OPERATING ROOM

TECHNIQUES
 
INTRODUCTION
A. General. The positioning of the patient for surgery is one of the most important
nonsterile procedures in which the OR specialist assists because placement of the
patient in the proper position safeguards the patient and affords him comfort while
enabling the medical officer and the anesthetist to work effectively.
B. Responsibility for Ordering the Patient's Position. The choice of position is made
by the surgeon, with minor adjustments, if necessary, for the type of anesthesia and its
administration. The responsibility for positioning the patient rests with the anesthetist;
however, since he is usually busy with the details of the anesthetic, he normally
delegates this responsibility to the specialist under his supervision. Important
considerations in positioning the patient include the following:

1.
1. The type of surgery scheduled. The operative area must be
accessible and easy to keep sterile, and the position must be
conducive to speed and efficiency of the surgeon.
2. The type of anesthesia to be given. The patient's position must
permit sufficient space for the necessary equipment.
3. Protection of patient's vital processes. The patient's vital
processes must not be impaired because of his position for
surgery.
C. Equipment for Positioning. Before he can effectively position patients, the
specialist must familiarize himself in detail with the mechanism of the operating table he
will use, as well as the table attachments and the various supplies used. Following the
acquisition of this basic knowledge, the specialist may gain skill and proficiency in the
manipulation of the table and the placement of the attachments through practice.
1. The operating table (see figure 1-4). Operating tables differ among hospitals and
among rooms in the same hospital. However, most of the tables consist of a rectangular
metal top that rests upon a hydraulic, wheeled base. The table is designed for
placement of the patient in many different positions, while enabling his body structures
and his vital processes to be safeguarded no matter what his surgical position is.
Various features of the table that enable it to fulfill its functions are as follows:
Figure 1-4. Operating table

(a)  The tabletop is divided into three or more hinged sections, each of which can be
manipulated by means of a lever or a push button. The individual sections of the table
can be flexed or extended so that the patient may be placed in any desired position.
This procedure of adjusting the sections is often called "breaking" the table since the
joints are referred to as "breaks."
(b)  The table is equipped with a crossbar (body elevator) that can be used as an
elevator for gallbladder or kidney operations. The bar is manipulated by a lever.
(c)  There are metal clamps along the sides of the table for the insertion of various table
attachments needed, such as the anesthetist's screen, the footboard, stirrups, shoulder
braces, and body rests.
(d)  Levers and lifts enable the entire table to be tilted from side to side or end to end
and raised or lowered as desired. There is a brake locking the table base and a
tiltometer that indicates the degree of tilt between vertical and horizontal.
(e)  A mattress or pad is designed to fit the table, constructed in sections, and covered
with conductive material for safety. This type of a covering also enables easy cleaning.
(f)  The proper maintenance of the table is essential in ensuring that the table is always
ready to serve its purpose. After each use, the operating table is cleansed with
antiseptic solution. If blood or secretions are on the table, it is first washed with soap
and water and then with an antiseptic solution. The metal table can be cleaned quickly
and easily. In addition, the table should be checked daily for the stability and workability
of all levers, brakes, and other mechanisms. Any faults should be reported immediately
for repair.
2. Table attachments. All attachments used to secure the patient in the desired position
must be adequately padded to prevent trauma. Fresh padding is used for each patient.
(a)  The anesthetist's screen is either a rectangular or a curved rod that keeps the sterile
drapes off the patient's face and separates the sterile from the nonsterile field at the
head of the table. Sterile drapes may be attached to intravenous (IV) standards on
either side of the table rather than placed over the anesthetist's screen.
(b)  The leg strap is made of leather or heavy canvas and is covered with conductive
rubber. Sometimes called a restraint strap, it is used to restrain the patient's legs during
induction of anesthesia and for placement in many positions. (Lithotomy, paragraph 1-
19, is an exception.) The strap must be tight enough to prevent movement, yet not so
tight that it will interfere with circulation.
(c)  The patient's arms are usually restrained in the "lift sheet," a draw sheet that is
placed across the operating table each time it is made up. The patient's arms should be
tucked into the sheet before the anesthesia is started. Wristlets (leather cuffs) may also
be used to secure the patient's hands and arms.
(d)  An armboard of metal or wood may be used in several instances, and it is slipped
under the mattress or attached directly to the table. Uses of an arm board include the
following: support an arm when an intra-venous infusion is employed; support the arm
on the unaffected side when the patient is in the lateral position; serve as an operating
table when the site of operation is the arm or hand; hold the arm away from the field
when the patient's arm at his side would be in the way of the operative area; or to
support the arms when the patient is too obese for the table and hold both his body and
his arms.
(e)  Body rests are curved pieces of metal padded with foam rubber. These are placed
in metal clamps on the sides of the table and slipped in from the table edge against the
body to support and stabilize it in certain positions.
(f)  Kidney rests are wider than body rests, but are also curved metal pieces with
grooved notches at the base. They are slipped in from the side of the table along the
kidney elevator (bar) to fit snugly against the side of the patient, supporting his body
during kidney surgery.
(g)  The metal footboard can be attached flat to increase the length of the table when
necessary, or it may be placed at a 90-degree angle to the table and padded to support
the feet in an upright position. The soles of the feet rest securely against it.
(h)  Shoulder braces are of curved metal and are used to prevent the patient form
slipping toward the head of the table while in certain surgical positions.
(i)  Stirrups are metal posts; they are placed one on each side of the table at the lower
(foot end) break and are used to support the legs and feet when the perineal area is the
site of operation. The knees and lower legs may rest on padded metal supports or the
feet may hang in canvas straps attached to an upright bar.
(j) The cerebellar headrest is a frame that supports the patient's head when he is in the
prone position, and is used in spinal and posterior thoracic surgery. It is shaped to fit the
face and has an opening for the nose and mouth.
3. Additional necessary supplies.
(a)  Pillows of various sizes are used to immobilize or to relieve pressure on a part.
(b)  The lift sheet is used to secure the patient's hands and arms during the operative
procedure.
(c)  Sandbags in various sizes are used to immobilize a part.
(d)  Adhesive tape of various widths and lengths is used when the patient is placed in
certain positions to stabilize the body.
(e)  Materials of foam rubber, sheet wadding, and cotton are used to pad attachments
so that the patient will not be injured.
(f)  Extra sheets and towels are used for stabilization in certain positions.
4. Dressing the table. The table is routinely "dressed" or made up by covering the pad
with a sheet doubled lengthwise and tucked in on the sides and ends. A lift sheet is
placed across the center of the table; it is folded in quarters (fan folded). Folding it thus
keeps the ends of the sheet from dangling down the side of the table, and enables the
ends of the sheet to be moved without disturbing the rest of the lift sheet or the other
linen on the table. The lift sheet facilitates moving and lifting the patient, and it is used to
secure his arms at his sides. The leg-restraining strap is included in "dressing" the table.
D. Principles Influencing Positioning. The principles discussed below govern proper
positioning. The specialist should follow the principles every time he positions a patient. The
observation of these principles will ensure maximum safety and comfort for the patient.

