification form #00245 and the death report form F#123.
4.0 PROCEDURE:
4.1 After the patient is certified as dead, the nurse must clean the body from
blood, remove the drains and tubes.
4.2 Fill the three identification tags.
4.3 Place the plastic shroud sheet on the transferring trolley.
4.4 Place the body on the shroud sheet.
4.5 Extend chin strap protecting face with cellulose pad.
4.6 Fold arms over abdomen to waist and tie, (For Moslem Patient right hand
above the left hand).
4.7 Attach I.D. tags 1st to the body, 2nd to outside and 3rd goes with body file.
4.8 Tie the body securely.
4.9 Call the mortuary to collect the body after 2 hours the patient was
pronounced dead.
4.10 Send the file back to the ward.
5.0 FORMS AND ATTACHMENTS:
5.1 Form # 00245
5.2 Form # 123
6.0 REFERENCE:
KKUH Broad Policy and Procedure.
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 038
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective the placement of drapes and this is done
immediately before surgery, on the patient’s abdomen. Draping is done by the
surgeon or Scrub nurse, except where other members of the Surgical Services
team are specified.
3.0 DEFINITIONS:
Barrier Material – are material that minimizes or retards the penetration of
microorganisms, particulate and fluids.
4.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective placement of abdominal drapes.
5.0 PROCEDURE:
5.1 Place the following items on basin or on mayo table or back trolley in
this order:
5.1.1 Four (4) utility drapes around the incision site.
5.1.2 Laparotomy Pack
5.2 Put four (4) utility drapes around the incision site.
5.3 Put first towel at near side of incision.
5.4 Put second towel at top of incision.
5.5 Put third towel at bottom of incision.
5.6 Go to the other side of the table and put fourth towel at far side of
incision line. Prevent contaminating sterile field by reaching across.
6.0 REFERENCE:
6.1 Alexander’s Care of Patient in Surgery, 12th Edition by Jane Rothrock
6.2 AORN Recommended Practices
6.3 Pocket Guide to the Operating Room by Maxine A. Goldman.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective placement of drapes and this is done immediately before
surgery, on the patient’s arm.
3.0 POLICY:
All OR Nurses are responsible and accountable to ensure safe and effective
placement of upper extremity drapes.
4.0 PROCEDURE:
4.1 Place drapes on basin, mayo stand or back trolley in this order:
4.1.1 Orthopedic Pack
4.1.2 One (1) arm stockinet
4.1.3 2 sticky towel – U shape with plastic and 1 H2O resistant towel
4.1.4 large Drape
4.1.5 Five (5) Utility Drapes
4.2 Place barrier towel lengthwise on the rip of first sheet to open it. Place it two-
thirds (2/3) up the board while the patient’s arm is held away from board. If a
hand board is not used, a table is. Each of the five (5) sheets must be left folded
in half when opened, for double thickness.
4.3 Open the second sheet on top of the first and tuck it under the patient’s
shoulder and chest. Keep sheets almost entirely cuffed to prevent them from
dropping below the sterile range.
4.4 Place U-shaped towel over tourniquet.
4.5 Use towel clip to hold the folded towel in position.
4.6 Place the barrier towel lengthwise under the operative site. This prevents
moisture penetration.
4.7 Before using stockinet, consider if arm needs other draping, i.e., draping hand
with towels. No other drapes are used when patient has a tourniquet.
4.8 Stretch the stockinet.
4.9 Place gloved hand inside the stockinet roll.
4.10 Grasp patient’s hand through the stockinet covering glove.
4.11 Unroll the stockinet up over the cuff of third sheet to the axilla, or as far as
possible. Keep gloved hands behind the stockinet to prevent contamination.
4.12 Place limb sheet over arm and open the sheet to cover the sterile area.
4.13 If necessary, add another sheet to cover the foot of the table.
4.14 The Scrub Nurse and/or surgeon is responsible for properly draping the patient.
5.0 REFERENCE:
5.1 AORN
5.2 http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 040
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
2.1 To ensure safe and effective placement of drapes, that is done immediately
before surgery, on the patient’s leg.
2.2 Draping is done by the Surgeon assisted by the Scrub Nurse, except where
other members of the Surgical Services team are specified.
3.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective placement of lower extremity drapes.
