SAVE LIFE COMFORT THE SICK

A Learning Module for BSN III

Clinical Learning Experience
Operating Room Technique Module

Prepared by
Thelma R. Babia, MAN
Lorna L. Cano, PhD.
Medel O. Cabalsa, PhDc
Roylan A. Almacen, MSN

Professors
Overview

This module is intended for Bachelor of Science in Nursing students who are aim to train a
scientific approach through active knowledge acquisition, problem-solving, critical analysis and reflection.
In this course, assignments in the form of lectures occur, video viewing, individual study assignments,
literature studies, proficiency training through practice of different operating room procedures and
techniques. The module compose of three major topics such as pre-operative preparation, intra operative
care, and immediate post operative care. It is presented as text with short discussion and figures and
tables. The students need indepth understanding and project the diffedent skills needed in operating room
since it is one of the special area that require optimum learning and application of different skills. Surgery
is a unique experience that require a delivery of quality nursing care during pre-operative, intra operative,
and post operative phases of surgery. The operating room is a very complex and dynamic environment
and each member of the operating room health team requires specific skills.

Learning Objectives

1. Discuss the principles of aseptic technique in operating room.

2.Describe the operating room attire and explain its pupose
3. Demonstrate step by step the correct procedures of surgical scrubbing, gowning, and gloving and
state each purpose.
4. Discuss the role of members of operating room team.
5. Perfom the proper handling of sterile instruments and materials.
6. Discuss proper draping and explain the purpose, techniques, and nursing responsibilities.
7. Identify the basic surgical instruments and it uses.
8. Discuss nursing responsibilities for immediate post operative patient.
9. Formulate nursing process based on the client need.
10. Discribe the operating room environment

Learning Content and Discussion

Introduction
Hello! There! Welcome to operating room – the most bloody and exciting area of nursing practice.
I would like to share a simple qoutation for you to inspire on starting this learning activity today, “Too
often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest
accomplishment, or the smallest act of caring, all of which have the potential to turn a life around.” – Leo
Buscaglia. Here, in this area we value the power of touch, smile, kind word, open ears, and honesty in all
activities that you have to do. For this, you open your mind, heart, and arms to have the power to pursue
your goal. Good luck and God bless.

OPERATING ROOM
It is the place where the people are always on the go and must be guided by the principles of aseptic
technique. It provides a sterile environment in which the operating room health team can perform surgery
either it is minor or major.

What is surgery?
Surgery is a medical specialty that uses operative manual and instrumental techniques on a
person to investigate or treat a pathological condition such as a disease or injury, to help improve bodily
function or appearance or to repair unwanted ruptured areas. Wikipedia
In surgery, it requires several skills to practice in oder to give quality care to the clients. There
are three phases of surgery, pre-opertive care, intra-operative care, and post operative care. Pre –
oprative care is the care of clients who will undergo sugical procedure upon they decided to do the
procedure. In this phase nurses ensure the preparation of clients for surgery and the operating room for
the necessary instruments, materials and anesthesia. Intra- operative care is care when the client is
physically , psychologically, and spiritually prepared, from the time the client transferred to OR suite and
position and secured in OR table, undegone anesthesia, and procedure was done until transfer to post
anesthesia care unit. Post Oprerative care is the care for clients after the surgery until transferred to
surgery ward/department and dischage to the hospital.
The preoperative preparation for clients in OR includes identifying the client identity, procedure,
and consent, verify and check the OR checklist, patient condition and readiness to surgey, and
contraptions such as IV fluids, blood, insertion site and cannula, tubes, etc. Check laboratory results and
treatment, and availabilty of materials, supplies and anesthetic drugs. OR heath team ensure that all
equipments, instruments, materials are avialable and at working condition. Ensure safety and
comfortable position of client in OR table. Surgical team must observe proper attire and perform hand
scrubbing and proper hand drying prior to enter restricted area in OR.
There are three zone in Operating room; unrestricted, semi restricted, and restricted where in the
OR team must observe so that the contamination will be less.
In intra-operative care includes the aseptic technique, proper hands srubbing, proper donning of
gown and gloves, preparation of sterile field and instruments, induction of anesthesia, skin preparation of
clients, urinary catheterization, and draping. Monitoring of client, surgical team and environment during
the whole course of operation. Observe the duties and reponsibilities of OR health team.
Post operative care is the immediate care after the procedure/surgery finished. The nurse ensure
that client vital signs are stable and apply appropriate dressing on the wound site and well
secured.Ensure all contraptions such IV, blood, tubes etc. are intact and functioning well. Proper cleaning
and changing client gown before tranferring to PACU.

OPERATING ROOM TEAM

SURGEON
The surgeon is the physician performing the procedure . As the head of the team, the surgeon is
responsible for all medical action and judgements. He/she is a licensed physician who is specially trained
and qualified. Qualifications may include certification by specialty board adherence to JCAHO standards,
hospital standards, and admitting practices and procedure.