1.
1. The patient should be told why he is being restrained, if he is
awake.
2. Unnecessary exposure of the patient should be avoided.
3. The wheels of the operating table and the litter (or the bed) are
always to be locked before the patient is moved.
4. A sufficient number of personnel must be present to assist with
positioning. At least two persons are required to place the patient in
the surgical position desired.
5. The patient is not to be touched or placed in position until the
anesthetist indicates that it may be done.
6. The patient's body alignment must be correctly maintained while he
is being positioned.
7. The persons who position the patient must be thoroughly familiar
with the mechanics of the table and with its attachments.
8. Personnel who position the patient must also know thoroughly the
different types of positions and the surgical procedures in which
they are used.
9. The specialist should assemble all attachments and supplies
before the patient arrives.
10. When it is necessary to change the patient's position, the specialist
should perform the procedure using movements that are slow,
smooth, and gentle.
11. All OR personnel must have a complete knowledge of the safety
precautions that are mandatory in positioning.

E. Precautions Mandatory in Positioning.

1.
1. Respiration must not be impaired by interfering either with the free
movement of the chest or with the airway. Therefore, anything that
would constrict the chest or put pressure on it must be avoided. A
change in position must be executed slowly, gently, and smoothly
to safeguard the patient from respiratory embarrassment.
 2. Circulation must not be obstructed, either by pressure against the
body parts or by too tight application of restraining straps.
Changing the position of the patient too rapidly may also cause a
circulatory depression (evidenced by a rapid fall in blood pressure).
Free circulation helps prevent thrombus (blood clot), phlebitis (vein
inflammation), and other postoperative circulatory disturbances. It
also helps the flow of intravenous solution or a transfusion, if either
is running and helps to maintain an even blood pressure.
3. Nerve damage must be avoided; nerve injury and paralysis may
result from either pressure on nerves or stretching of nerve tissue.
To avoid such injury, the specialist should place attachments
correctly, making sure that they are well padded. He should also
exercise care that the patient's arms do not drop over the edge of
the table, that they are not pressing against the edge of the table,
and that they are not hyper-extended. Permanent paralysis of a
part may occur because of prolonged pressure on the nerves.

EXAMPLE: Paralysis of the arm may result from incorrect placement of the shoulder
braces.
4. Muscles, tendons, and bones must be protected from injury. Excessive stress on
these structures causes damage and must be avoided. Damage to these structures
results in such postoperative complications as backache, foot-drop, and wrist drop.
F. Positioning the Patient.

1.
1. Equipment. The circulator should assemble the equipment needed.
He should take all needed supplies into the room in preparation for
the operation in addition to the equipment.
2. Practice. The specialist should refer to the procedural manual and
practice positioning until he has acquired skill and confidence. Until
he is well practiced in placing patients in various positions, he
should do practice trials of the position--preferably the evening
before surgery--using a co-worker as the patient. The specialist (if
in doubt about any step of the procedure) should consult his
immediate superior at this time, not when the patient is
anesthetized and ready for positioning,
3. Complications. Positioning looks easy on demonstrations, but the
actual situation is usually complicated by infusion tubes, drains,
size of the patient, and his wound, or his anesthetized condition.
Sufficient assistance must be available before any position is
attempted. Positioning may also have to be changed during the
course of surgery when the drapes, already in place, present a
complication. In this situation, a thorough understanding of how the
table operates is of primary importance.
G. Commonly Used Positions. Frequently used surgical positions are discussed in paragraphs 1-
14 through 1-23. These positions may be modified to conform with local policy, or upon order of
the surgeon. In the illustrations of positions, covers are left off the patient for clarity of
illustration only. The specialist should avoid exposing a patient.
1-14. SUPINE POSITION (DORSAL RECUMBENT)
a.Use. This is the usual position (see figure 1-5) for administering general anesthesia
and for doing most surgery of the abdomen such as laparotomy, herniorrhaphy, and
appendectomy. With slight modifications, it is also used for other types of surgery, such
as surgery on the arms or legs.

Figure 1-5. Supine (dorsal recumbent) position

b. Equipment Needed.
1. The anesthetist's screen.
2. A sheet or bath towel. If support of the head is desired, a sheet or towel is folded and
used--not a pillow, as it would be in the anesthetist's way.
c. Procedure.

1.
1.
1. Look at the operating table to be sure that it is parallel to
the floor.
2. Place the patient flat on his back, his knees over the
lower break of the table, feet slightly apart. The soles of
the feet are supported by a foam rubber support or a
padded footboard.
3. Place the patient's arms and hands at his sides. His
elbows should be slightly flexed and his fingers
extended.
4. Secure his hands and arms with the lift sheet.
5. Place the leg strap at the distal third of his thighs, about
two inches proximal to his knees. Fasten the leg strap
tight enough to secure his legs, but not tight enough to
constrict circulation. Check it by running a hand under it.
If it is fastened too tightly to allow the hand to be run
under it, loosen it enough to correct this. The leg strap is
secured before anesthesia is begun.
6. Remove the covering from the operative area and adjust
the light. (This step is done when the anesthetist gives
"OK," after patient is anesthetized.)
7. Attach the anesthetist's screen.
 8. In order to prevent post-operative discomfort, flex the
table slightly at both breaks or place a rolled towel or
small pillow under the knees. This padding should be
very soft, and should not make the strap too tight.

d. Precautions. Observe the precautions set forth in paragraph 1-13e.

e. Modifications of the Supine Position. The most usual modified supine position is one in which
the table is flexed slightly at both breaks. Sometimes the knees are flexed with a small pillow
instead. A number of other modified positions are mentioned in this paragraph. When the
position of the table is changed with the patient on his back, special precautions are necessary to
protect him.

1.
1.
1. When the head is turned to one side or the other, it
should be supported to keep the spine in alignment and
secured in the desired position with a doughnut cushion,
sandbag, or special headrest.
2. Pressure over bony prominences where nerves and
blood vessels run superficially must be avoided. The
eyes must be carefully guarded against pressure, and
they must be protected as drapes are placed to prevent
corneal irritation from textiles, solutions, and other
foreign bodies.
3. For operations on the neck, the neck may be extended
by placing a narrow support between the shoulder
blades or by lowering the headpiece of the table. There
should be no gaps in the support of the neck in this
position. A special screen that protects the face may be
used in thyroid surgery.
4. For anterolateral incisions and for surgery on the
shoulder or the chest, the patient's affected side may be
elevated on rolls or pads. To prevent twisting of the
spine, the full length of the body needs support that will
keep the hips and shoulders in a plane. Body supports or
straps in appropriate locations maintain the position and
prevent rolling without interfering with the surgical
approach.
5. An arm-board may be used to support the arm on the
affected side. In some cases, both arms are supported
on arm-boards. In a few cases, the arm may be
bandaged to the ether screen, using specific precautions
against nerve and circulatory disturbances. In many
procedures, one arm is usually extended on an arm-
board to administer intravenous therapy. One or both
 arms may be extended in radical mastectomy and other
surgery on the upper extremity and chest regions.
6. The arm-board is padded to protect the skin and
superficial tissues from pressure. The arm is extended at
an angle less than 90 degrees to the table and level with
the table. The arm-board is of the type that locks into
position on the table to prevent inadvertent angle
changes. Hyperabduction at the shoulder may cause
both vascular and neural damage. Venous thrombosis
may result when superficial veins are compressed by
supports or straps or by the weight of body structures.
The subclavian or axillary arteries may be occluded in
abduction.