4.0 PROCEDURE:
4.1 Place drapes on ring, mayo or back trolley in this order:
4.1.1 Orthopedic pack
4.1.2 2 Sticky Utility drapes
4.1.3 U-shape with plastic + 1 drape water resistant
4.1.4 One (1) leg stockinet
4.1.5 One (1) leg drape to cover the upper part
4.1.6 One (1) 6-inch stockinet x2
4.2 Stand at foot of operating table, open first U-shape towel and place it to patient’s
mid-thigh while his/he leg is held away from the table. Circulating RN will hold
leg until draping is completed.
4.3 A “U”-shape towel will be placed over the tourniquet.
4.4 Towel Clip the cuffed edges of the towel together.
4.5 Place barrier towel on half sheet, lengthwise under the operative leg. (Prevent
moisture penetration and help maintain sterile field.)
4.6 Consider if leg needs other draping before using leg stockinet, i.e., enclosing foot
in towel. Do not boot or add any extra drapes, if tourniquets in use stretch the
stockinet.
4.7 Place gloved hand inside the stockinet roll.
4.8 Grasp patient’s foot through the stockinet covering glove.
4.9 Unroll stockinet to cuff of sheet. Keep hand behind the stockinet to prevent
contamination.
4.10 Place leg through hole in 2 sheets around and unfold the limb sheet to cover
sterile field.
4.11 The Scrub Nurse and/or surgeon is responsible for properly draping the patient.
5.0 REFERENCE:
AORN http://www.aorn.org/PracticeResources
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 041
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective placement drapes, which is done immediately before
amputation of the patient’s leg begins.
3.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective placement of drapes for lower extremity amputation.
4.0 PROCEDURE:
4.1 Place drape on basin stand, mayo stand or back trolley in this order:
4.1.1 Orthopedic Pack
4.1.2 Two (2) Sticky drapes
4.1.3 U-shape with plastic & one H2O resistant drape
4.1.4 One (1) 6-inch stockinet x2
4.2 Stand at the end of operating table, open first sheet and place it to patient’s mid-
thigh while his/her operative leg is held away from the table. Circulating RN
will hold leg until draping is completed. Have each sheet cuffed over your
gloved hand to prevent contaminating them. Bring it under the operative leg.
Cuff it about one (1) inch above site of incision. Towel clip the cuffed edges of
the sheet together. Tuck sheet up under patient’s buttock.
4.3 Roll 6-inch stockinet one (1) inch above site of incision.
4.4 Place leg through hole in extremity drape and unfold drape to cover sterile field.
4.5 The Scrub Nurse and/or surgeon is responsible for properly draping the patient.
5.0 REFERENCE:
AORN, http://www.aorn.org/Practice Resources/Toolkits.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All O.R. RN’s
2.0 PURPOSE:
2.1 To ensure safe and effective placement of drapes, which is done immediately
before the patient’s radical mastectomy surgery begins.
2.2 Draping is done by the Surgeon assisted by the Scrub Nurse, except where
other members of the Surgical Services team are specified.
3.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective placement of radical mastectomy drape.
4.0 PROCEDURE:
4.1 Place drapes on basin stand, mayo stand or back trolley in this order:
4.1.1 EENT pack
4.1.2 Half drape
4.1.3 Large drape x2
4.1.4 Medium drape
4.1.5 Sticky Utility Drape
4.2 Place half drape on the side of the patient’s leg from shoulder to waist side.
4.3 Place large drape on the arm board, drape the hand being held by Circulating
nurse with medium drape folded like a triangle and wrap with crepe bandage.
4.4 Place the first sheet by starting drape and end of arm board and continue until
drape is under patient’s shoulder and chest.
4.5 Place one (1) 30 x 30 each on the side of the shoulder and side of the neck.
5.0 REFERENCES:
5.1 AORN Recommended Practices
5.2 Pocket Guide to the Operating Room by Maxine A. Goldman
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective preparation and assistance in Rigid
Sigmoidoscopy
3.0 DEFINITIONS:
Sigmoidoscopy – is an endoscopic visualization of the anal canal, rectum &
sigmoid colon.
4.0 POLICY:
All Registered Nurses are responsible and accountable to ensure safe and
effective preparation and assistance in Rigid Sigmoidoscopy Procedure.