SURGICAL ASSISTANT

Works closely with the surgeon in performing the operation. The number of the assistants varies
according to the complexity of the procedure. Assistant surgeon maybe a physician, a nurse, or another
trained personnel. The assistant performs such duties as exposing the operative site, retracting nearby
tissues, sponging and suctioning secretions, ligation of bleeding vessels, suturing or helping suture the
surgical wound.

ANEASTHESIOLOGIST

The anaesthesiologist is a physician who specializes in giving anaesthetic agents. A certified

nurse anaesthetist is a registered nurse with additional credentials who delivers anaesthetic agents under
the supervision of the anaesthesiologist, surgeon, dentist , or podiatrist. The anaesthesiologist or CRNA
evaluates the client preoperatively , administers the anaesthesia and other required medications,
transfuses blood or other blood products, infuses intravenous fluids, continuously monitors client’s
physiologic status, alerts the surgeon to developing problems and treats them as the arise, and
supervises the client’s recovery in the PACU.

HOLDING AREA NURSE

The holding area nurse manages the care while the clients are waiting for the procedure The
nurse greets, identify, verify, & evaluate(GIVE) the client readiness for surgery. HA nurse review medical
records, preoperative checklists, and ensure the operative consent form are properly signed.

CIRCULATING NURSE

The circulating nurse is a highly experienced registered nurse who coordinates and manages a
wide ranges of activities before, during, and after surgical procedure. Protect the patient safety and
health by monitoring the activities of the surgical team, checking the OR condition, and continually
assessing the patient for any signs of injury and implementing appropriate intervention

SCRUB NURSE

Scrub nurse is a well trained registered nurse who performed surgical hand scrub, properly wear
sterile gown and gloves, set up the sterile field, drapes the client, and hands sterile supplies, equipment
and instruments to the surgeon and the assistant. Scrub nurse should be knowledgeable about the
surgical procedure to anticipate which instrument and type of sutures to be serve to the surgeon and the
assistant. Together with the circulating nurse, perform accurate counting of sponges, needles, sharps,
and instruments.
PREPARATION OF THE SURGICAL SUITE TEAM SAFETY

SURGICAL UNIT ENVIRONMENT

It is known for its cold temperature. Operating room layout prevents infection by reducing
contaminants through air exchanges, and limiting traffic, and activities. The surgical suite is behind the
double doors and access is limited to authorize personnel. Policies governing this environment address
such issues as the health of the staff, cleanliness of the room, sterility of equipments and surfaces,
processes for scrubbing, gowning, and gloving, and OR attire. Surgical asepsis requires meticulous
cleaning and maintenance of the environment. Floors are cleaned frequently with detergent, soap, and
water, or detergent germicidal. All equipment used to the patient during the procedure must be sterile. To
decrease airborne bacteria, standard OR ventilation provides15 air exchanges per hour, at least 3 of
which are fresh air. Temperature at 20 to 24 degrees centigrade, humidity between 30 to 60 percent,
positive related to adjacent areas are maintained.
OR has special air filtration devices to screen out contaminating particles, dust, and pollutants. Laminar
air flow units provide 400 to 500 air exchanges per hour. Ensure electrical safety through proper
placement of grounding pads and use electrical equipment that meet safety standard. Maintenance and
monitoring of the equipments is necessary. Prevention of fire and complication from the use of hazardous
or toxic substances are the main concern. Some ORs have laminar air flow unit. These provide 400 to
500 air exchanges per hour. Laminar airflow unit when used appropriately ensure the decrease of
bacteria by 10 CFUs (colony forming unit) per cubic foot per minute during surgery. The goal of laminar
airflow unit is to equipped the OR to decrease the infection rate than less to 1%. OR equipped with this
unit are designed for total hip replacement, or organ transplant surgery.

Safety Goals in Operating Room (2005, JCAHO) are the following: 1. Improve the accuracy of patient
identification 2. Improve effectiveness of communication among care givers 3. Improve safety of using
medications 4. Improve safety of using infusion pumps 5.Reduce the risk of health care- associated
infection 6. Accurately and completely reconcile medications across continuum of care 7. Reduce the risk
of surgical fires
Three zones in Surgical Area includes the following; 1. Unrestricted zone - to help decrease microbes
OR personnel must wear proper attire. Here, where street clothes are allowed. 2. Semi - restricted zone -
OR personnel's are required to wear clean scrub suite, caps, and clean washable foot wear. 3. Restricted
zone. OR personnel must wear complete attire such as scrub clothes, cap, shoe cover, and mask.

Principles of sterile technique

The patient must be the center of the sterile field, the following are considered to be sterile; area
of the patient, operating table and furniture covered with sterile drapes, and the scub team
(surgeon,assistant surgeon, scrub nurse- instrument and suture nurse).

The principles of sterile technique are applied in the following: 1. Preparation for operation by
sterilization of instruments, materials and supplies. 2. Preparation of the scrub team to direct contact in
operative site. 3. Creation and maintenace of sterile field, including the preparation, and draping of patient
and area throughout the operation procedure.4.terminal disinfection and sterilazation at the end of
procedure.