1-15. TRENDELENBURG POSITION

a. Use. The Trendelenburg position (see figure 1-6) is used for operations on the
bladder, prostate gland, colon, female reproductive system, or for any operation in
which it is desirable to tilt the abdominal viscera away from the pelvic area for better
exposure.

Figure 1-6. Trendelenburg position. Note that the knees are over the lower break in the table and
shoulder braces are in place

b. Equipment Needed.

1.
1.
1. Shoulder braces.
2. Padding, made of sponge rubber or of folded hand
towels.

c. Procedure.

1.
1.
1. Place the patient in the supine (dorsal recumbent)
position and adjust the mattress so that his knee joints
are directly over the lower break. The knees must bend
where the table breaks to prevent pressure on blood
vessels and nerves in the popliteal region, avoiding
complications of phlebitis or paralysis of the leg. Secure
patient's arms and legs.
 2. Attach well-padded shoulder braces to the table. Check
to see that the braces are the same distance from the
head of the table.
3. Adjust braces so that they are on the outer part (bony
joint) of the shoulders rather than against the neck.
Braces should be adjusted one-half inch from shoulders
to prevent excessive pressure when the head of the
table is lowered.
4. Flex the table at the knees, dropping the leg portion
usually to an angle of 30 to 40 degrees.
5. Tilt the entire table, the head low, to the angle desired by
the surgeon, usually 30 to 40 degrees. The head should
be lower than the knees.

d. Precautions.

1.
1.
1. The nerve supply to the upper extremities comes from
the spinal cord, gathers at the brachial plexus and
emerges under the muscles in front at the root of the
neck, where the neck and shoulder join. It is very
important to protect these nerves when using the
Trendelenburg position. This is done by using adequate
padding on the shoulder braces, and by placing the
braces at the outer aspect of the shoulders over the
acromion and spinous process of the scapula.
2. Careful positioning of the knees over the break is needed
to prevent pressure in the popliteal space and safeguard
the perineal nerve. Breaking the table at the knees takes
some of the body weight off the shoulder braces and
reduces pressure there. The legs are straightened before
the patient is returned to a horizontal position.
3. While this is mainly the anesthetist's concern, you should
also know that this position may result in respiratory
distress.
e. Modification of the Position. The Trendelenburg position is often mistakenly confused with
shock position (extreme Trendelenburg position). The two are the same, except that in shock
position, the table is straight (unbroken) at the knees so that the feet are higher than the head.
1-16. REVERSE TRENDELENBURG POSITION
a. Use. The reverse Trendelenburg position (see figure 1-7) may be used for surgery on
the neck, such as thyroidectomy, and for certain abdominal surgery, such as liver or
gallbladder operations.
Figure 1-7. Reverse Trendelenburg position.

b. Equipment Needed.

1.
1.
1. Two small pillows or two folded sheets.
2. Footboard, padded.

c. Procedure.

1.
1.
1. Place the patient flat on his back. Adjust the mattress so
that his shoulders are at the upper break of the table. If
surgery is in the neck area, place a small pillow or a
folded sheet transversely under the neck and shoulders,
as shown in figure 1-7.
2. Attach the padded footboard at a 90-degree angle to the
table and adjust it so that the soles of the feet are resting
against it. Place padding under the legs (see figure 1-7)
to take pressure off the heels.
3. Secure the arms and legs.
4. Tilt the table, foot forward, to the desired angle.
d. Elevator Bridge. Some surgeons make use of the elevator bridge of the operating table to
expose the gallbladder. When this is anticipated, the patient must be positioned with the costal
margin at the level of the elevator. If an elevator is lacking, the table may be flexed at this level,
or a pad may be inserted to achieve the desired position.
1-17. LATERAL KIDNEY POSITION
a. Use. The lateral kidney position (see figure 1-8) is used for surgery on the kidney or
the proximal third of the ureter.

Figure 1-8. Right kidney position.Note the kidney strap across the hips for stabilizing the body and raised
kidney elevator for hyperextending operative areas.

b. Equipment Needed.

1.
1.
 1. One or two large, soft pillows.
2. Armboard, well padded.
3. Short kidney rest.
4. Long kidney rest.
5. Foam rubber cushion.

c. Procedure. The patient is in the dorsal recumbent position until he is anesthetized. When the
patient is ready for positioning, the circulator and his "unsterile" assistants are to proceed as
follows:

1.
1.
1. Turn the patient onto his unaffected side and bring his
back near the edge of the table. Then wait until the
anesthetist has checked the patient's blood pressure
before continuing with (2) below.
2. Manipulate the mattress as necessary until the patient's
kidney area (the area between the crest of the ilium and
the first rib cephalad from the iliac crest) is over the body
elevator (crossbar, para 1-13c(1)(b)) of the table.
3. Flex the (lower) leg on the unaffected side at the knee,
extend the (upper) leg on the affected side and place a
pillow lengthwise between the legs. Also, place padding
under the leg in contact with the table at the sites of bony
prominences (hip, knee, and ankle).
4. Place a restraining belt or adhesive strap across the hips
and chest to stabilize the body. Check the belt or strap
for tightness by running your hand under it. Your hand
should run smoothly under the belt or strap. Adjust as
necessary.
5. Position the arms by bringing them to the front of the
patient. Flex the elbows slightly and place the arms on a
well-padded double arm-board or Mayo stand. The arm
of the unaffected side is usually used for intravenous
infusion or transfusion.
6. A well-padded short kidney rest is placed at the patient's
back.
7. Place a long kidney rest, well padded, in front.
8. Adjust the body elevator only upon the order of the
anesthetist or the surgeon. When manipulating the bar,
 move it slowly, because too sudden a change may result
in complications in the patient's respiration or circulation.
9. Adjust the table to make the operative area horizontal.
1-18. LATERAL CHEST POSITION
a. Use. The lateral chest position (see figure 1-9) is used for thoracoplasty,
pneumonectomy, and lobectomy.

Figure 1-9. Right lateral position. Note the strap across the hips and body rest for stabilizing the body.

b. Equipment Needed.