5.0 EQUIPMENT:
5.1 Sigmoidoscope Set with Accessories
5.2 Light Source
5.3 4 x 4 Gauze
5.4 Long Biopsy Forceps/snare – if needed
5.5 K-Y Jelly
5.6 Long Applicator
5.7 Suction
5.8 Prep Set: Specimen jar (if indicated)
6.0 PROCEDURE
6.1 Place patient in the lithotomy position
6.2 Drape the patient appropriately
6.3 Anus is digitally lubricated and examined.
6.4 Sigmoidoscope is inserted and advanced under direct visualization.
6.5 Air may be insufflated for better visualization and/or definitive
inspection of rectal mucous membrane.
6.6 Specimens are taken by the use of biopsy forceps or snare.
6.7 Suctioning and electro coagulation maybe needed.
7.0 REFERENCE:
Pocket Guide to the Operating Room by Maxine A. Goldman
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 044
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective preparation and assisting cystoscopy procedure.
3.0 DEFINITIONS:
Cystoscopy – is the endoscopic examination of the interior of the urethra, the bladder
and the ureteral orifices.
4.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective preparation and assisting cystoscopy procedure.
5.0 EQUIPMENT:
5.1 Cystourethroscope Monitor Trolley with light source, Camera, Recorder &
Monitor.
5.2 Cystoscopes with corresponding obturators and sheaths Fr. 17 to Fr. 22
5.3 Penile Clamp (for male procedure)
5.4 Half Vaginal Speculum (for female procedure)
5.5 1000 cc. sterile water bag with tubing
5.6 Cystoscopy irrigation tubing
5.7 IV Pole
5.8 Cystoscopy Pack
5.9 K-Y Jelly (Sterile) (Xylocaine Jelly)
5.10 Preparation Set:
5.10.1 Prep bowl with 4 x 4 green gauze
5.10.2 Savlodil sachets x 4-6 each or Povidone iodine
6.0 PROCEDURE:
6.1 Explain procedure briefly to patient if under local anesthesia.
6.2 Position patient in lithotomy and drape patient with privacy.
6.3 Cleanse the area with Savlodil and introduce Xylocaine Jelly
6.4 Assist surgeon as needed.
6.5 Provide emotional support to patient during procedure.
6.6 If specimen is obtained, label immediately and follow established biopsy policy
and procedure.
7.0 REFERENCE:
Pocket Guide to the Operating Room by Maxine A. Goldman
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 045
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective preparation and assisting for cystoscopy and Urethral
Dilatation Procedure.
3.0 DEFINITIONS:
Urethral Dilatation – is dilating the urethra to release urethral stricture, etc.
4.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective preparation and assisting cystoscopy and urethral dilation procedure.
5.0 EQUIPMENT:
5.1 Cystoscopy Irrigation Set with Fr. 17 to Fr. 22 + Light Cable
5.2 Sounds (male, female) – Storz, Simons, Hegars
5.3 Bladder Syringe
5.4 Cystoscopy irrigation tubing
5.5 Xylocaine Jelly
5.6 Storz Telescope 0˚ & 30˚
5.7 K-Y Jelly (sterile)
5.8 Prep Set: Sterile Prep bowl with 4 x 4 green swabs, Savlodil solution – 5 to 6
sachets
7.0 REFERENCE:
Pocket Guide to the Operating Room by Maxine A. Goldman.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective removal of suture for cleft lip and cleft palate.
3.0 DEFINITIONS:
3.1 Cleft lip – a congenital anomaly consisting of one or more clefts in
the upper lip that results from the failure in the embryo of the
maxillary and median nasal process to close.
3.2 Cleft Palate – a congenital defect characterized y a fissure in the
midline of the palate resulting from the failure of the two sides to
fuse during embryonic development.
4.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective suture removal for cleft lip and cleft palate.
5.0 EQUIPMENT:
5.1 Suture Removal Set
5.2 4 X 4 Gauze
5.3 Q-tips sterile if needed
5.4 Steri-strips (optional)
5.5 Prep Set: Sterile prep bowl with 4 x 4 green swabs
Savlodil Solution – 5 to 6 sachets
6.0 PROCEDURE
6.1 Prepare trolley for sterile equipment
6.2 Place patient in comfortable position and remove dressing using aseptic
technique.
