Module 1: Sterile Technique & Perioperative Care

Course Structure, Policies, and Grading Criteria

• PPNC 2 Overview and Focus:

  • Builds directly upon concepts from PDNG 1.

  • PDNG 1 focused on identifying nursing concepts and facts.

  • PPNC 2 expands into clinical reasoning: executing actions, understanding procedural step-by-step rationales, and prioritizing nursing interventions based on evolving patient scenarios.

  • Emphasizes preparation for course examinations and the HESI standardized exam by focusing on clinical judgment priorities.

• Lab and Simulation Schedule:

  • Simulation and laboratory components occur during the final $6\text{-week}$ period of the course.

  • Lab skills and procedures (e.g., sterile field setup, gloving, urinary catheterization/OLEs) are taught early in lecture to maximize exposure before practical skills evaluations.

  • Skills videos, quick sheets, and step-by-step procedure sheets must be reviewed thoroughly before practical execution.

• Grading Breakdown and Progression Benchmarks:

  • Course Examinations: Two exams, each weighted at $20\text{\%}$ of the final grade.

  • HESI Specialty Exam: Weighted at $20\text{\%}$ of the final grade.

  • Total Testing Component: Exams plus HESI equal $60\text{\%}$ of the total grade.

  • Exam Passing Threshold: Students must achieve an overall exam average of at least $74\text{\%}$ to pass the course.

  • HESI Benchmark: Students must achieve a minimum score of $800$ on either their first or second attempt to progress in the nursing program.

  • Historically, course failure is primarily driven by failing to achieve the HESI benchmark rather than standard classroom coursework.

• Coursework and Assignment Platforms:

  • SharePack / Involved Work: Access coursework directly using the designated "SharePack link" inside the Canvas module. Alternative navigation routes or direct external links may fail to record grades properly.

  • Late Assignment Policy: Late work is accepted with a deduction of $10\text{\%}$ per day up to a maximum of $3$ days late ($30\text{\%}$ total penalty). Assignments turned in past $3$ days receive no credit. Automated system flags (Canvas) that miscalculate hours into late days must be reported to the instructor immediately for correction.

  • Supplemental Platforms: Osmosis videos, Health Assessment Fundamentals modules, and case studies are assigned weekly and are typically due on Sunday evenings.

• Attendance, Participation, and Top Hat Policy:

  • Grace Period: A strict $5\text{-minute}$ grace period is enforced at the start of class.

  • Top Hat Points: Arriving past the $5\text{-minute}$ grace period forfeits participation credit for that session.

  • Missed Questions / Discrepancies: Any missed Top Hat responses or technical discrepancies must be reported to the instructor before leaving the classroom on the day of occurrence or via email that same day. Retroactive adjustments at the end of the semester are strictly prohibited.

Principles of Asepsis: Medical vs. Surgical Asepsis

• Definition of Asepsis:

  • Asepsis refers broadly to the absence of pathogenic microorganisms and the prevention of contamination.

• Medical Asepsis (Clean Technique):

  • Goal: To reduce the overall number of microorganisms and prevent their transfer from person to person or environment to person.

  • Key Interventions:

    • Performing hand hygiene.

    • Cleaning environmental surfaces (e.g., wiping bedside tables).

    • Wearing clean gloves for non-sterile care (e.g., perineal hygiene, routine blood pressure checks).

    • Cleaning IV injection hubs (scrubbing the hub) prior to medication administration.

    • Practicing respiratory hygiene and cough etiquette (covering coughs/sneezes).

    • Controlling transmission vectors: Items brought into an isolated patient room must not be returned to clean supply areas. For example, fresh water liners should be brought into the room rather than removing the main water pitcher.

• Surgical Asepsis (Sterile Technique):

  • Goal: To completely eliminate all microorganisms and spores from an area, equipment, or field to prevent infection during invasive procedures.

  • Indications: Any procedure that invades a sterile body cavity or breaks skin integrity (e.g., indwelling urinary catheter insertion, central venous catheter dressing changes, surgical incisions, complex wound care).

• Strict Rules of the Sterile Field:

  • Sterile-to-Sterile Only: Only sterile items may come into contact with a sterile field. Contact with any non-sterile object renders the item contaminated.

  • Waist-Level Boundary: Any item or sterile gloved hand held below waist level or table level is automatically considered contaminated.

  • Outer $1\text{-inch}$ Border: The outer $1\text{-inch}$ ($2.54\,\text{cm}$) border around the edge of a sterile field or drape is considered non-sterile and contaminated.