1.
1.
1. Single armboard.
2. Small, hard pillow/form rubber cushion. Large, soft
pillow.
3. Two chest rests/sandbags.
4. One or two kidney straps.
5. Three inch adhesive tape.

c. Procedure.

1.
1.
1. Place the patient on his unaffected side with his back
near the edge of the table. This requires two people: the
anesthetist managing the head and shoulders, and the
assistant moving the hips.
2. Place the upper leg straight with the patient's body, and
flex the leg on the lower side. Place a pillow lengthwise
between the legs.
3. Place a folded sheet or a small hard pillow under the
patient so that it is immediately beneath the operative
area (see figure 1-9). This relieves some of the pressure
on the arm on the unaffected side and permits the free
flow of any replacement fluids infused through the
vessels of this arm.
4. Place a chest rest near the lumbar area, and another at
the level of the axilla.
 5. Bring the patient's arms and hands in front of him near
his face and secure them. Secure the arm on the
unaffected side to a padded arm board and the other
arm rests on a pad as it hangs over the side of the table.
This draws the scapula away from the operative area.
 
6. A pad or small pillow is used to align the head and neck.
7. Secure a strap over the hips. A second strap is
sometimes used to stabilize the shoulder.
8. Tilt the table slightly, with the patient's head towards the
floor if the patient needs postural drainage during
surgery. If the patient's head is to be lowered, secure the
mattress to the table to prevent it from slipping.
1-19. LITHOTOMY POSITION 
a. Use. The lithotomy (see figure 1-10) position is used for surgery in the perineal area,
such as drainage of rectal abscesses and perineal prostatectomies, and for
gynecological surgery such as vaginal hysterectomy.

Figure 1-10. Lithotomy position.

In the lithotomy position, the patient is on his back with the foot section of the table
lowered to a right angle with the body of the table. Knees are flexed and the legs are on
the outside of the metal posts with the feet supported by canvas straps. The buttocks
are even with the table edge.
b. Equipment Needed

1.
1.
1.
1. Bucket
2. A double-ringed basin stand, or an extra Mayo
stand.
3. One pillow.
4. A rubber sheet, a Kelly pad, or a disposable
paper mat, and a kick
5. Extra folded sheet or bath towel.
6. Folded hand towels for padding the stirrups.
7. Stirrups-upright bars with canvas straps.
c. Preliminary Preparation of the Table. The specialist makes some adjustment and preparation
of the table before positioning the patient.

1.
1.
1. Pad a double-ringed basin stand or an extra Mayo stand
with a pillow and place it at the foot of the table. The
stand is used as a temporary table extension. If the table
has a removable headrest, the headrest can be used as
the temporary table extension.
2. Cover the table from the knee break to the foot; first with
a rubber sheet or a Kelly pad, and then with an extra
folded sheet or bath towel.
d. Procedure. For the administration of anesthesia, the patient is placed in the supine
position with buttocks at the edge of the knee break. In this position, the patient's legs
will of course extend beyond the end of the table, but they will be supported by the extra
basin stand, Mayo stand, or headrest. When the patient is anesthetized, the specialist
and an "unsterile" assistant place the patient in position as follows:

1.
1.
1. Remove the leg restraint.
2. Fold the patient's arms and hands either across his
upper abdomen or across his chest. See paragraph 1-
19e, Precautions.
3. Make sure the two stirrups are level, and at the proper
height. Each of the two "unsterile" team members takes
a position on either side of the patient at the foot end of
the table. Each team member grasps a patient's leg near
the knee with the other hand. The team members then
flex the patient's legs and simultaneously lift them and
place them in the padded stirrups. It is important that
both legs be lifted at the same time to prevent injury to
the patient.
4. Place the legs in the padded metal supports and secure
the straps. To position the legs using canvas straps,
bring the legs to the outside of the upright bars. Loop the
strap once around the sole of the foot and once around
the heel. Pad the bars with folded hand towels in the
areas where they are touching the legs or where the legs
may press against the bars.
5. Remove the basin stand or Mayo stand, if used.
6. Remove foot section of the table mattress and break and
drop the foot of the table.
 7. Pull the stirrups forward to extend slightly beyond the
foot end of the table. Viewed from the side, the legs
should form a "Z" shape with the angle of the buttocks.
8. Place the end of the Kelly pad (if one is used) in the kick
bucket. This pad keeps the table dry under the patient
during the surgical prep. The pad is removed after the
prep and before the patient is draped.

e. Precautions. This unnatural posture is fraught with danger and discomfort for the patient, and
these hazards increase as the position is exaggerated for radical surgery. Extreme flexion of the
thighs impairs respiratory function by increasing intraabdominal pressure. Gravity flow of blood
from elevated legs causes blood to pool in the splanchnic region. Arms also require special care
in lithotomy position. The hands should not extend along the sides, since they will reach below
the break of the foot section of the table and be in danger of injury from manipulation of table
parts. They may be folded loosely across the abdomen and supported by the folded gown or
cover sheet, or one may be extended on an arm-board for infusion while the other is suspended
from the anesthesia screen. Be sure they do not impede chest movement.
1-20. PRONE POSITION
a. Use. The prone (see figure 1-11) position is used for surgical procedures-major or
minor-that are performed on the back, shoulders, neck, or back of the head. Placement
of the patient in the prone position for minor surgery, using local anesthesia, differs in
some respects with placement for general anesthesia.

Figure 1-11. Prone position.

In the prone position, the patient lies on his abdomen. Note shoulder rolls under axillae
and sides of chest to raise body weight from the chest to facilitate respiration. The
patient is anesthetized and the endotracheal tube inserted in dorsal position. He is then
turned to prone.
b. Prone Position for Local Anesthesia.

1.
1.
1. Equipment needed. This equipment is the necessary
material to support the body in good alignment and to
relieve pressure on blood vessels and nerves. Pillows,
sheets, towels, and padded arm-boards are needed.
2. Procedure.
(a) Adjust the table so that it is flat and horizontal.
(b)  Assist the patient in turning onto his abdomen, and have him turn his face to one
side. Place a small pillow or ring cushion under his head to avoid pressure on his ear.
(c)  Place a pillow under his thighs and hips.
(d)  Place a pillow under his feet so that it extends nearly to the knees.
(e)  Flex the arms at the elbows and place alongside the patient's head, on padded arm
boards.
(f)  Place a small pillow or a rolled sheet under each shoulder and down the sides of the
chest, as shown. This prevents pressure on the chest and allows for free respiration.
(g)  Secure the leg strap to the lower third of the thigh and check it for tightness.
c. Prone Position for General Anesthesia (Extended Prone Position). When the surgical
procedure is to be done with the patient in prone position under general anesthesia, the cerebellar
headrest is used to allow the anesthetist access to the patient's respiratory tract.
1. Equipment needed. In addition to that set forth above, the following items are
needed:
(a)  A well-padded cerebellar headrest.
(b)  Shoulder braces, if the patient is to be placed in a head-low position.
2. Procedure. The patient is placed in the dorsal recumbent (supine) position for the
administration of anesthesia. While the patient is being anesthetized, the specialist rolls two
sheets so that they will extend from the patient's axilla to his iliac crests. Turning the patient onto
his abdomen requires four persons plus the anesthetist, who manages the patient's head and any
tubing in use. The procedure is as follows:
(a)  Lift the patient's head slightly, remove the hinged headpiece, and attach the
cerebellar headrest in its place.
(b)  While the anesthetist manages the patient's head, two persons on each side of the
patient turn him first on his side, and then onto his abdomen. At the same time, pull him
toward the head of the table in order that his face and forehead will rest properly in the
cerebellar headrest. Check to see that there is not pressure on the patient's eyes, nose,
or mouth.
(c)  Place pillows.
(d)  Place the two rolled sheets, one on each side, from the patient's axilla to his iliac
crest, thus raising his chest from the mattress and providing free respiration.
(e)  Both arms are arranged on boards.
d. Precautions. These are as described previously (see para 1-13e).
1-21. JACKKNIFE (KRASKE) POSITION
a.  Use. The jackknife (Kraske) (see figure 1-12) position is used for surgery on the
coccyx, buttocks, or rectum, particularly when the patient has had spinal anesthesia and
there is no objection to his being placed either face downward or head low.