These are the principles of sterile technique; 1. Sterile persons have scrubbed and sre gowned
and gloved. Unsterile person have not. 2. Only sterile items are used within the sterile field. 3. Gowns are
considered sterile only from the waist to shoulder level infront and the sleeves. 4. Table are sterile only at
table level. 5. Persons who are sterile touch only strile items or areas; Persons who are not sterile touch
only unsterile items or areas. 6. Unsterile person avoid reaching over a sterile field. Sterile person avoid
leaning over an unsterile area. 7. Edges of anything that encloses sterile contents are considered
unsterile. 8. Sterile fields is created as close as possible to time use. 9. Sterile areas are continuously
kept in veiw. 10. Sterile person keep well within the sterile area. 11. Sterile persons keep contact with
sterile areas to a minimum. 12. Unsterile person aviod sterile areas. 13. Distruction of integrity of
microbial barriers result in contamination. 14. Microorganism must be kept to an irreducible minimum
Courtesy image; google.com operating room attire

Operating Room Attire

It consist of clean scrub suite/dress, head cover or cap, surgical face mask, shoes cover. Sterile
gown and gloves should be worn by scrubbed team. The purpose of wearing all these is to provide
effective barriers that prevent contamination and spread of microorganisms to client and protect staffs and
personnel from infection.

SCRUB DRESS must be clean and cotton dress only worn in operating suite. HEAD COVER or HEAD
GEAR - Should completely cover the hair to prevent hair fall in the operative site. SHOES OR
WASHABLE SLEEPER must be comfortable and supportive. Shoe cover must be use if spills or splashes
are expected. MASK are worn at all times in the restricted zone of OR. High filtration mask decrease risk
of [post operative wound infection by containing filtering microorganism from the oro and nasopharynx.
Eye Goggles are worn to protect from the splashing of body fluids and blood from clients.

Covid 19 attire is worn when clients is infected with covid virus, to have maximum protection from
contamination. Operating Room (Sterile) covid 19 attire -N95 (reuse), Face shield (reuse), Surgical gown,
Double gloves, Cloth hat, Bouffant, Boot covers

Covid -19 Operating Room Attire

Courtesy Image: https://med.emory.edu/departments

The pictures below show the proper technique in donning and removing of Covid 19 PPE in the
operating room.

Courtesy Image: https://med.emory.edu/departments

Courtesy Image: https://med.emory.edu/departments
Courtesy Image: teachmesurgery.com

Courtesy Image: teachmesurgery.com

SURGICAL HAND SCRUB

What is surgical scrub?

Surgical scrub is the most effective infection control measures. It is a systematic approach to
scrub both hands and arms efficiently and ensure proper technique to remove microorganisms as many
as possible. It is done prior to sterile gowning and gloving for each procedure.
The purpose of the surgical hand rub or hand scrub is to remove debris and transient
microorganisms from the nails, hands, and forearms, to reduce the resident microbial count to a
minimum, and to inhibit rapid rebound growth of microorganisms
Preparation prior to surgical scrubbing are; 1. Skin and nails should kept clean and in good
condition and cuticle uncut. 2. Finger nails should short and no nail polish to avoid glove puncture. 3.
Inspect hands for cuts and abrasions. Skin of hands and forearms should be intact, without lesions or
cracked skin. 4. Be sure hair is fully covered by headgear or cap. 5. Adjust disposable face mask and
snugly and comfortably over the nose and mouth. 6. Adjust water temperature to a tolerable degree of
heat.
POLICY: An antiseptic surgical hand scrub or antiseptic hand rub shall be performed before
gowning and gloving preoperatively by all personnel performing or assisting with surgical procedures.
Fingernails must be trimmed short and be free of artificial nails and enhancements. Hands and forearms
must be free of open lesions and breaks in skin integrity.

SURGICAL SCRUB PROCEDURE

1. Time method - Fingers, hands, and arms are scrubbed by alloting a prescribed amount ot time to
each anatomical areas or each step of the procedure.
1. Complete scrub takes 5-7 minutes – it is done in the morning before the first
gowning and gloving
a. Following clean case if glove have been removed inadvertently, before the
gown.
b. Following a clean case, if gloves have had a hole between them.
c. Following a clean case if hands have been contaminated in any other way
d. Before an emergency case at anytime.
2. Short scrub takes 3 minutes, this is done following a clean case, if hands and
arm have been contaminated.
2. Brush stroke method – a prescribed number of brush strokes, applied lenghtwise of the brush or
sponge is use each surface of the finger, hands, and arms. Scrub nails of one hand for 30
strokes, all sides of each finger 20 strokes, the back of the hand 20 strokes, the palm of the hand
20 strokes, the arm 20 strokes for each third of arm, to 3 inches above the elbow.

Proper scrub technique for the first 5 minutes of a 10-minutes scrub

1. Turn on water and get antiseptic solution.
2. 2. Wash hands prior to scrub.
3. Clean finger under running water.
4. Scrub the hand. Close - up of scrubbing left fingertips.
5. Scrub left arm and left elbow area
6. Rinse brush and transfer to other hands
7. Scrub right hand, right arm and elbow area
8. Rinse left hand and brush
9. Rinse left arm and elbow area.
10. Rinse right hand and elbow area
11. Complete scrub as indicated with anatomical timed or stroke count scrub method
12. Turn off the water in faucet using brush if faucet is hand control.
13. Walk in the operating room

Drying Hands after Surgical Scrub

When drying hands stand away from objects and people to eliminate unnecessary movement of
the towel, move the hands that is being dried rather than the towel.