  • Line of Sight: Never turn your back on a sterile field. Leaving a sterile field unmonitored renders it contaminated.

  • Reaching Over Fields: Never reach across or over a sterile field. Dropping unsterile particles or skin flaking over the field contaminates it.

  • Moisture and Capillary Action: If liquid contacts a sterile field drape and seeps through (strike-through), capillary action draws microorganisms from the unsterile surface underneath, contaminating the entire field.

  • Gloving Errors: Touching the outer surface of a sterile glove with an unsterile bare hand invalidates sterility.

• Operating Room (OR) Environment Rules:

  • In the OR, any equipment or draping covered in blue fabric/drapes is sterile.

  • Time Limitations: According to Association of periOperative Registered Nurses (AORN) standards, sterile setups left open to air are acceptable only for a brief window ($2\text{--}3\,\text{hours}$ maximum). Unmonitored or long-exposed sterile fields must be discarded due to airborne contamination risk.

Preoperative and Postoperative Nursing Care

• Preoperative Informed Consent:

  • Provider Responsibility: The physician/surgeon performing the procedure is legally responsible for explaining the nature of the surgery, risks, benefits, alternatives, and expected outcomes to the patient.

  • Nurse Responsibility:

    • Verify that the informed consent form is completed and placed in the medical record prior to surgery.

    • Act as a legal witness to the patient's signature.

    • Confirm that the patient has verbalized complete understanding of the provider's explanation.

    • Advocate for the patient: If the patient expresses confusion, lacks understanding, or has unanswered medical questions, the nurse must contact the provider to return and re-explain the procedure before the patient signs.

    • Scope Limit: The nurse does not explain surgical details or deliver initial diagnostic findings (e.g., biopsy results showing malignancy).

• Preoperative Diagnostic Testing and Medication Management:

  • Required Baseline Testing: Complete Blood Count (CBC: Hemoglobin, Hematocrit), Coagulation Panel (PT, INR, aPTT), Blood Urea Nitrogen (BUN), Serum Creatinine, Type and Screen, and Blood Crossmatch. Blood glucose testing is routinely performed for diabetic patients or per baseline surgical protocols.

  • Medication Reconciliation:

    • Obtain an accurate list of all home medications, dosages, compliance, and last dose taken.

    • Hold non-essential medications on the morning of surgery (e.g., anticoagulants, antiplatelets) as directed by the surgeon to mitigate hemorrhage risks.

    • Essential medications (e.g., specific antihypertensives, scheduled insulin doses per protocol) may be administered with a sip of water as ordered.

• Preoperative Patient Education:

  • Initiate postoperative care instruction before surgery to ensure patient comprehension prior to anesthesia recovery.

  • Teach Coughing, Turning, and Deep Breathing (CTDB) techniques and incisional splinting using a pillow to prevent postoperative atelectasis and wound dehiscence.

  • Establish an individual Pain Goal: Ask the patient what numerical pain level on a $0\text{--}10$ scale is acceptable for them to remain comfortable and functional postoperatively (e.g., a goal pain level of $3\,\text{or}\,4$ out of $10$).

• Postoperative Nursing Priorities:

  • Core Order of Operations: Assess patient status, Verify orders/labs, Prepare necessary equipment, and Teach/re-educate.

  • Early Ambulation: Early postoperative mobilization expedites tissue healing, restores gastrointestinal motility, and dramatically decreases the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE).

  • Pharmacologic VTE Prophylaxis: Subcutaneous low-dose Heparin or Enoxaparin (Lovenox) as ordered.

• Venous Thromboembolism (VTE) Management and Sequential Compression Devices (SCDs):

  • Deep Vein Thrombosis (DVT): Thrombus formation in deep veins (typically lower extremities). Characterized by unilateral calf pain, erythema, edema, warmth, and occasionally a positive Homans sign (pain upon passive dorsiflexion of the foot).

  • Pulmonary Embolism (PE): A severe, life-threatening complication occurring when a DVT detaches and travels through the venous circulation to obstruct pulmonary arteries. S/S: sudden severe dyspnea, chest pain, tachypnea, anxiety, and a feeling of impending doom.

  • SCD Application & Nursing Care:

    • Pneumatic sleeves wrapped around lower extremities hooked to a compression pump that inflates and deflates sequentially to promote venous return.

    • Measure calf/thigh circumference to ensure correct sleeve sizing.