Figure 1-12. Kraske position. Note that the hips are over the table break, and the table is flexed at a 90-
degree angle.

b. Equipment Needed. Pillows for support. Padded armboards. Adhesive straps. Body
rolls.
c. Procedure. The patient is anesthetized in the appropriate position, depending upon
the type of anesthesia used. When he is ready for positioning, the following steps are
taken:

1. Turn the patient on to his abdomen. (This is done by four persons plus the
anesthetist as described in paragraph 1-20c(2).
2. Place the patient's hips directly over the break of the table. A pillow may be
placed under his hips (not shown in figure 1-12).
3. Position the patient's head by turning it to one side. Place small pillow or a
ring cushion under his head as discussed above. The feet may be allowed to
hang over the foot end of the table to prevent pressure on the toes. Place a
pillow or padding under the legs.
4. Secure the leg strap and check it for tightness.
5. Flex his arms and elbows, and place his arms on padded armboards or Mayo
stands.
6. Flex the table at the knee break to the angle desired by the surgeon. Tilt the
table and the head floorward to the angle ordered. The patient's hips are thus
placed higher than the rest of his body.
7. Separate the buttocks by securing strips of adhesive tape from the patient to
the side of the table. Before putting the tape on the patient, first paint the area
where the tape is to be placed with tincture of benzoin. Use a sponge forceps
and a 4 x 4 sponge. Be careful not to let the tincture of benzoin spill on the
table or the floor. Let the tincture benzoin dry thoroughly before applying the
tape. An application of tincture of benzoin ensures that the tape will remain
firmly in place and will not be loosened, even during the prep. Patients who
are hairy in the area where the tape is to be placed should have this area
shaved before

1-22. SITTING POSITION

a. Use. Included in surgery for which the patient sits upright are various operations on the nose
and throat, as well as some plastic surgical procedures. The sitting position (see figure 1-13) is
described using the operating table as a chair.
Figure 1-13. Sitting position.

b. Equipment Needed. Most of the items discussed below for the support of the patient are
omitted from figure 1-13 for clarity of illustration. The equipment needed are one pillow, two
sheets, shoulder straps, and a padded footboard.
c. Procedure.

1.
1.
1.
1. Attach the footboard at a 90-degree angle to
the table.
2. Secure adhesive straps across the mattress
for stabilization.
3. Secure ends of lift sheet under the mattress.
4. Break the table into a sitting position.
5. Pad the footboard with a folded sheet.
6. Assist the patient onto the table.
7. Adjust and secure the leg strap. Adjust the
footboard so that the feet are resting securely
on it.
8. Place a sheet around the patient so that it
reaches from the axilla to the iliac crest. Leave
the arms free. Tie the sheet behind the table,
using a square knot.
9. Place a pillow in the patient's lap to support his
arms. The arms may then be restrained in the
lift sheet.

1-23. POSITIONS FOR SPINAL ANESTHESIA

a. Discussion. The patient may be in either a lying or a sitting position for the
administration of spinal anesthesia. The position used will depend upon the condition of
the patient and the preference of the anesthetist.
b. Lying Position (see figure 1-14). Most subarachnoid blocks are given with the patient
lying on his side.

Figure 1-14. Lying position for spinal anesthesia.

This is the Sims position and is often referred to as the curled lateral position and is
useful in establishment of subarachnoid and epidural anesthesia. (From Martin, J.T.,
M.D.; Positioning in Anesthesia and Surgery, ed. 2, Toledo, Ohio, 1987, W. B. Saunders
Company.)
 1.
1.
1. Principles. The two basic principles for the steps
discussed are to get the spinous processes of the
vertebral column parallel to the table and keep them in
that position while the patient is well flexed in order to
open the vertebral interspaces.
2. Procedure.
(a)  Adjust the table so that is flat and horizontal.
(b)  Place the patient on his side with his back even with the edge of the table. Instruct
the patient (if he is able to do so) to bring his knees up toward his chest, and to flex his
head (chin on chest). Ask the patient to curl up, arching his back like an "angry" cat.
(c)  Check to see that the patient's knees are together and that his shoulders are in
alignment, one directly above the other, to facilitate the anesthetist's entering the needle
into the vertebral interspace.
(d)  Caution the patient not to move. Assist him in holding his position by placing one
arm behind his neck and the other arm behind his knees.
(e)  Do not place the patient in the desired surgical position after the anesthetic has
been administered until instructed to do so by the anesthetist.
c. Sitting Position (see figure 1-15). Sometimes, the anesthetist has reason to believe
that, due to the condition of the patient, he may have difficulty in performing the lumbar
puncture satisfactorily with the patient lying down. Faced with this type of situation, the
anesthetist may order that the specialist place the patient in a sitting position.

Figure 1-15. Sitting position for spinal anesthesia.

1.
1. Equipment needed. A stool for the patient to rest his feet upon is
needed.
2. Procedure.

(a)   Place the patient in a sitting position with his legs over the side of the table.  Put the
stool under his feet.
(b)  Instruct the patient to lean forward, his chin on his chest, and to arch his back as
much as possible. Caution him not to move.
(c) While the lumbar puncture is being performed and the anesthetic is being
administered, stay with the patient. Support the patient by holding his head and
shoulder with one arm and his thigh with the other arm. Watch the patient closely for
any unusual signs or symptoms such as paleness, weakness, and dizziness. Do not
place the patient in the desired surgical position until the anesthetist orde
 
click the link to view in .pptx format  OR TEAM-1.pptx

OR TEAM
OR TEAM MEMBERS:

1. STERILE TEAM

 Team members scrub their hands and arms, put on sterile gown and gloves,
and enter the sterile field.
 STERILE TEAM consists of:
o Surgeon
o Assistant surgeon
o Scrub Nurse
STERILE FIELD

2. UNSTERILE TEAM

 Anesthesiologist
 Circulating Nurse
 Others:
o Medical tech
o Radio Tech
o Transport Aides

DUTIES & RESPONSIBILITIES OF EACH TEAM:

The Scrubbed Sterile Team:
1. SURGEON
  
  He serves as the leader of the team.
 He performs the surgery.
 He must be certain that all members are aware of what is needed during the
surgery and that all necessary equipment and instruments are available.