Drying Procedures are as follows:

A. Pick up the sterile towel to dry hands from gown pack, do it with a swift, efficient motion.
B. Unfold the towel
C. Hold the towel in the middle, be careful not to contaminate the sterile gown under it.
D. Bend at the waist to prevent inadvertly touching to unsterile gown, while drying of hands and
arms.
E. Place a third over right hand ; two thirds will hanging toward left hand.
F. Dry hand to mid-lower arm, then transfer dry end of towel to other hand.
G. Do not dry hand then arm and return to the same hand’
H. Dry left hand followed by left arm.
I. Transfer dry end of towel to left hand, a third over left hand, two thirds toward right hand.
J. Dry right hand, followed by right arm.
K. After the second hand and mid – lower have been dried, fold towel in thirds and dry elbow area.
L. Be sure hand is well covered. When transfer of towel is made from hand to hand, do not allow
hand to touch where elbow has touched.
M. Discard towel in linen hamper.
STERILE GOWN

Consideration when donning sterile Gown

1. To exclude skin as contaminant and to create a barrier between sterile and unsterile areas.
2. Gown packages preparably are open on separate table from other packages to avoid any
chances of contamination from dripping of water.
3. After scrubbing, hands and arms must be thoroughly dried before the sterile gown is donned to
prevent contamination of the grown by strike- through of organisms from skin and scrub attire.
4. The gown package for the scrub nurse contains one sterile gown, folded before sterilization, with
the inside out so that the bare hands will not contaminate the sterile outside of the gown.
5. A towel for dry hands is places on top of the gown during packaging. Scrub nurse holds the towel
away from the body, dries only well-scrubbed areas, hand first, and avoids contaminating hands
on the areas proximal to elbows.
6. Dry both hands, then then one arm at the end of the towel, use the opposite end of the towel, use
the opposite end of the towel for the other arm.
7. To put on sterile gown, the scrub nurse needs assistance of the circulating nurse. The scrub
nurse receives the sterile gown from the circulating nurse when the gown is not individually
packed.

Purpose: To apply attire necessary to safely carry out sterile procedure done in operating room and
delivery room.

STERILE GOWNING FOR CLOSED GLOVE TECHNIQUE

Preparation
1. Assess client for latex allergies.
2. Assemble equipment and supplies;
a. Sterile pack containing a sterile gown
b. Sterile gloves
3. Insure the sterility of the package of gloves.

Procedure
1. Explain to the client what you are going to do, why is it necessary, and how she can cooperate.
2. Wash hands and observe other appropriate infection control measures.
3. Provide the client privacy.

Donning a Sterile Gown

1. Open the package of sterile gloves by removing the outer wrap (unsterile) and the inner sterile
pack of gloves on the sterile area.
2. Open the sterile pack of gown on separate flat and clean surface of table.
3. Wash and dry hand carefully.
4. Put on the sterile gown.
a. Wear a complete attire design for OR room only especially in restricted area and perform a
surgical scrub.
b. Grasp the folded sterile gown from the sterile package and step away from the table into the
clear area to provide a wide margin of safety while gowning.
c.Holding the folded gown, carefully locate the neckband or centerfold of the gown.
d.While holding the neckband with both hands, or holding the centerfold with one hand, gently
shake the fold of the gown.
e. Slip both hands into the sleeves, holding the hands upward on the level of the shoulder with
out touching the outside part of the gown with bare hands.
f. Circulating nurse reaches inside the gown to the sleeve seams and pull the gown on, leaving
the off of the sleeves extended over the hands.
g. Circulating nurse fastens back part, ties waist band, without touching outside part of the gown.

GOWNING FOR OPEN GLOVE TECHNIQUE PROCEDURE

1. Reach down to the sterile package and lift the folded gown directly upward or scrub nurse received
sterile gown from the circulating nurse.
2. Step back away from the table, into a clear area, to provide a wide margin of safety while gowning.
3. Holding the folded gown, carefully locate the neckband or centerfold.
4. While holding the neckband with both hands or holding the center-fold with one hand, gently shake the
folds from the gown.

5.Slip both hands into the sleeves, holding the hands upward on shoulder level without touching the
outside part of the gown with bare hands.

6.Circulating nurse reaches inside the gown to the sleeves seams and pulls the sleeves over the hands to
the wrists.

7. Circulating nurse fasten back part, ties waist band, touching outside of the gown at tail of ties or
fasteners in the back only.

GOWNING ANOTHER PERSON

A team member in sterile gown and gloves may assist another team member in gowning.

1. Offer the towel to the surgeon and assistant surgeon being carefully not touch the bare hands.

2. Unfold the gown, holding it at the neckband.

3.Hands on the outside part of the gown under protective cuff and shoulder area, offer the gown to the
surgeon slips into the sleeves.