    • Monitor skin integrity, pedal pulses, skin color, and limb temperature regularly.

    • Contraindications: Open skin lesions, severe dermatitis, active DVT, skin grafts, peripheral vascular disease/neuropathy, extreme leg deformity, or limb amputation.

  • Amputation Nursing Care Note: Do not apply SCDs to an amputated limb. To promote circulation and reduce contracture risk, elevate the stump for no longer than $2\text{ hours}$ continuously, and alternate with placing the patient in a prone position as ordered.

• Incentive Spirometry (IS) Guidelines:

  • Indication: Used postoperatively to restore lung volume, encourage deep breathing, expand alveoli, and prevent atelectasis and pneumonia.

  • Patient Instruction Step-by-Step:

    1. Sit fully upright in bed or chair.

    2. Take a deep breath out and exhale completely.

    3. Seal lips tightly around the mouthpiece.

    4. Inhale slowly and deeply through the mouth (like sucking through a straw) to elevate the visual sphere or indicator to the specified target line.

    5. Hold breath for $3\text{--}5\text{ seconds}$ at maximum inhalation, then remove mouthpiece and exhale normally.

    6. Repeat $5\text{--}10\text{ times}$ every hour while awake.

  • Common Error: Patients must never blow/exhale into the incentive spirometer; it is an inhalation exercise device.

Patient Restraints: Types, Legal Protocols, and Safety Standards

• Definition and Scope:

  • Restraints are any manual method, physical/mechanical device, material, or equipment attached or adjacent to the patient's body that restricts freedom of movement or normal access to one's body.

  • Restraints are a last resort intervention when all non-restrictive safety measures (sitters, family presence, bed alarms, diversion techniques) have failed.

  • Restraints are not an automatic fall prevention strategy; unmonitored restrained patients remain at high risk for injury or falls.

• Restraint Classifications:

  • Physical Restraints: Soft wrist straps, ankle restraints, mitts (if tied down), leather restraints, vest/belt restraints.

  • Chemical Restraints: Psychotropic medications administered specifically to restrict movement or control aggressive/violent behavior outside standard medical care (e.g., Haloperidol [Haldol], Lorazepam [Ativan]).

  • Environmental Restraints: Elevating all $4$ side rails on a hospital bed, or locking an overbed tray table across a chair so a patient cannot stand up.

• Medical (Non-Violent) vs. Behavioral (Violent) Protocols:

  • Medical / Non-Violent Restraints:

    • Indication: Applied to prevent an unsafe, non-violent, or confused patient (e.g., sundowning dementia patient) from interrupting necessary medical treatments (pulling out IV lines, endotracheal tubes, or Foley catheters).

    • Monitoring: Perform patient assessments, offer toileting, check skin, and verify neurovascular status at least every $2\text{ hours}$.

  • Behavioral / Violent Restraints:

    • Indication: Applied when a patient exhibits aggressive, violent, or physically destructive behavior that poses an immediate threat to the safety of self or staff.

    • Monitoring: Requires continuous $1\text{-to-}1$ observation. Vital signs, mental status, skin condition, and restraint security must be documented every $15\text{ minutes}$. Perform a comprehensive assessment every $2\text{ hours}$.

• Physician Orders and Timeframe Constraints:

  • In an emergency, a nurse may apply restraints first, but must immediately notify the provider and obtain a formal written/electronic restraint order within $1\text{ hour}$.

  • If a physician order is not obtained within $1\text{ hour}$, the restraints must be removed immediately.

  • Restraint orders must be renewed periodically per facility policy and legal limits (PRN/as-needed restraint orders are illegal).

• Nursing Care Standards for Restrained Patients:

  • Two-Finger Rule: Ensure that $2\text{ fingers}$ can easily fit between the restraint strap and the patient's skin to prevent neurovascular impairment and skin breakdown.

  • Attachment Site: Tie restraint straps directly to the movable bed frame using a quick-release knot. Never tie restraint straps to the bed side rails.

  • Every $2\text{-Hour}$ Interventions: Release restraints one at a time to assess skin integrity, perform range-of-motion (ROM) exercises, evaluate circulatory status (pulses, warmth, capillary refill), provide hygiene/toileting, and offer food/hydration.

  • Discontinuation: Restraints must be discontinued at the earliest possible moment when safe behavior is restored.

• Risks and Adverse Events Associated with Restraints:

  • Severe adverse events include pressure injury, nerve compression, limb loss due to ischemia, joint contractures, strangulation, respiratory depression, aspiration, choking, and death.

