Perioperative Nursing Module 2

PERIOPERATIVE
INTRAOPERATIVE
PART 1
__________
CHARLES IVAN SANTIAGO, RN, MAN
St. Luke’s College of Nursing
PHYSICAL
FACILITIES
AREAS IN THE OPERATING ROOM
• UNRESTRICTED
AREA
– street clothes
– serves as a
transition zone
from
unrestricted
area to semi
restricted area
Photo taken from:
http://www.rongxinyiliao.net/product_detail_en/id/21.html
SEMI RESTRICTED AREA:
• For authorized personnel that are
properly attired with scrub suits,
head covers.
• Includes the peripheral support area,
central processing and access to
corridors
• Patient is also dressed and the head is
covered.
• Transition area from semi restricted
to restricted area of the operating
room. The transition area must have
a place for mask, shoe cover and
cover gown as well as caps.
Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating Room Technique
13th Edition. Missouri: Elsevier.
RESTRICTED AREA:
• Properly attired personnel
equipped with mask which
the sterile items and sterile
team are in the field.
• Substerile room consist of
scrub sink
• Personnel who will
temporarily enter the this
area may wear surgical cover
gowns or jumpsuits to cover
street clothes together with
mask and head cover.
Photo taken from: https://www.fgiguidelines.org/wp-
content/uploads/2015/10/FGI_Update_ORs_140915.pdf
PREOPERATIVE ADMISSION AND
HOLDING UNIT
• Area to change the patient clothes from street

clothes to hospital gown with personal locker
for safe keeping
• Holding with their families and provided with
privacy.
• Intravenous Line may be inserted at this area.
OPERATING ROOM
• Restricted area to maintain
controlled environment such as
sterility and minimal traffic.
• Location – usually located in the
area accessible to other critical
areas of the hospital and other
ancillary area such as central
service or sterilization area,
pathology and radiology.
• Room temperature: 20 degrees
Celsius to 24 degrees Celsius
• Filtered air, free of dust
• Shelves and cabinets are wall
mounted
OPERATING ROOM
• Materials inside the Operating Room:
1. Operating table
2. Surgical instruments and tables such as mayo table and large
table
3. Anesthetic equipment (anesthesia machine, intubation set,
oxygen regulators and other gases)
4. Kick bucket
5. Stool
6. Intravenous Stands
7. Suction machines
8. Sponge count boards and equipment
9. Emergency Cart
OPERATING ROOM
PIPED-IN GASES
1. Oxygen – Green
2. Nitrous Oxide –
Blue
3. Pressurized Air –
White
LIGHTNING – adequate
lightning and good
visualization throughout
the procedure. There’s
mounted light at the ceiling
of the operating room that
is sterile and can be
handled by the sterile team.
Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

Room Technique 13th Edition. Missouri: Elsevier.
SPECIAL PROCEDURE ROOMS
1. INTERVENTIONAL
RADIOGRAPHY ROOM –
indicated for endovascular
stenting, balloon
angioplasty, cardiac
catheterization and other
fluoroscopic examination
and management.

SPECIAL PROCEDURE ROOMS
2. MINIMALLY INVASIVE
SURGERY ROOMS – indicated
for laparoscopic procedures
with video monitors inside for
visualization but has the
capability to convert the room
into an open procedure room if
an untoward event noted.
a. Endoscopy Room
b. Cystoscopy Room
c. Cesarean Delivery Room

SURGICAL TEAM IN THE OPERATING
ROOM
STERILE TEAM – these members perform surgical asepsis