4. Release the gown, when the surgeon holds arm outstretched while the circulating nurse pulls the gown
into the shoulder and adjust the sleeves of the gown.

CHANGING GOWN DURING OPERATION

Circulating nurse unfasten the neck and waist band. By gasping at the shoulder the gown is pull
off inside out. The gown is always removed first before the gloves. If only the sleeves are contaminated, a
sterile sleeve may be put on over the contaminated one. Preferably a sterile team member may gown
another. If it is not possible, step aside and put on a sterile gown.

REMOVING OF THE GOWN

The gown is always removed before the gloves. It is pulled downward from the shoulders, turning
the sleeves inside out as it is pulled off the arms. Sequence of the scrub nurse removing soiled gown after
the operation is gloves, eye google, gown, face mask, and head gear or cap. Clean arms and scrub dress
are protected from contaminated outside part of the gown.

PROCEDURE IN REMOVING GOWN

1.With gloves on, loosen cuffs of the gown and shake them down over the wrists.

2.Grasp the right shoulder of the gown (unbuttoned or untied) with left hand.

3. In pulling the gown, off arms, turned arm gown away from the body with flexed elbow.

4. Grasp the other shoulder with the other hand and remove the gown entirely, pulling it off out, thus the
arm kept clean.
GLOVING

A sterile gloves complete the attire for scrubbed team members. Sterile gloves are put on immediately
after gowning.

PUPOSES:

To exclude skin as a possible contaminant. To create a barrier between sterile and unsterile areas. To
permit the wearer to handle sterile supplies or tissues of the operative wound.

CLOSED METHOD

1. Using the left hand, keeping it within the cuff of the left sleeve, pick up the glove, from the inner wrap of
the package, grasping the folded cuff.

2. Extend the right forearm with palm upward. Place the palm of the glove against the palm of the right
hand, grasping in the right hand the top edge of the cuff, above the palm. In correct position, glove
fingers are pointing towards you and the thumb side of the glove is to the right. The thumb side of the
glove is down.

3. Grasp the back of the cuff in the left hand and turn it over at the end of the right sleeve and hand. The
cuff of the glove is now the stockinet cuff of the gown, with hand still inside the sleeve.

4. Grasp the top right glove and underlying gown sleeve with the covered left hand. Pull the glove over
right extended until it completely covers the stockinet cuff.

5. Glove left hand in the same manner, of the right hands using the gloved hand to pull on the left glove.

This method of gloving uses a skin to skin , glove to glove technique. The hand, although
scrubbed but it is not sterile and must not contact the outer part of the glove which is sterile one. The
everted cuff of the gloves exposes the inner surfaces. The first glove is put on with skin to skin technique,
bare hand to inside cuff. The sterile part of the gloved hand then may touch sterile exterior part of the
second glove, which is glove to glove technique.

Open Gloving Technique

This method of gloving uses a skin to skin , glove to glove technique. The hand, although
scrubbed but it is not sterile and must not contact the outer part of the glove which is sterile one. The
everted cuff of the gloves exposes the inner surfaces.

The first glove is put on with skin to skin technique, bare hand to inside cuff.

The sterile part of the gloved hand then may touch sterile exterior part of the second glove, which
is glove to glove technique.

It is use when only sterile glove is worn, as for intravenous cut down or administering of spinal
anaesthesia or in emergency department when suturing laceration or wound.

STEPS OF OPEN GLOVING

1.With left hand, grasp the cuff of the right glove on the fold. Pick up the glove and step back from the
table. Look behind you before moving.

2. Insert right hand into the glove and full it on the fold. Pick up the glove and step back from the table.
Look behind before moving.

3. Insert right hand into the glove and pull it on, leaving the cuff turned well down over hand.

4. Insert hand into the left glove and full it on leaving the cuff turned down over the hand.

5. With fingers of the right hand, pull the cuff of the left glove over cuff of the left sleeve. Avoid touching
the bare wrists.

6.Repeat step 5 for the right cuff, using the left hand, and thereby completely gloving the right hand.

GLOVING ANOTHER PERSON

1.Pick up the right glove, grasp firmly, with fingers under the everted cuff. Hold the palm of the glove
towards the surgeon.

2. Stretch the cuff sufficiently for the surgeon to insert the hand. Avoid touching the hand by holding
thumbs out.

3.Exert upward pressure us as the surgeon plunges the hand into the glove. Unfold the everted cuff of the
glove cuff over the cuff of the sleeve.
4.Repeat for the left hand.

DRAPING – is covering of the patient & surrounding area with sterile barrier to create sterile
field.