6.3 Asses condition of skin, including healing of suture lines.
6.4 Cleanse area with Savlodil Solution.
6.5 Pat dry 4 x 4 gauze
6.6 Using forceps to lift each suture cut the suture with surgical scissors
between the knot and the skin as close to skin as possible and remove one
by one.
6.7 Reassess skin condition / wound closure.
6.8 Application of Steri-strips:
6.9 Apply liquid adhesive around suture line and allow to dry.
6.10 Place and adhesive strip on one side of the wound and pull the strip
gently to other side.
6.11 Anchor the tape to the skin when wound edges appear to be aligned.
7.0 REFERENCE:
Pocket Guide to the Operating Room by Maxine A. Goldman
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.OR- 047
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
O.R. RN’s
2.0 PURPOSE:
To ensure safe and effective preparation and assisting in Incision and Drainage
Procedure
3.0 POLICY:
All OR Registered Nurses are responsible and accountable to ensure safe and
effective preparation and assistance in Incision and Drainage Procedure.
4.0 EQUIPMENT:
4.1 Incision & Drainage Set with the following: Hemostats, mosquitoes, Kelly
forceps, metz and Kelly scissors, pick-up forceps and sponge forceps, etc
4.2 19 gauge needle 1½ inch
4.3 Betadine swabs
4.4 Basic Pack & Large Drape
4.5 Sterile 4x4 Gauze
4.6 Scalpel #15 & 11 blade
4.7 Xylocaine (as directed)
4.8 NU Packing Gauze
5.0 PROCEDURE:
5.1 Assemble all equipment listed above
5.2 Reinforce explanation of procedure to the patient if under local
6.0 REFERENCE:
Pocket Guide to the Operating Room by Maxine A. Goldman
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure safe and effective admission of patient in the PACU.
3.0 DEFINITIONS:
Post- anesthesia care unit (PACU), also called Recovery Room (RR) is a space a patient is
taken to after surgery to safely regain consciousness from anesthesia and receive
appropriate post-operative care a pain management.
4.0 POLICY:
All PACU RNs are responsible and accountable to ensure highest standard of post
anesthesia care to all admitted patients and promote a safe, comfortable and
therapeutic environment for the patient
5.0 PROCEDURE:
5.1 The patient will be transferred from operating room at the completion of the
procedure when the anesthetist feels that the patient is stable.
5.2 The patient will be accompanied to the PACU by the anesthetist and the O.R.
circulating RN.
5.3 The PACU nurse shall receive post anesthesia patients endorsed from the
anesthetist and the O.R. nurse who accompanied the patient.
5.4 On arrival in the PACU, the patient shall be monitored and a verbal and written
report provided to the PACU nurse by the anesthetist.
5.4.1 The patient’s status on arrival to the PACU shall be assessed and
documented.
5.4.2 Information concerning the pre-operative and intra- operative
surgical/ anesthetic course shall be endorsed to the PACU nurse.
5.5 The patient’s condition shall be monitored and documented giving particular
attention to:
5.5.1Airway ( oxygenation, ventilation)
5.5.1.1 giving oxygen.
5.5..1.2 providing patent airway by proper positioning.
5.5..1.3 providing oral/ nasal airway as needed
5.5.1.4 suctioning of secretions
5.5.2 Breathing
5.5.3 Circulation
5.5.4 Drug to relieve pain, Drain care and checking of wound dressing, tubes
and catheters, skin condition and documentation.
6.0 REFERENCE:
AORN http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/.
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.-PACU 002
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure early notification of the attending anesthetist or surgeon for patients in the
PACU for any problem encountered with post operative patients.
3.0 POLICY:
The PACU RNs should immediately notify the attending anesthetist/ surgeon for any
problem encountered with the post operative patients.
4.0 PROCEDURE:
4.1 PACU personnel are responsible for proper assessment of each patient and
notification of the anesthetist when necessary.
4.2 When pain is present, DO NOT administer pain medication ordered in the
postoperative floor orders by the surgeon. Refer to PACU pain management
orders.