and apply sterile accessories such as gown and gloves so that
these personnel may have a direct contact in the sterile field.
All the equipment needed for the procedure that is not
currently at the sterile field must be given in a sterile manner.
1. Surgeon
2. First Assistant
3. Scrub Nurse
STERILE TEAM
SURGEON:
- In charge of the operating bed and its members
- Knowledgeable, able to judge the situation and skillful in
performing invasive operations.
- Has the capability to be flexible when there is an
unexpected medical situation encountered.
- Ability to diagnose patient perioperatively
- Assumes all the responsibility for all medical actions and
the management of surgical patient.
STERILE TEAM
FIRST ASSISTANT
- Maybe a RN or surgeon.
- Aids the surgeon to maximize visibility of the surgical site,
provides homeostasis such as bleeding control, wound closure
and dressings.
- Handle and manipulate tissue and use surgical instruments to
provides homeostasis.
- The role and the necessity for a first assistant will depend on the
type and complexity of the case and will vary on the type of
anesthesia, expected blood loss and risk for complication.
- Surgeon will decide if the need for first assistant is warranted.
SCRUB NURSE
STERILE TEAM
- Patient care staff member of the sterile member.
- Scrub nurse does not simultaneously function as the first or second
assist.
- Primary responsibility of maintaining the sterile field and facilitates
the surgical procedure
- The scrub person is responsible for promoting integrity, safety and
efficiency in the sterile field throughout the surgical procedure.
- Adhere to strict aseptic technique and knowledgeable about the
surgical instruments and supplies.
- They must be knowledgeable in the sequence of the procedure to be
able to anticipate the next move of the surgeon by observing the
sterile field
- Two scrub nurses can participate in the procedure when for the
purpose of teaching and in the event of complex cases in which
there are two teams performing the procedure.
- Responsible in handling surgical instruments and serve to the
surgeon
- Responsible in maintaining the accountability of the surgical
instruments, sponges, needle, sharps and sutures.
SURGICAL TEAM IN THE OPERATING
ROOM
UNSTERILE TEAM – on the contrary to the sterile personnel, those
who are assigned in the unsterile team are not allowed to have a
direct contact in the sterile field. They give sterile supplies to the
sterile field in an aseptic manner. Further, they manage any
complication or untoward events during the perioperative care.
1. Anesthesiologist
2. Circulating Nurse
3. Perianesthesia Nurse
4. Others (Medical Representatives, laboratory and radiology
personnel)
UNSTERILE TEAM
ANESTHESIA PROVIDER:
- Anesthesiologist/Nurse Anesthetist
- Responsible in handling the physiological status
throughout the procedure.
- Provides medications and advance airway
management together with monitoring the vital signs
perioperatively.
- Maintaining the anesthesia’s therapeutic level and
handling unexpected medical events throughout the
surgical procedure.
UNSTERILE TEAM
PERIANESTHESIA TEAM
- Consist of RN and trained patient care
assistant who manage the manage pre and
post-surgical.
- Asses the patient and the documents such
as surgical checklist
CIRCULATING NURSE:
UNSTERILE - Advocate and protector of the patient throughout the perioperative phase.
- Aids the sterile team by monitoring the activities inside the operating
theater and simultaneously provide care to the patient together with the
TEAM anesthesiologist.
- Facilitating safe and comfortable environment for the patient by the means
of ensuring asepsis throughout the procedure. It reflects the strong
surgical conscience. The circulating nurse must be cautious and alert on
the possible break in the asepsis, however, the whole surgical team are
responsible in ensuring aseptic technique.
- Provides support to the whole surgical team guided by evidence-based
knowledge. Ensures the completeness of the items needed for the surgical
procedure and knowledgeable about its location and purpose.
- Identify the possible complication of the procedure related to the patient
and/or surgical team.
- Promote open communication between the surgical team and other people
outside the operating room.
- Has the ability to supervise and teach to maintain safe environment.
- Performs Surgical Checklist
- Documents the intraoperative patient care
GOALS OF
CARE
ASEPSIS
Infection related to surgical operation is life

threatening complication. Ensuring sterility during
operation is important and should not be set aside
for the convenience of the surgical team.
Postoperative wound infection can be originated
from the intraoperative phase by the means of
reusing disposable equipment, utilization of surgical
instruments or any inappropriate action during
intraoperative phase.
ASEPSIS
“Absence of microorganism that

cause disease; freedom from
infection”
ASEPSIS
Aseptic Technique – way to prevent the contamination
of microorganism.
o Key Elements:
▪ “Clean technique”
▪ Safe to handle with bare hands since it was cleaned
and decontaminated
▪ Items that are cleaned, decontaminated, disinfected
or minimally sterilized are place in a clean dry clean
area.
▪ Items are classified as semi critical or non-critical.
ASEPSIS
- The surgical bed should be at the working

level to prevent contamination
- Microorganisms grow in a warm, moist
environment
ASEPSIS
- Sterile – free from any microorganism

including spores.
- Sterile Technique – to prevent
microorganism and maintain the
sterility.
STERILE TECHNIQUE
KEY ELEMENTS:
▪ Items are used in sterile field only
▪ Utilized by the sterile surgical team
▪ Used in the patient’s body where the site has been prepared.
▪ Indicated for invasive surgery
▪ Used in the non-intact skin such as membranes and vascular
system
▪ Spaulding’s: Critical category
▪ Items should be cleaned and decontaminated before sterilization
▪ Individualized used; reusable can be resterilized, however,
disposable items cannot be resterilized.
▪ Equipment that is contaminated should be discarded and replaced.
STANDARD PRECAUTIONS
These are ways to protect