THINGS TO REMEMBER IN DRAPING are the following: Allow sufficient time to permit careful
application. Allow sufficient space to observe sterile technique. Handle the drape as little as possible.If
drape become contaminated, do not handle it further. Discard it without contaminating gloves & other
particle. If in doubt of sterility, considered it contaminated. If end of sheet fall below the waist level,
discard it. Never reached across the operating table to drape the opposite side, go around the table. Put
the towel and towel clips to the side of the table from which the surgeon is going to apply them before
handling them to him. Carry the folded drapes to the operating table, watch the front of the sterile towel or
laparotomy sheet, it may bulge and touch the non sterile table or blanket of the patient. Stand well back
from the non sterile table. Hold drapes high enough to avoid touching them with the blanket or surface of
the patient but avoid touching the light or lamps.Do not let your gloved hand touch the skin of the patient.
Hold the linen high until it is directly over the proper area then lay it down where it is kept in place.If the
drape is incorrectly placed, the circulating nurse discard it from the table with out contaminating other
drapes or site. In folding the sheet on the operative site, towards the foot or the end of the table, protect
the gloved hand by enclosing it in the turn back cuff of the sheet provided for the purpose. A towel clip
that has been fastened through a drape has its points are contaminated. Remove it only if absolutely
necessary then discard it. Draping with sterile laparotomy sheet the scrub nurse carries folded sheet to
table. Standing far back from table, with one hand lay sheet on the patient so that opening of the sheet is
directly over the prepared skin area. Unfolding upper end of laparotomy sheet over anaesthesia screen.
Note that hands approaching unsterile area were protected in a cuff on the drape and the sheet is
stabilized with other hands.

Preparing & Maintaining a Sterile Field

Purpose: to remove an environment that helps ensure the sterility of supplies and equipment and prevent
transfer of microorganisms during sterile procedure.

Opening A Sterile Drape:

1. Remove the sterile drape from the wrapper and place the inner drape in the surface of the
work surface, at or above waist line level, with the outer flap facing away from you. Rationale:
Maintains sterility of the package and allows for opening the drape in a manner that will not
contaminate the sterile field.
2. Touching the outside of the flap, reach around (rather than over) the sterile field to open the
flap away from you. Rationale: Maintains sterility of the field
3. Open the side flaps in the same manner, using the right hand for the right flap and the left
hand for the left flap. Open the innermost flap that faces you, being careful that it does not
touch your clothing or any object.

Draping of Mayo Table

The scrub nurse start draping mayo table by protecting hands in cuff of the drape. Fold of drape are
supported on arms, in bend elbows, to prevent falling below the waist level. Nurse may place foot on base
of the stand to stabilize it. Complete the draping of mayo table and protect hands from contamination.

Setting up of instruments in Mayo table: the contents are scalpel, straight and curved scissors, smooth
and toothed tissue forceps, retractors, straight hemostats, Kelly clamps, allis, sponges, suture, towel,
sponges and needleholders.

Preparing scalpel blade on knife handle. To avoid injury, always use an instrument like needle holder
or never use your hands. Holding it down and away from the eyes

Adding a Sterile Supplies to the Sterile Field:

1. Open unsealed edge of pre-packaged sterile supplies, taking care not to touch the supplies with the
hands.

2. Holds supplies 10 to 12 inches above the sterile and allow them to fall to middle of the sterile field.
Rationale: Ensures that sterile supplies are placed within the sterile field.

3. Wrapped sterile supplies are added by holding the sterile object with one hand and unwrapping the
flaps with the other hand. Carefully drop the object onto the sterile field.
POURING SOLUTIONS TO A STERILE FIELD

Check the label and expiration date of the solution. Note any signs of contamination. Rationale: Ensures
that the correct solution is used and that is sterile. Remove cap and place it with the inside facing up on a
flat surface. Do not touch inside of cap or rim of bottle. Pour a small amount into a sink or waste container
to rinse the rim of the container. Hold bottle 6 inches above the receptacle on the sterile field and pour
slowly to avoids spills. Rationale: Spilling fluid on the sterile field results in contamination because wet
surface allows microorganisms to transfer from the flat surface which is not sterile. Recap the solution
bottle, place it outside the sterile field and label it with date and time of opening if the solution is to be
reused. Rationale: Keep solution in the bottle sterile and avoids use of solution that has passed
expiration date. Add any additional supplies and don sterile gloves before starting the procedure.
Rationale: Donning a sterile gloves just prior to beginning the procedure helps to ensure sterility.

SCRUB NURSE complete proper hands scrubbing, gowning, and gloving to set up the back table, Mayo
tray and prep stands, and have all the instrument ready. Starting to drape the Mayo table or stand by
hands are protected in cuff of the drape. Folds of drape are supported on arms in bend of elbows to
prevent falling below the waist level. Nurse may place the foot on base of the stand to stabilize it.
Completing the draping of Mayo stand. The nurse’s hands are protected in the cuff. Arrange the
instruments according to the policy of institution. Putting scalpel blade on the knife handle. To avoid
injury, always use an instrument never use your hands. Holding it down wards away from the eyes with
strong needle holder not a hemostat, grasp blade at its widest, strongest part, and slip the blade to groove
on the handle. Prevent damage of the blade.