4.3 The attending anesthetist or surgeon will be notified of any of the following
occurrences:
4.3.1 Pulse rate of less than 50 or greater than 120 per minute
4.3.2 Any arrhythmia or irregular pulse
4.3.3 Systolic blood pressure less than 90 mm Hg
4.3.4 Hypertension 40% or higher or lower than surgical blood pressure
4.3.5 Respirations are less than 10 per minute and/or there is difficulty
with breathing
4.3.6 Uncontrolled pain management
4.3.7 Excessive nausea and vomiting
4.3.8 Immediate post OP complication like( allergic reaction)
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure safe and effective monitoring of arterial line pressure.
3.0 DEFINITION:
Arterial Cannula Insertion is the insertion of an indwelling cannula into the redial,
Ulnar, brachial, femoral, and dorsalis pedis artery for blood analysis and for invasive
blood pressure monitoring.
4.0 POLICY:
All PACU RNs are responsible and accountable to ensure safe and effective monitoring
of arterial line pressure and notifying anesthetist of abnormal findings.
5.0 PROCEDURE:
5.1 Monitoring equipment must be calibrated upon arrival of the patient to the
PACU.
5.2 Arterial catheter blood pressure reading is to be checked against a cuff
pressure upon admission to the PACU and as needed.
5.3 Arterial line site checks must be documented every 15- 30 minutes on the
PACU record. The anesthetist shall be notified of abnormal findings.
5.4 The arterial catheter alarm system will remain activated at all times. Alarm
parameters should be set at 20 above and 10 below the patient’s normal
arterial pressure.
5.5 Keep pressure bag at 200- 300 mmhg to maintain catheter patency.
5.6 Calibration of Monitoring Equipment:
5.6.1 Attached transducer cable to pressure tubing
5.6.2 Level transducer air reference port at the same level as the patient’s
right atrium
5.6.3 Open stopcock of transducer to air
6.0 REFERENCES:
http:/www.biomedcentral.com/1471-2369/9/15
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITION:
All registered Nurses (PACU)
2.0 DEFINITION:
Spinal anesthesia is the injection of a local anesthetic into the subarachnoid space, a
wide space within the vertebrae that contains cerebrospinal fluid. A level of anesthesia
will be achieved that is dependent on the dosage of the agent used, rate of injection, the
specific gravity of the fluid injected, the position of the patient following injection and
the physiological condition of the patient. The level of anesthesia is referred to as the
"dermatome level." Each dermatome is a cutaneous area that gets its nerve supply from
a single nerve root.
3.0 PURPOSE:
To ensure safe and effective care of patients post spinal anesthesia.
4.0 POLICY:
All PACU RNs are responsible and accountable to ensure safe and effective care of post
spinal anesthesia patients.
5.0 PROCEDURE:
5.1 Initial assessment of the anesthetic level provides a baseline so that any future
deviation can be detected promptly.
5.2 Avoid rapid change of position to prevent orthostatic hypotension.
5.3 Monitor vital signs every five (5) minutes x three (3). Then, if stable, every 15
minutes for first two (2) hours, then every 30 minutes while in the PACU. The
patient shall be encouraged to cough and deep breathe every 15 minutes to reduce
the incidence of atelectasis.
5.4 Check the patient frequently for any signs of bladder distention. Catheterization
may be required if the patient cannot void.
NURS.-PACU 004 POST ANESTHESIA CARE OF THE PATIENT WITH SPINAL ANESTHESIA Page 1 of 2
5.5 Spinal level shall be checked every 30 minutes. Nurses' Notes shall reflect level,
sensation and return of motor function.
5.6 Complications of spinal anesthesia are high or total spinal block, hypotension,
nausea, vomiting, backache, palsies, bradycardia, urinary retention and headache.
All complications shall be reported immediately to the anesthesiologist.
5.7 Spinal or dermatome levels are designated as follows:
5.7.1 Nipple line T-4: motor paralysis of lower extremities
5.7.2 Umbilicus T-10: motor paralysis of lower extremities
5.7.3 Groin T-L-1: movement of both feet
5.7.4 Thighs L-2 - L-3: flex knees and move legs
6.0 REFERENCES:
www.allnurse.com/PACU.nursing
NURS.-PACU 004 POST ANESTHESIA CARE OF THE PATIENT WITH SPINAL ANESTHESIA Page 2 of 2
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.-PACU 005
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITION:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure a safe return of the surgical patient to his/her normal status.