2. ASSISTANT SURGEON

 He may be a surgeon, a resident, an intern or a clerk.

 He assists the surgeon during the surgery in any way the surgeon requests.
 He holds retractors in the wound to expose the operative site.
 He assists in suturing and ligating bleeders.

3. SCRUB NURSE
A. Before the surgeon arrives:

 Do a complete scrub

 Put on sterile gown and gloves

 Drape tables as necessary

 Drape the mayo stand
 Count sponges, instruments, needles and sharps.
 Arrange the instruments on mayo stand
o Instruments are classified as:
 Cutting or dissecting – knives & scissors
 Grasping & holding – tissue & thumb forceps
 Clamping & occluding – Hemostatic forceps and clamps
 Exposing – retractors
 Suturing – needle holders
  Put blades on knife handles/ blade holders (scalpel) 
o Blade holder # 3 – Blade #10, 11, 12, 15
o Blade holder # 4 – Blade #20 & above
o Blade holder # 7 – Blade # 11 & 15    

 Prepare sutures in the sequence in which the surgeon will use them.
 Free ties – use to ligate blood vessels if not they can also use the cautery
machine.
 Count surgical needles with circulating nurse.
 Count all sponges with circulating nurse. Circulating nurse immediately record
it.
o Counts before the start of the operation.
 Counts before the surgeon starts closure of the body
cavity or deep or large incision.
1. Table count
2. Floor count
3. Field count
 Counts all over again before subcuticular closure.
 If sponges are intentionally retained for packing or
instrument remains with the patient, this should be
documented in the patient’s chart.

Incorrect count?  What should be done?

B. After the surgeon and assistant Scrub:
 Gown and glove the surgeons and assistants as soon as they enter the room.

 Assist in draping – offer towel and towel clips, and drapes.

 Bring mayo stand into position after draping is completed.

C. During the Operation

 Hand skin knife to surgeon & hemostat to assistant.*
  Watch field and anticipate needs of the surgeon. Keep one step ahead of him
offering instruments, sutures or sponges. Notify CN for supplies not in the
table.
 Pass instruments in a positive manner. When surgeon extends hand,
instruments should be slapped firmly into palm in proper position for use.
Hemostat – bleeding
Metz Scissor – to cut tissues
Mayo scissor – cuts sutures
 Keep instruments clean as possible, wipe blood with moist sponge.
 Return instruments to mayo stand promptly after use or cleaning.
 Save all tissue specimens.*
 Maintain sterile technique. Watch for any breaks.
4. CIRCULATING NURSE
 CN washes hands and arms 5 minutes at the beginning of the day before
entering the OR but does not use gown or gloves.
 CN must assist the sterile SN by providing the sterile supplies needed.

The Unscrubbed Unsterile Team

1. ANESTHESIOLOGIST
 A physician who specializes in anesthesiology.
 Gives and controls the anesthetic
 Sees to it that all the equipment & supplies.
 Monitors the patient’s vital signs during the operation. 
 Keeps the surgeon aware of the patient’s condition.
 Determines when the patient may be moved to PACU.
2. CIRCULATING NURSE
 the overseer of  the room during the procedure
a. After Scrub Person/ nurse scrubs
o
 Fasten back of scrub person’s gown.
  Open packages of sterile supplies

 the overseer of  the room during the procedure to  maintain sterility.

a. After Scrub Person/ nurse scrubs


o
 Flip suture  or open onto the instrument table or open
over wraps for scrub nurse to take packets.*


o
 Pour NSS into the round basin.
 Count sponges, needles, & instruments
b. After the Patient arrives (CN attends to the Patient).

o
 Greets & identify the patient. Check wristband.
 Check NCP and patient’s chart for pertinent info.
Including consent.
 Be sure patient’s hair is covered with cap.*
 Assist patient in moving from the stretcher/ wheelchair to
the OR table. Use proper body mechanics.
 Apply restraint straps over legs and arms. Keep patient
covered with blanket for privacy and provide warmth.
 Help anesthesiologist, surgeon or assistant as needed.
c. During induction of the anesthesia

o
  Stay in the room and near patient to provide comfort &
assist the anesthesiologist in the event the patient gets
excited.*
 Be quiet as much as possible.
 Excitement may occur during induction from tactile or
auditory stimulation esp. in alcoholics.
 d. After the patient is anesthetized.

o
 Reposition patient only after the anesthesiologist says
so.
 Attach anesthesia screen & other table attachments.
 Note patient’s position. All safety measures must be
observed.


o
 If cautery is to be used, place inactive dispersive
electrode plate in contact with the patient’s skin to
ground the patient properly. Avoid scar tissues, bony or
hairy areas.


o
 Expose appropriate area for the skin preparation.


o
 Turn overhead spotlight over site of incision


o
 Arrange sterile preparation tray & pour solutions.
 Cover the prep tray immediately after use.
e. After surgeon and assistants scrubs

o
 Be alert to anticipate needs of the sterile team.
 Stay in the room. Inform SN if you must leave.
 Keep discarded sponges carefully collected, separately
by sizes and counted.
 Use sponge forceps or gloves. Never with bare hands. 
 Assist in monitoring blood loss. Weigh sponges if
requested by surgeon.
 measure blood volume from suction bottle.
 Obtain blood products for transfusion as needed.
 Know the condition of the patient.
 Prepare & label specimens.
 Complete pt’s chart.
 Be alert to any break in sterile technique
f. During closure

o
 Count sponges, sharps and instruments with the SN
 If another patient is scheduled to follow
 CN shld. Call the ward 45 mins. before the
scheduled time.
 Ask transport aide to fetch patient 30 mins. before
operatrion.
g. After operation is completed

o
 Open neck & back closures of gowns of surgeons &
assistants.
 Assist with dressing.
 Connect all drainage systems.
 See to it that the client is clean- wash off blood, feces.
Put on a clean gown & blanket.
OPERATING ROOM CONCEPTS
Outline:

 Terminologies
 Types of surgery
 Phases of surgery
 OR attire
 OR team/ Duties and responsibilities
 Principles of OR technique
 Surgical Incisions
 Different positions
 Skin preparation
 Anesthesia – Types; stages
 Basic instruments – Functions

Return Demonstration

 Surgical scrub
 Gowning
 Gloving – open/ closed technique
 Serving the gown & gloves

Surgery
Is a unique experience of a planned physical alteration.
Terminology

 Excision surgery names often start with a name for the organ to be excised
(cut out) and end in -ectomy.
 Hysterectomy

 Procedures involving cutting into an organ or tissue end in -otomy.

o A surgical procedure cutting through the abdominal wall to gain
access to the abdominal cavity is a laparotomy.
  Reparation of damaged or congenital abnormal structure ends in -rraphy.
Herniorraphy is the reparation of a hernia, while perineorraphy is the
reparation of perineum.