Handling Sterile Supplies

Circulating nurse is responsible for opening the outer wrapper of the sterile supplies that will be use for
the operative procedure. Unsterile nurse should not reach over a sterile surface or sterile field. Opening a
sterile article that is wrapped in a doubled thickness of linen with four corner is folded in, the corner
farthest from the nurse should be open first and the corner nearest to the nurse opened last. Solution
must be poured into the sterile pitcher that is on the sterile table, the circulating nurse should wait until the
scrub nurse can hold the pitcher away from the table or set the pitcher away from the table or set the
pitcher on the corner of waterproof draped table. The unsterile nurse must not touch the sterile supplies or
equipment. A distance of 12 inches (29 cm.) should be maintained by the circulating nurse from the sterile
field or equipment. Unsterile nurse must be very careful when walking around sterile field. Only the top of
sterile table are considered sterile. Anything falls over the edge of sterile table is considered unsterile.
Splashing can be avoided when pouring solution by tilting the bottle so that air can get into the bottle at
the same time the solution poured out. Circulating nurse should take an extra precaution to avoid
contamination when removing lid or caps from the sterile supplies. Once the bottle of saline solution is
open, the lid or cap should not be replaced. Irrigating solution must be tested the sterility. When using of
wet transfer forceps, it should not touch the sterile area unless it is waterproof. Tips of forceps are kept
down so that the solution will not run down to the unsterile handles. Only tips are used to handle sterile
items or supplies.

CARE OF PATIENT PRIOR TO SURGERY

The pre operative medication must be given a chance to work. When checking the patient chart, the
circulating nurse should ascertain the following: Consent were signed according to hospital policy.
Laboratory reports complete and verify the result for any abnormalities for referral to doctor. Surgeons
order been carried out. Pre-op meds given as ordered. Has patient prepared properly.

Duties of Circulating Nurse: Be aware of emergency procedures. Anticipate the needs of the scrub
team all equipments and supplies ready including solution, and dressings. Keep operating room neat for
safety. Complete specimen cards and labels. Complete records. Inform head nurse the progress of the
procedures so that next case must be prepare at once. Observe scrub team for perspirations and wipe it.
Give medication as ordered. Count used sponges to approximate blood loss and report to
anesthesiologist.

Immediate Post Operative Care is assessment in immediate period after surgery before tranfering to
Post aneathesia Care Unit (PACU). CLINICAL ASSESSMENTS: Adequacy of airway- no obstruction.
Oxygen saturation -95 to 100 % by pulse oximeter. Adequacy of ventilation (RR, rhythm, & depth, use
accessory muscle, breath sounds). Cardiovascular status(HR, & rhythm, Peripheral pulse, amplitude &
equality, BP, Capillary refilling).

Post Anesthetic Care  Nursing Responsibilities are maintenance of pulmonary ventilation by

positioning the client to side lying or semi-prone position to prevent aspiration. Oropharyngeal or
nasopharyngeal airway is left in place following administration of general anaesthetic until pharyngeal
reflexes have returned. It is only removed as soon as the client begins to awaken and has regained the
cough and swallowing reflexes All clients should received O2 at least until they are conscious and are
able to take deep breaths on command.
Surgical Instrumentation

Classification of instrument

a. Cutting and Dissecting

i. Scalpels

ii. Knives

iii. Scissors

 Tissue/dissecting: must have sharp blades; for cutting tough tissues

 Sutures scissors: have blunt points
 Wire scissor: have short, heavy blades used to cut stainless steel sutures
 Dressing/bandage scissor: used to cut drains and dressings and to open items such as
plastic packets.
 Bone cutters and debulking tools

b. Grasping and holding

i. Tissue forceps
> Smooth/thumb/pick-ups: resemble tweezers; tapered and have serrations at the tips; used for
delicate tissue
> Toothed: has a single tooth on one side that fits between two teeth on the opposing side or
have a row of multiple teeth; for tough tissues

ii. Allis: has a scissors action; holds gently but securely

iii. Babcock: has ends that are round to fit a structure or to grasp without injury
iv. Stone forceps: used to grasp calculi
v. Tenaculums: penetrates tissue to grasp firmly (i.e. uterine tenaculum)
vi. Bone holders: for stabilizing bones (i.e. grasping forceps, vice-grip plier)

c. Clamping and Occluding

i. Hemostatic forceps

> Hemostats: for clamping blood vessels

> Crushing: used to crush tissues or to clamp blood vessels (i.e. Kocher and Oschner
forceps: Pean intestinal forceps: kidney forcep)

ii. Noncrushing vascular clamps: used to occlude peripheral or major blood vessels temporarily

d. Exposing and Retracting

i. Handheld retractors
> Malleable: may be bent to desired angle and depth for retraction
> Hooks: for retracting delicate tissues

ii. Self-retaining: used to spread the edges of the incision and to hold them apart

e. Suturing and Stapling

i. Neddle holder: used to grasp and hold curve surgical needles

> Tungsten carbide jaws: used to eliminate twisting and turning of the needle in the
needle holder
> Crosshatched serrations: provides smoother surface and prevents damage to the
needle
> Smooth jaws: used with small needles such as those used for plastic surgeries

ii. Staplers

 Clip appliers: used to mark tissue and to occlude vessels or small lumens of tubes
 Terminal end staplers: designed for closing the end of hollow organs (e.g. bowel and
stomach) with a double staggered line of staples
 Internal anastomosis staplers: connects hollow organ segments to fashion a large pouch or
reservoir
 End-to-end circular staplers: used to staple two hollow, tube like organs end to end to create
a continuous circuit (i.e. bowel anastomosis after resection)/
f. Viewing

