A surgical instrument is a tool or device designed to perform a specific function, such as cutting, dissecting, grasping, holding, retracting, or suturing. Surgical instruments may be curved, straight, sharp, blunt, serrated, toothed, or smooth. Many are made of stainless steel and are reusable; others are disposable.
Forceps are surgical instruments used to grasp, handle, compress, pull, or join tissue, equipment, or supplies. All forceps are available in many sizes, with or without serrations or teeth, with curved or straight blades, and with ring tips, blunt tips, or sharp tips. Many have ratchets in the handles to hold the tips tightly together; these are notched mechanisms that click into position to maintain tension. You should study the names and purposes of each type of forceps to assist the physician when a specific instrument is required.
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1. Activity restrictions : Includes exercising and bathing
2. Diet restrictions : In cases of diarrhea, vomiting, or abdominal pain, a liquid diet may be recommended
3. Wound care : Changing the dressing, applying medications to the wound, observing for signs of infection
4. Medications : How and when to take them, how it should be stored, when to take them
5. Follow-up appointments
The primary method for sterilizing instruments and equipment is the use of pressurized steam in an autoclave (Figure 44-8). This device forces the temperature of steam above the boiling point of water (212°F, or 100°C). Sterilization by autoclave is a widely accepted method of sterilization for two reasons:
1.
Steam autoclaves can operate at a lower temperature than is required for dry heat sterilization. The moist heat from steam more quickly permeates the clean, porous wrappings in which all instruments are placed prior to loading them into the unit.
2.
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The moisture causes coagulation of proteins within microorganisms at a much lower temperature than is possible with dry heat. When cells containing coagulated protein cool, their cell walls burst; this kills the microorganisms.
General Autoclave Procedures In general, the autoclave process involves the following steps:
1.
Prepare sanitized and disinfected instruments and equipment for loading into the autoclave by wrapping them in muslin, special porous paper, plastic bags, or envelopes and labeling each pack. (Include sterilization indicators.)
2.
Check the water level in the autoclave; add distilled water if necessary.
3.
Preheat the autoclave according to the manufacturer's guidelines. (Some models require putting instruments in before preheating.)
4.
Perform any required quality control procedures (in addition to sterilization indicators in instrument packs).
5.
Load the instruments and equipment into the autoclave. Allow adequate space around the items to ensure that steam reaches all areas.
6.
Choose the correct setting based on the load type (unwrapped items, pouches, packs, liquids, etc.). If the autoclave is not automatic, set the autoclave for the correct time after the correct temperature and pressure have been reached.
7.
Run the autoclave through the sterilization cycle, including drying time.
8.
Remove the instruments and equipment from the autoclave.
9.
Store the instruments and equipment properly for the next use. Rotate stored items so packages with the oldest date are used first. Do not use packages past their expiration date.
10.
Clean the autoclave and the surrounding work area.
During each step of the process, assume the instruments and equipment are contaminated, and follow Standard Precautions:
Wear gloves to avoid contamination by blood, body fluids, or tissues.
Take measures to protect against needlesticks or cuts—for example, use forceps to handle sharps.
Wash your hands thoroughly after all cleaning procedures.
Wrapping and Labeling All ItemsWrap items in porous fabric, paper, or plastic before placing them in the autoclave. This material helps surround the items with the correct levels of moisture and heat. Instruments and equipment to be used immediately after autoclaving can be placed on trays with material above and below the items. Items that must be stored in a sterile state for later use are wrapped and sealed before autoclaving. Refer to Procedure 44-4, at the end of this chapter, for wrapping and labeling instructions.
A number of products are available for wrapping items for sterilization. Muslin (140 count) is the most commonly used wrapping fabric. Other products include permeable paper, disposable nonwoven fabric, and clear plastic envelopes with one side made of permeable material. Figure 44-9 shows several common wrapping products and sterilization indicators.
Instruments that will be used together should be wrapped together to form a sterile pack. Wrap the pack loosely so the steam can reach the instruments inside. After using a pack, consider all items (even those not used) unsterile and return them for sanitization, disinfection, and sterilization.