3.0 POLICY:
All PACU RNs are responsible and accountable to ensure highest standard of post
anesthesia care to all pediatric patients and promote a safe, comfortable and therapeutic
environment for the patient.
4.0 PROCEDURE:
4.1 Airway Management:
4.1.1 Pediatric patients are subjected to the same admission process as adult
patients with a few exceptions. Airway assessment is always the first
consideration. The signs of respiratory distress are flaring of the nostril,
sternal retractions, noisy breathing and cyanosis. Some common
respiratory problems are described below.
4.1.1.9 Aspiration and its complications are not very different in a child
as compared to an adult. Children respond to treatment more
rapidly than do adults.
4.2.1 General considerations: Some children cry, not only from pain, but also
from fear and anxiety. Respiration status must be carefully assessed before
administration of pain medication. Careful assessment prior to
administration of medication is key to appropriate pain management.
4.3.1 Temperature:
4.3.3 Bradycardia is defined as a persistent heart rate (pulse) of less than 100-120 beats per
minute (bpm) in the neonate and infant and less than 80 bpm in the child. Transient
bradycardia can be normal in the neonate during feeding or sleeping; therefore, the
term “bradycardia” is only applied to a persistent decrease in the heart rate.
4.3.4 Tachycardia is defined as a pulse over 200 bpm in the neonate and infant and above
140-160 bpm in the child. Transient tachycardia may occur with crying or other
activity that increases the demand for oxygen. For instance, the child’s heart rate will
increase 10 bpm for each degree Celsius elevation in temperature. Heart rate
elevation will also be seen if ventricular stroke volume decreases, as in congestive
heart failure, tamponade or low cardia output.
4.4.1 Lower the blood pressure cuff pressure cuff by 5 mm Hg and leave at that level
for three to four (3-4) seconds. Repeat procedure until flushing is observed in
the blanched limb.
4.4.3 Due to the immature temperature regulating system in the brain, temperatures
can rise quickly and drop just as quickly in the small child. Continuous
monitoring of temperature is mandatory to detect and treat any changes
promptly.
4.5.1.1 A crash cart and pediatric-sized equipment and a flip chart with
emergency pediatric medication dosages listed. Standard emergency
drugs shall be on the cart, with pediatric dose Narcan, single pediatric
dose vials of atropine and calcium readily available. Various sizes of
endotracheal tubes and laryngoscope blades, small IV needles and
suction catheters ranging from 6 Fr through 14 Fr should be easily
accessible.
4.6.1.1 Infants and children have a metabolic rate that is two to three (2-3) times
higher than in an adult. Children can rapidly develop heart failure and
4.6.2 Assessment:
4.6.4 Output:
4.6.4.1 Urine output in the pediatric patient should be 1-3 mL per kg per hour.
If it is less than this, careful monitoring is required.
4.8.1 Emesis:
4.8.1.1 Nausea and vomiting are seen frequently in children; often a child feels
better after vomiting and the nausea subsides. However, some children
require medication for control of nausea and vomiting.
4.8.2 Aspiration:
4.8.3 Hemorrhage:
4.8.3.1 Excessive bleeding in the pediatric patient can develop into shock
more rapidly than in an adult. Frequent assessment of the wound
site and cardiovascular status is necessary.
4.8.4 Delirium:
4.8.5 Distention:
4.8.5.1 Abdominal distention in infants is common after the surgical
procedure and burping may be required to relieve the discomfort.
4.9 REFERENCES:
4.9.1 American Society of Perianesthesia Nurses, Competency Based Orientation
Credentialing Program, 2002 Edition
4.9.2 The Lippincott Manual of Nursing Practice, 5th edition, p. 1140.
4.9.3 Manual of Pediatric Nursing Procedures, Nedra Skale, p. 35.
4.9.4 Manual of Pediatric Nursing Procedures by Nedra Skale, p. 46.
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITION:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure safe and effective post anesthesia care given to Geriatric patients.