Blood Transfusion Protocols and Nursing Management

• Indications and Blood Components:

  • Whole Blood: Used for acute, massive hemorrhage to replace intravascular volume and all cellular blood components.

  • Packed Red Blood Cells (PRBCs): Given to increase oxygen-carrying capacity in severe anemia or acute blood loss (commonly ordered when Hemoglobin drops below $6\,g/dL\text{ or }7\,g/dL$).

  • Platelets: Infused to treat severe thrombocytopenia and prevent/control active bleeding by restoring normal hemostasis.

  • Fresh Frozen Plasma (FFP): Restores plasma volume and supplies essential coagulation factors.

  • Albumin: Acts as a plasma volume expander by pulling fluid from interstitial spaces into the intravascular compartment.

  • Autologous Transfusion: Patient donates their own blood prior to an elective procedure, which is collected and reinfused if needed.

• Pre-Transfusion Assessment and Screening:

  • Informed Consent: Confirm that the provider has explained the risks/benefits and that signed consent is present in the record.

  • Patient History: Inquire about prior blood transfusions, previous transfusion reactions (and how they were treated, e.g., pre-medication with Diphenhydramine [Benadryl] or Acetaminophen [Tylenol]), history of anxiety, and underlying cardiac or renal disease (fluid overload risks).

  • Baseline Assessment: Obtain full baseline vital signs (especially temperature and lung sounds) immediately prior to fetching blood from the blood bank.

  • Vascular Access: Ensure dedicated venous access using a large-bore peripheral IV catheter ($18\text{-gauge}$ preferred; $20\text{-gauge}$ acceptable).

• Bedside Verification Procedure:

  • Must be performed independently by $2\text{ licensed nurses}$ (or one RN and a physician) at the patient's bedside immediately prior to spiking the bag.

  • Verify: Patient name, date of birth, medical record number, blood band identification number, donor unit number, ABO group and Rh factor, product expiration date, and physician order.

  • Student Scope Limit: Nursing students cannot independently sign off or administer blood products without licensed nurse sign-off.

• Administration Rules and Tubing Setup:

  • Tubing: Must use specialized blood Y-tubing containing an in-line microaggregate filter.

  • Priming Fluid: Prime the blood tubing exclusively with $0.9\%\text{ Normal Saline}$ ($0.9\%\,NaCl$). Never use dextrose solutions (causes hemolysis) or Lactated Ringer's (causes clotting).

  • Time Limitations: Initiate transfusion within $30\text{ minutes}$ of retrieving the product from the blood bank. Infusion must be completed within $4\text{ hours}$ maximum from the time of issue to prevent bacterial proliferation.

  • Initial Monitoring: Infuse slowly for the first $15\text{ minutes}$ (e.g., $2\,mL/min$ or approx. $50\text{--}75\,mL/hr$). The primary RN must remain in the room with the patient for the first $15\text{ minutes}$. Recheck vital signs at the $15\text{-minute}$ mark.

• Transfusion Reactions: Types, Clinical Signs, and Mechanisms:

  • Febrile Non-Hemolytic Reaction:

    • Cause: Recipient antibody reaction against donor white blood cells.

    • Signs: Sudden onset of shaking chills/rigors, fever (elevation $\ge 1^\circ\text{C}$ or $2^\circ\text{F}$), headache, flushing, anxiety, and muscle aches.

  • Acute Hemolytic Reaction:

    • Cause: ABO or Rh incompatibility leading to intravascular destruction of donor RBCs. Life-threatening emergency.

    • Signs: Chills, fever, severe low back/flank pain, chest pain, dyspnea, tachycardia, hypotension, hemoglobinuria, DIC, shock, and cardiac arrest.

  • Allergic Reaction (Mild to Moderate):

    • Cause: Hypersensitivity to donor plasma proteins.

    • Signs: Urticaria (hives), pruritus (itching), facial flushing, mild dyspnea, or wheezing.

  • Anaphylactic Reaction:

    • Cause: Severe IgA anti-body reaction in IgA-deficient recipients. Life-threatening emergency.

    • Signs: Sudden severe hypotension, marked tachycardia, severe bronchospasm, laryngeal edema, shock, and respiratory arrest. Treated with Epinephrine.

  • Transfusion-Associated Circulatory Overload (TACO):

    • Cause: Blood product administered too rapidly for cardiac capacity, leading to hypervolemia. High risk in elderly ($>70\text{ years}$), infants, and CHF patients.