 Reconstruction, plastic or cosmetic surgery of a body part starts with a name

for the body part to be reconstructed and ends in -oplasty.
 Rhino is used as a prefix for “nose”, so rhinoplasty is basically reconstructive
or cosmetic surgery for the nose.

 Minimally invasive procedures involving small incisions through which an

endoscope is inserted end in -oscopy. For example, colonoscopy.

 Procedures for formation of a permanent or semi-permanent opening called a

stoma in the body end in -ostomy.

3 Phases:
1. Pre-operative phase - begins when the client decides to have surgery and ends
when the client is transferred to the OR bed.
Nursing Activity

 Assessment of the client, evaluate medical history

 Identification of potential or actual health problems.
 Planning specific care based on individual needs
o preoperative skin preparation as appropriate
o provide GI preparation as prescribed NPO (restricting solid food
and fluid for 8 to 10 hours before surgery, administering enema)
 Pre-operative teaching including client and family.
o deep breathing and coughing exercises
o relaxation techniques
o postoperative exercises of extremities
o turning and moving techniques
 o pain-control techniques
o incentive spirometer use
 Perform standard preoperative procedure (complete pre-op checklist)
o Take and record Vital signs, weight
o verify allergy, identification bands
o Validate NPO status
o remove jewelry, nail polish and hair pins, dentures, eyeglasses
o have the client void and don a clean hospital gown and turban
o administer pre anesthetic medication and instruct the client to stay
in bed.

2. Intraoperative Phase – begins with the admission of the client to the operative bed
and ends when the client is admitted to the post anesthesia care unit (PACU) or
recovery room (RR).
Nursing Activity

 To provide the client with comprehensive, safe, and effective care during the
surgical procedure.
 Assess the client’s physiologic and psychologic status
 Reviewing the results or the dx test and lab studies
 Positioning the client for surgery
 Performing the surgical skin prep.
 Assisting in preparing the sterile field.
 Opening and dispensing sterile supplies during surgery.
 Monitoring and maintaining a safe, aseptic environment.
 Managing catheters, tubes, drains and specimens.
 Performing sponge, sharps, and instrument counts.
 Administering medications and solutions to the sterile field.
 Documenting the nursing care provided and the client’s response to the nsg.
Interventions.

3. Postoperative Phase- begins with the admission to the post anesthesia care unit
and ends with the discharge from the hospital or facility providing the continuing care.
3 segments of Postoperative phase
a. Immediate post-op period- care given to the client in the RR and in the 1st few hours
in the surgical floor.
b. Intermediate period- care given during the course of surgical convalescence to the
time of discharge.
c. Postoperative stage- discharge planning, teaching, referral
Nursing Activities
  Monitor client’s response to the surgery
 Teaching and providing support to client & support persons.
 Main goal is to assist client to achieve the most optimal health status by:
o client free from infection
o client’s F/E balance will be maintained
o Client’s skin integrity will be maintained.

TYPES OF SURGERY
A. Degree of Urgency
1. Elective Surgery – planned weeks or months ahead and is based on the client’s
choice. It is performed for the client’s and the surgeon’s convenience.
Example: circumcision, hemorrhoidectomy, thyroidectomy, cosmetic surgery.
2. Urgent Surgery – frank attention within 24-48 hours Example: Appendicitis, kidney
stones, amputation 3. Emergency Surgery – performed to preserve client’s life, body
parts, or body functions. Example: Gunshot wounds or stab wounds, control of
hemorrhage
B. Degree of Risk Major - it involves a high degree of risk for a variety of reasons, it
maybe complicated or prolonged. (large losses of blood, vital organs may be involved.
Examples: open heart surgery removal of kidney
2. Minor - it involves little risk; produces few complications. Examples: Breast biopsy
Removal of tonsils
C. Purpose 1. Diagnostic - to confirm a diagnosis e.g. Excision Biopsy

2. Exploratory – e.g. Exploratory Laparotomy - To estimate the extent of a disease &

Confirm diagnosis As well.

a. Ablative – removal of a diseased organ e.g.Hysterectomy

b. Constructive –repair of congenital defects e.g. Cheiloplasty

c. Reconstructive –restoration of a damaged organ organ or cosmetic revision e.g.

Rhinoplasty
4. Palliative – relieves symptom but does not cure the disease e.g. myringotomy (otitis
media)

INFORMED CONSENT

 Operative permit/ Surgical Consent

 An agreement by a client to accept a course of treatment or a procedure after
complete information, including the risk of treatment and facts relating to it
has been provided by the physician.
 The client signs the form and the nurse acts as a witness.

Operative permit/ Surgical Consent

INFORMED CONSENT
3 ELEMENTS:
1. It must be given voluntarily
2. It must be given by an individual with the capacity and competence to understand.

 18 years and above, conscious & oriented.’

 Are not considered functionally competent:
 Confused, disoriented, sedated, minors, unconscious, mentally ill

3. The client must be given enough info to be the ultimate decision maker.
CIRCUMSTANCES REQUIRING A CONSENT:

1. Any surgical procedure where a scalpel, scissors, sutures, hemostats maybe used.
2. Entrance into a body cavity.
3. General anesthesia, local infiltration, regional block.


o In a life-saving emergency, the surgeon may operate without consent.
o Every effort must be made to contact the family.

12 Principles of OR technique
Surgical Conscience
  is one’s inner voice for the conscientious practice of asepsis and sterile technique at
all times.
 Is the foundation for the practice of strict aseptic and sterile techniques.
 It is self-regulation in practice according to a deep personal commitment to the
highest values.

1. All articles in the OR are previously sterilized.

2. Persons who are sterile touch only sterile articles; persons who are unsterile touch only
unsterile articles.

3. If in doubt of the sterility of something consider it unsterile.

4. Non-sterile persons avoid reaching over the sterile field; sterile persons avoid leaning over
unsterile field.

5. Tables are sterile only at table level.

6. Gowns are considered sterile only from the waist to shoulder in front level, and on the sleeves.

7. Edges of anything that encloses sterile articles is considered unsterile.

8. Sterile persons keep well within the sterile area.

9. Non-sterile persons keep away from sterile area.

10. Sterile persons keep in contact with sterile areas in a minimum.
11. Moisture may cause contamination.
12. When bacteria cannot be eliminated from a field, they must be kept to irreversible minimum.
 