Clearly label each pack with a nontoxic marker to identify the item or items inside the wrapping and the person who completed the procedure. The label also must include the date to prevent use after expiring.
Preheating the AutoclaveCheck for solutions that may have boiled over and for deposits that may have formed on any of the inner surfaces. Make sure the water reservoir is filled to the proper level with distilled water. Also check the discharge lines and valves to make sure there are no obstructions. If lines or
valves are blocked, air may remain trapped inside the chamber, rendering the load unsterile.
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Following this inspection, preheat the unit according to the manufacturer's guidelines. Loading cold instruments into an overheated chamber can cause excess condensation, so be sure to understand and follow the preheating instructions.
Understanding Autoclave SettingsModern autoclaves are designed to operate as automatically as possible; however, manual autoclaves are still used. Because you are responsible for the sterility of the items processed by the autoclave, you must be able to identify the various gauges and interpret their readings correctly.
Manual autoclaves have three gauges and a timer. The jacket pressure gauge shows the outer chamber's steam pressure. The chamber pressure gauge shows the inner chamber's steam pressure. The temperature gauge shows the temperature inside the inner, or sterilization, chamber. The timer allows you to control the number of minutes the load is exposed to the high-temperature, pressurized steam.
Exact temperature and pressure requirements vary with the model and type of autoclave, and with the instruments and packaging in the load. In general, the temperature must reach 250°F to 270°F (121°F to 132°C) and the chamber pressure gauge must show 15 to 30 pounds of pressure. Follow the manufacturer's instructions precisely for each autoclave load. Procedure 44-5, at the end of this chapter, describes the general steps to follow for running a load through the preheated autoclave.
Sterilization Indicators and Quality ControlIt is important to monitor all sterilization procedures. This is accomplished through the use of various types of indicators and quality control measures.
Sterilization indicators are tags, inserts, tapes, tubes, or strips that confirm the items in the autoclave have been exposed to the correct volume of steam at the correct temperature for the correct length of time. Several types of indicators are available (Figure 44-10).
For example, you place tags or inserts within the load, whereas you affix tapes to the outside of wrapped instrument packs. These types of indicators have designated areas or words that change color when the correct temperature has been reached. Some also show when the proper temperature, pressure, and duration have occurred. Although it is generally acceptable to rely on these indicators as a guarantee of sterility, they are, in reality, only indicators that the load has been exposed to conditions that usually result in sterile surfaces. They do not guarantee that the autoclave contents are actually sterile.
Biological indicators—containing bacterial spores—are used as a quality control method to confirm that sterilization has occurred. Bacterial spores come in various forms including strips, disks, and ampules. They are used because they are more resistant to common sterilization processes than non-spore-forming organisms. The general procedure for using biological indicators is as follows:
Place a biological indicator in a load to be sterilized.
Place another biological indicator outside the autoclave as a positive control.
Run the load as usual.
Interpret the biological indicator and positive control as directed by the manufacturer or send to an outside lab for processing.
Incubate as recommended by the manufacturer.
In general, place indicators in a sufficient number of places in the load so you can be reasonably confident of the sterility of all items in the chamber. The following locations are suitable for indicator positioning:
Within instrument packs.
On the outside of wrapped instrument packs.
Inside containers, especially those that cannot be positioned to allow steam to surround the item.
Near the air exhaust valve.
In any other areas into which steam might not be able to flow freely.
For more information regarding interpreting the results of a biological indicator, see the Caution: Handle With Care feature.
Preventing Incomplete SterilizationAlthough the autoclave is generally considered the simplest and most effective method for sterilizing instruments and equipment, certain pitfalls can cause incomplete sterilization. The four leading factors that cause incomplete sterilization are incorrect timing, insufficient temperature, overcrowding of packs, and inadequate steam levels. Once again, the manufacturer's guidelines provided with the autoclave unit are the best source of accurate information on how to operate it correctly.