    • Signs: Dyspnea, orthopnea, cough, hypertension, jugular venous distension (JVD), and fine crackles/rales at lung bases.

  • Bacterial Contamination / Septic Reaction:

    • Cause: Infusion of bacterially contaminated blood.

    • Signs: Rapid onset of high fever, severe chills, profound hypotension, flushed skin, vomiting, diarrhea, and septic shock.

    • Complication: Disseminated Intravascular Coagulation (DIC), characterized by widespread microvascular abnormal clotting followed by uncontrolled systemic hemorrhage from all puncture sites/mucous membranes.

• Priority Steps for Suspected Transfusion Reaction:

  1. STOP the blood transfusion immediately.

  2. Disconnect the blood tubing set from the IV catheter hub.

  3. Attach new IV tubing, connect $0.9\%\text{ Normal Saline}$, and run at a keep-vein-open (KVO) or fluid-resuscitation rate directly into the IV hub to preserve venous access.

  4. Perform a complete physical assessment and obtain vital signs.

  5. Position the patient upright (elevate head of bed) if dyspneic or in circulatory overload.

  6. Notify the healthcare provider immediately.

  7. Administer prescribed emergency medications (Diphenhydramine, Acetaminophen, Furosemide, Epinephrine) as ordered.

  8. Send the remaining blood bag, blood tubing, filter, and blood tag back to the blood bank for analysis.

  9. Collect blood cultures and urine samples (to check for hemoglobinuria) as ordered.

• Ethical and Religious Considerations (Jehovah's Witness Case Study):

  • Autonomy: Competent adult patients possess the legal and ethical right to refuse blood products based on religious beliefs (e.g., Jehovah's Witness doctrine), even if refusal leads to death.

  • Incapacitated / Dementia Case: If an incapacitated individual (e.g., dementia patient requiring emergency surgery) has an established Durable Power of Attorney (DPOA) for healthcare, the DPOA's explicit refusal of blood products based on the patient's documented wishes must be respected.

  • Role of Ethics Committee: In complex clinical dilemmas involving surrogate decision-makers, emergency lifesaving care, and ambiguous directives, consult the hospital Ethics Committee.

Review Scenarios and Practical Practice Questions

• Scenario 1: Technique Classification

  • Question: Wiping a patient's bedside table prior to a dressing change.

  • Answer: Medical Asepsis (Clean Technique).

• Scenario 2: Technique Classification

  • Question: Setting up the sterile field for a surgical procedure.

  • Answer: Surgical Asepsis (Sterile Technique).

• Scenario 3: Technique Classification

  • Question: Inserting an indwelling urinary catheter.

  • Answer: Surgical Asepsis (Sterile Technique).

• Scenario 4: Technique Classification

  • Question: Wearing clean gloves while performing routine perineal care.

  • Answer: Medical Asepsis (Clean Technique).

• Scenario 5: Technique Classification

  • Question: Performing hand hygiene before entering a patient room.

  • Answer: Medical Asepsis (Clean Technique).

• Scenario 6: Technique Classification

  • Question: Changing a central line dressing (requiring masks on nurse and patient).

  • Answer: Surgical Asepsis (Sterile Technique).

• Scenario 7: Restraint Contraindications

  • Question: When preparing to apply an SCD for a postoperative patient, which condition is a contraindication?

  • Answer: Local open wounds, active DVT, or severe peripheral vascular sores on the extremity.

• Scenario 8: Restraint Classification

  • Question: A male patient with elevated blood alcohol level attempts to pull out his IV line. When redirected, he verbally threatens staff and tries to kick nurses from his bed. What restraint order type applies?

  • Answer: Behavioral / Violent Restraint.

• Scenario 9: Restraint Monitoring Frequency

  • Question: Following application of behavioral restraints, how often must observation and monitoring occur?

  • Answer: Continuous $1\text{-to-}1$ observation with monitoring and documentation recorded every $15\text{ minutes}$ (and full assessment every $2\text{ hours}$).

• Scenario 10: Transfusion Reaction Identification

  • Question: A blood transfusion has been infusing for $30\text{ minutes}$. The patient develops a cough, dyspnea, and crackles at lung bases. What reaction is occurring?

  • Answer: Transfusion-Associated Circulatory Overload (TACO).

• Scenario 11: Priority Nursing Action

  • Question: What is the immediate priority nursing action when a patient experiences any sign of a blood transfusion reaction?

  • Answer: Stop the transfusion immediately.