Serving gown and gloves
(assisted)
 
 
 

I. GOWNING AND GLOVING TECHNIQUE

1. Gowning: To don the gown, the scrub person:
a. Lifts the folded gown directly upward from the sterile package.
b. Steps back from the table into an unobstructed area;
c. Carefully locates the neckband and holds the inside front of the gown just
d. below the neckband with both hands;
e. Lets the gown unfold while keeping the inside of the gown toward the body without
touching the sterile exterior of the gown with bare hands. (NOTE: IF the gown does not
unfold completely, then the circulating nurse may assist by pulling down the unfolded
bottom inside the gown);
f. Holds the hands shoulder level and slips both arms into the armhole simultaneously.
2. Gloving:
A. Closed Glove Technique- In the closed-glove technique, the scrub person's hands
remain inside the sleeves and should not touch the cuffs. In the open-glove technique,
the scrub person's hands slide all the way through the sleeves out beyond the cuffs.
a. Keeps both hands within the cuff so that the hands do not touch the cuff edges;
b. Grasps the folded cuff of the left glove with the right hand;
c. Holds the top edge of the cuff in the left hand above the palm;
d. Places the palm of the glove against the palm of the left hand-the glove fingers point
up the forearm;
e. Grasps the back of the cuff in the right hand and turn it over the open end of the left
sleeve and hand while holding the top of the left glove and underlying gown sleeve with
the covered right hand;
f. Pulls the glove over the extended left finger onto the wrist by pushing the hand
through the glove until it completely covers the cuff of the glove;
g. Gloves the right hand in the same manner by reversing the above steps
h. lnspects the gloves for integrity after denning; and
i. Hands the tie end to the circulator and secures the wraparound glove (when used.)
B. Open Glove Technique- The closed glove technique should not be used when
changing one or both gloves because once the hand has been passed through the
cuffs, they are contaminated. When a glove must be changed without assistance during
a surgical procedure, the open-glove technique is used.
a. To change one glove during the procedure using the open-glove technique, the
scrub Person:

o


1. Steps away from the sterile field;
2. Extends the contaminated glove
away from the sterile field so that
the circulator, using exam gloves to
protect his/her hands, can remove it;
3. Lifts the new sterile glove under the
cuff with the uncontaminated gloved
hand;
4. Inserts the hand into the glove and
pulls it on, leaving the cuff turned
well down over the hand and
avoiding inward rolling of the cuff.
The bare hand does not touch the
outside of the glove; and
5. Rotates the arm and pulls the cuff of
the glove up and over the sleeve
cuff, letting the gloved fingers touch
only the outside of the other glove.

b. To change both gloves during a procedure using an open-glove technique, the scrub
Person:

1.
1.
1.
1.
1. Follows instructions I and 2 above;
 2. Picks up the left glove cuff, touching
only the edge of the cuff with his or
her right thumb and index finger;
3. Pulls the glove onto the left hand
and leaves the glove cuff turned
down;
4. Picks up the right glove with the
gloved left hand, keeping the gloved
fingers under the folded cuff;
5. Slides the right hand fingers inside
the right glove cuff and pulls the
glove onto the right hand while
avoiding inward rolling of the cuff;
6. Pulls the right glove cuff over the
sleeve cuff by rotating the arm;
7. Places the gloved right-hand fingers
under the folded left glove cuff,
rotates the arm, and pulls the left
glove cuff over the sleeve cuff.

II. Assisted Gowning and Gloving

1. Assisting gowning- The scrub person may assist another member in drying,
gowning, and gloving by:
a. Opening the towel that the other member will use to dry his/her hands
b. Laying the towel on the team member's hand without touching his/her hands;
c. Holding the gown at the neckband and carefully unfolding it
d. Keeping the hands on the outside of the gown, forming a protective cuff of the neck
and shoulder area as the person being gowned holds both arms outstretched;
e. Offering the inside of the gown to the other member so he or she can slip his or her
hands into the sleeves; and
f. Releasing the gown when the team members' hands are in the sleeves.
2. Assisted gloving- To glove another team member, the scrub person always
gloves the other person's right hand first. The scrub person:
a. Picks up the glove with his or her fingers under the cuff
b. Holds the palm of the glove toward the person being gloved
c. Stretches the cuff to open the glove and holds his or her thumbs out to keep them
from touching the other team member's bare hands
d. As the other person inserts his or her hands into the glove, exerts upward firm
pressure making sure the hand does not go below the waist
e. Unfolds the inverted glove cuff over the cuff of the sleeve
f. Gloves the left hand with the assistance of a team member by repeating the steps
g. Hold the tie as the other team member turns to secure wraparound sterile gown when
it is used.
3. Assisted re-gloving- When a team member other than the scrub nurse
contaminates a glove during the surgical procedure, the circulator, using exam
gloves so that his or her hands are protected, will grasp the outside of the glove
and pull it off inside out. the scrub person then re-gloves the team member as
describe above in assisted gloving.
The options for the scrub nurse who needs to change gloves are to: remove both
gown and gloves, have another team member assist in re-gloving, or use the
open-glove technique.
The closed-glove technique cannot be used to re-glove. In closed gloving, the
hand passes through the cuff of the gown, contaminating the edge of the cuff.
This would cause the outside of the new glove to be contaminated.

III. Removing Gown and Gloves

At the end of the procedure, the gown is always removed before the gloves to
prevent cross contamination of the wearer's scrub attire. The circulator can assist
by unfastening the neck and back closures of the gown. The scrub person:

1. grasps the shoulders of the gown, pulls it downward from the shoulder and off
the arms, and turns the sleeves inside out;
2. folds the contaminates surface of the gown on the inside and rolls it away
from the body; and
3. Discards the rolled gown in the appropriate receptacle.

As the gown comes off, it usually turns the cuffs of the gloves down. To removes
the gloves the wearer uses a glove-to-glove and then a skin-to-skin technique.
This approach protects hands from the contaminated glove. The scrub person:

1. grasps the under cuff of the left glove with the gloved fingers on the right and
pulls it off inside out;
2. slips the ungloved fingers of the left hand inside the right glove and slips it off
inside out;
3. discards the gloves in the appropriate receptacle; and
4. Washes hands and arms with soap and water.
Removing the gloves after removing the gown prevents the bare hands from
contamination that would usually occur from handling the soiled gown.

IV. Maintaining a Sterile Field:

The surgical team should take precautions to avoid contamination and maintain
the sterile field. The hands should be kept above the waist and insight at all
times.
The sterile areas are:

1. The front of the gown from the table level or sterile field to two inches below
the neck
2. The sleeves from two inches above the elbow to the cuff
3. The surgical gloves

The underarms are considered nonsterile. The back of the gown is not
considered sterile even if it is the wraparound style. If any part of the sterile attire
becomes contaminated, immediate corrective steps must be taken (e.g. if a glove
becomes contaminated, it must be changed immediately). Once the original
gloves are donned, the gown cuffs should be considered contaminated because
the scrubbed hand passed through them.