3.0 POLICY:
All PACU RNs are responsible and accountable to ensure highest standard of post
anesthesia care to all geriatric patients and promote a safe, comfortable and therapeutic
environment for the patient
4.0 PROCEDURE:
4.1 Airway:
4.1.1 Administer oxygen with humidification:
4.1.1.1 Supplements a decreased carbon dioxide/oxygen exchange
4.1.1.2 Decreases hypoxia in chronic illnesses, such as anemia and
cardiopulmonary diseases
4.1.3 Observe for dyspnea and shortness of breath, which may be caused by:
4.1.3.1 Preexisting cardiopulmonary disease
4.6 Communication and sensory stimulation will reduce stress and anxiety:
4.6.1 Continuous verbal communication will help to improve the patient's
sensorium which may have been dulled by sedation and/or pre-existing
confusion.
5.0 REFERENCE:
www.allnurse.com/Pacu-nursing
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITIONS:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure safe and effective post operative care given to patients having a cesarean
section with or without complications.
3.0 POLICY:
All PACU RNs are responsible and accountable to ensure safe and effective post
operative care given to patients having a caesarian section with or without
complications.
4.0 PROCEDURE:
4.1 Nursing interventions:
4.1.1 Vital signs taken every 15 minutes
4.1.2 Check dressing
4.1.3 Maintain patent IV line with adequate hydration
4.1.4 Assess respiratory and airway status
4.1.5 Administer analgesics
4.1.6 Assess intake and output
4.1.7 Encourage expression of feelings and give reassurance
5.0 REFERENCES:
www.allnurses.com/PACU.nursing
NURS.-PACU 007 POST ANESTHESIA CARE OF PATIENT POST CESAREAN SECTION Page 1 of 1
Department : Unit: Policy Number:
King Khalid University Hospital
NURSING SURGICAL AREAS NURS.-PACU 008
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITION:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure safe and effective management of patient with malignant hyperthermia.
3.0 POLICY:
All PACU RNs are responsible and accountable for the safe and effective management of
patient with malignant hyperthermia.
4.0 PROCEDURE:
4.1 Patients experiencing malignant hyperthermia may exhibit a number of
different symptoms, including, but not limited to:
4.1.1 Unexplained Masseter muscle rigidity
4.1.2 Unexplained tachycardia or cardiac dysrhythmia
4.1.3 Hypercarbia
4.1.4 Change in skin color from flush to mottling to cyanosis
4.1.5 Myoglobinuria
4.1.6 Altered renal function
4.1.7 Tachypnea
4.1.8 A later symptom is fever, with temperatures elevating rapidly, as much
as 1.8 degrees F (1 degree C) every three (3) minutes, creating
temperatures as high as 114 degrees F (45.5 degrees C).
Dr. Ayman Abdo Dr. Abdulaziz Al Saif Prof. Mussaad M.S. Al-Salman
Vice Dean for Quality Vice Dean for Hospitals Dean of College
1.0 CONDITION:
All registered Nurses (PACU)
2.0 PURPOSE:
To ensure safe and effective discharge of post operative patients from PACU to the
ward.
3.0 POLICY:
All PACU RNS are responsible and accountable to ensure safe and effective discharge of
post operative patients from PACU to the ward.
4.0 PROCEDURE:
4.1 The anesthetist will assess and decide the patients discharge in PACU.
4.2 Patients have to meet the following criteria:
4.2.1 Awake, alert and oriented
4.2.2 No active nausea and/ or vomiting
4.2.3 Stable vital signs
4.2.4 Free of pain and comfortable
4.2.5 Numesic scoring system (Alderete score)
4.2.6 Clinical assessment of dressing
4.3 Movement of lower extremities for patients under spinal or epidural anesthesia
4.4 The PACU RN calls the ward RN to collect the patient
4.5 Patient should be transported on a stretcher or patients bed with side rails on
4.6 Patients dignity is maintained at all times
4.7 All relevant information is documented and endorsed to the ward RN
4.7 The patient is accompanied by the ward RN and the porter during transport
NURS.-PACU 009 DISCHARGE OF POST OPERATIVE PATIENT FROM PACU TO THE WARD Page 1 of 2
5.0 FORMS:
Recovery Room Post Anesthesia Care Unit Form
6.0 REFERENCES:
http://allnurses.com/pacu-nursing/pacu-discharge-criteria-55046.html.
NURS.-PACU 009 DISCHARGE OF POST OPERATIVE PATIENT FROM PACU TO THE WARD Page 2 of 2