Timing GuidelinesAfter loading the autoclave, make sure the heating cycle lasts long enough to allow the steam to permeate all wrappings to reach the instruments and equipment inside. Timing for items to be sterilized should not be started until the unit has reached the proper temperature. Automatic autoclaves have preset timing for each load type. You should keep up with the amount of time an automatic autoclave takes to complete a cycle, noting any differences between loads. Large differences in the amount of time it takes to complete a load cycle should alert you to a problem with the autoclave. Although following timing guidelines helps ensure sterilization, you also should use sterilization indicators.
If you have any doubt about the sterility of an instrument or piece of equipment, do not use it. Instead, put it aside for another cycle of sanitization, disinfection, and sterilization. The risks to patients and to you are too great to take chances.
Temperature GuidelinesThe length of the sterilization cycle is only one factor that has an impact on the final quality of autoclave operations. If the autoclave is manual, the unit must operate at the correct temperature. Unit thermometers and sterilization indicators help confirm correct temperatures have been reached.
Temperatures that are too high can cause problems as easily as those that are too low. If the temperature is too high inside the autoclave compartment, the steam does not have the correct level of moisture. The heat and moisture will not penetrate wrapped instrument packs, resulting in an unsterilized load.
If the temperature is too low, the steam contains too much moisture. Packs will be oversaturated and the drying cycle will be insufficient. Wet packs can easily pick up contaminants from surfaces they touch after you unload them from the autoclave. Common causes of low temperature are failing to preheat the autoclave chamber, loading cold instruments into an overheated chamber, opening the unit door too wide during drying, and overfilling the water reservoir. Always make sure you are familiar with the manufacturer's recommendations before running a load through an autoclave.
OvercrowdingPacks or instruments placed in too close proximity in the autoclave chamber may not be sterilized because of the inability of the steam to penetrate or reach all surfaces.
Steam Level GuidelinesIf the correct level of steam is not present during the autoclave cycle, items will not be sterile at the end of the cycle. It is vital that the unit force all air out of the chamber at the beginning of the sterilization cycle. It is also essential that you place items in the chamber in positions that will not cause formation of air pockets.
To help ensure proper operation of the unit, check all release valves and discharge lines to make sure they are free from obstruction. Clogged valves and lines may prevent elimination of all air from the chamber.
To prevent the formation of air pockets, load items in the autoclave so that the steam can circulate freely around all sides of the items. Place containers on their sides to avoid trapping air. Besides allowing the free flow of steam, careful positioning helps ensure that all items dry thoroughly before you remove them from the autoclave.
Storing Sterilized SuppliesAfter packs and instruments are sterilized in the autoclave, you must store them in a clean, dry location, where they will not be disturbed or shuffled around. This keeps the wrapping material from being torn or otherwise compromised.
The method you use to wrap an item for sterilization determines the item's sterile shelf life. As a general rule, double-layer fabric- or paper-wrapped packages are considered sterile for 30 days. The manufacturers of other wrapping products provide their own guidelines for sterile shelf life.
Return items for sanitization, disinfection, and sterilization after the sterile shelf life period has elapsed. Do not reuse any wrapping or labeling products. Instead, open the packs or wrappings and process each item as if it had never been cleaned.
Cleaning the Autoclave and Work AreaClean the autoclave after each use to prevent accumulation of deposits that might affect the unit's operation. You may
use a nontoxic all-purpose cleaner, although specific cleaning products are available for autoclave use.
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You are responsible for ensuring that routine cleaning is done correctly and thoroughly. When you clean the unit, also check for signs of cracking or wear in gaskets, drain valves, and tubing. Check the level of distilled water in the reservoir. Service representatives who specialize in the maintenance of your unit should periodically clean and check all seals and gauges.
The work area around the autoclave unit should be divided into two clearly marked areas: one for nonsterile, not-yet-autoclaved items and one for sterile equipment as it is removed from the unit. Do not use supplies from one area in the other. Be sure to move any sterile packs or equipment to the correct storage areas when cleaning the counters and other work surfaces. If anything is spilled on a sterile pack or instrument, return the item for sanitization, disinfection, and sterilization.