> Speculums: enlarges and hold open a canal

> Endoscopes: inserted through an orifice or incision to view a specific anatomic site

g. Suctioning and Aspirating

i. Suction: involves the application of pressure to withdraw blood or fluids for visibility o surgical
site
> Poole abdominal tip: used during abdominal laparotomy or within any cavity with copious
amount of fluid or pus
> Frazier tip: used when little of no fluid except capillary bleeding and irrigating fluid such as in
brain, spinal, plastic or orthopedic procedures is encountered
> Yankuer tip: for use in the mouth or throat and during surgeries involving ruptured aneursym
> Autotransfusion: for removing blood for autotransfusion

ii. Aspiration

 Trocar: for cutting through tissues for access to fluid or a body cavity
 Cannula: used to aspirate fluid without cutting into tissues; may be used also to open blocked
vessels or ducts for drainage or to shunt blood flow from the surgical site

h. Dilating and Probing: dilators are used to enlarge orifices and ducts while probes are used to explore
the depth of a wound or to trace the path of a fistula

PROPER USE OF SURGICAL INSTRUMENTS

a. Scissors and Hemostats

 The thumb and ring finger are inserted into the rings of the scissors while the index and
middle fingers are used to guide the instrument.
 The instrument should remain at the tips of the fingers for maximum control.
 The ring finger should be inserted into the ring. The tips of the scissors should be pointing
upwards.

b. Thumb Forceps: thumb forceps are held like a pencil

c. Scalpels
 The scalpel is held with thumb, middle and ring finger while the index finger is placed on the
upper edge to help guide the scalpel.
 Long gentle cutting strokes are less traumatic to tissue than short chopping motions.

Learning Evaluation

Case Scenario:

A 35 years old mother G2P1 had previous cesarian section in her first child was admitted in OB ward.
She is 39th weeks pregnant and scheduled for elective cesarian section . She has history of elevation of
blood sugar during the course of pregnancy. The latest fasting blood sugar result is 120mg/dL. The latest
vital signs are Blood pressure – 120/85mmHg, temperature 370c, Respiration- 21bpm, Pulse rate –
88bpm. Doctor order for cesarian section today after pre-op preparation accomplished. The nurse started
intravenous fluid of D5LRs 1 liter on the right cephalic vein and regulated to 40gtts per minute. The ward
nurse inform the operating room staff about the patient’s shedule for operation. OR nurse ensure that the
major set of instruments, materials and equipments for cesarian section is ready. The Operating room
nurse fetch the patient in OB ward accompanied by the nursing aide. Endorsement was done between
OB ward nurse Wenna and OR nurse Micah regarding the patient’s status, Physical and psycholgical
preparation and other necessary concerns.

OR nurse started the pre-op preparation in OR; transfering patient to OR table, psychological and spiritual
support provided. Setting up of the sterile field done by scrub nurse Lorie. The scrub team were informed
and proceed to scrubbing room. Induction of anesthesia was done by anesthesiologist Dr. Hilotin assisted
by nurse Buddy. Skin preparation,draping of patient, and counting of instruments done then followed by
surgical “TIME OUT” by circulating nurse Buddy. Continuous monitoring of patient and scrub team was
done until the procedure finished and immediate post op care was provided by nurse Buddy.

Answer the following and submit through my e-mail- [email protected]. The due date of
submission will be posted in group chat or google chat.

1. Make a Nursing procees using ADPIE format.

2. Enumerate what are the important data to be asked to patient and OB ward nurse during
endorsement.
3. Enumerate the considerations to remember by the scrub team prior to surgical scrubbing.
4. Enumerate the duties and reponsibilities of the OR health team.
5. Enumerate the Nursing responsibilities of Nurse Buddy after the procedure was done.
6. Describe the operating room set-up.
7. Describe the sequence of donning and doffing of PPE in OR.

Essay

1. What would you do if, during your OR experience, you accidentally touched an unsterile object
with your sterile gloved hand?
2. What would you do if, while scrubbing, you accidentally touched the faucet?
3. Is it OK to prepare a sterile field an hour before the scheduled surgical case and leave the room
to set up another OR room? Why or why not?
4. What should you do if you notice a break in sterile technique by another member of the OR team
that they may/or may not be aware of?

Reference

Berman, A., Snyder, S., Frandsen, G., (2018) Kozier & Erb’s Fundamental of Nursing, Concept, Process
and Practice, 10 ed., Pearson Education Ltd.

Barela, E., et, al. (2010) Operating Room Technique Instrutional Manual, 2 nd ed. Wiseman’s Book Trading

Hinkle, J., Cheever, K., (2014) Brunner & Suddarth’s, Textbook of Medical – Surgical Nursing 13 th Ed.
Wolter’s Kluwer Health/ Lippincott, Williams & Wilkins.

Ignatavicius Workman (2016). Medical-Surgical Nursing Patient Centered Colaborative Care.8th Ed.