the healthcare workers from
bodily fluids of patients.
STANDARD PRECAUTION
o Protective barriers and personal protective equipment
▪ Gloves, eyewear, gown, hair covers, masks
o Prevention of puncture injuries
▪ Do not manipulate sharp object with bare hands
▪ Do not recap needle and syringes
▪ Place the sharp objects in a puncture resistant container
o Management of puncture injuries
▪ Remove gloves and change gloves immediately
▪ If skin is punctured, removes gloves, squeeze the skin and release the blood and
perform handwashing and then report and document.
o Oral procedures
▪ Respiratory secretions are usually infectious
o Care of specimen
▪ Stored in a puncture-resistant container to prevent leakage during delivery to the
laboratory
o Decontamination
▪ Areas of the operating room are decontaminated with high level disinfectant such as
floors and surfaces that the bodily fluids contacted.
STANDARD PRECAUTION
o Laundry
▪ Soiled linens should not be manipulated as it may disperse
microorganisms.
▪ Commercial dry cleaning is preferred than home laundering.
o Waste
▪ Must be disposed on a drain connected to a sanitary sewer
▪ Trash bags should be leakproof for transport.
o Handwashing
▪ Practice 5 moments of handwashing
o No touching of mucous membrane
▪ Eating and drinking are not allowed to decrease the risk of exposure.
▪ Eyes and mouth membranes has the highest risk
o Prophylaxis
▪ Determine the antibody status such as HIV and Hepatitis Profile
▪ Disclosure to the institution is recommended
TRANSMISSION OF MICROORGANISM
▪ AIRBORNE – particles smaller than 5mm carries airborne

droplet nuclei such as varicella, tuberculosis, and rubeola.
▪ DROPLETS – particles larger than 5mm and transmitted by
coughs, sneezing and talking. Should provide more than 3
feet distance from the source of infection. Applying
personal protective equipment such as mask should be
practiced. These diseases are diphtheria, mumps and
influenza.
▪ CONTANT – using of personal protective equipment such
as gloves when touching contaminated bodily fluids. Usage
of gown are also recommended when there is a risk of
splashing
TRANSMISSION OF MICROORGANISM
Sources of Infection:
Carries of Infection: ▪ Community acquired
▪ Skin Infection
▪ Hair ▪ Communicable Infection
▪ Nasopharynx ▪ Spontaneous Infection –
requires surgical
▪ Human Error
intervention to alleviate
▪ Cross Infection infection
▪ Fomites ▪ Healthcare Associated
▪ Air Infection (HAI) – formerly
nosocomial infection
Surgical Site Infection (SSI)
Surgical Site Infection (SSI) – most common type of surgical infection
▪ Superficial Incisional SSI
• Infection occurs within 30 days of the procedure
• Skin or subcutaneous
▪ Deep Incisional SSI
• Infection occurs within 30 days after the procedure when there is
no implant or within 1 year if there is an implant placed.
• Deep tissues and muscle
▪ Organ/Space SSI
• Infection occurs within 30 days after the procedure when there is
no implant or within 1 year if there is an implant placed.
• Organs or spaces other than the surgical incision was made or
manipulated
SURGICAL ATTIRE
- To effectively provide barriers

and protection from the
microorganism for the patient
and protect the healthcare
worker from the bodily fluids.
- It consists of two-piece pant
suit (Scrub Suit), head cover,
mask, and shoe cover.

SURGICAL ATTIRE
- Whenever in the sterile field,

an additional sterile gown and
gloves are added, other PPE
such as googles can be added if
there is a risk of splashes.

CONSIDERATION FOR APPROPRIATE ATTIRE
o Dressing rooms should be in an unrestricted area, where the personnel

should change their clothes from street clothes to surgical clothes.
o Clean and not reused surgical attire should be used with appropriate
cleaning done by the institution.
o OR attire should not be worn outside the operating theatre, however, in
the moment that the personnel must leave the premises, he or she
must into street clothes or put a single-worn laboratory coat that is
completely buttoned, but the later is not advisable.
o Comfortable skip-proof shoes are advised. Clog and clothes shoes are
not advised at this may provide hazard to the healthcare worker.
o Well maintained personal hygiene such as bathing (using antibacterial
soaps) and other personal hygiene such as putting deodorant. Body
odor is the effect of accumulation of microorganism.
o Personnel who has an acute infection should not be allowed to work

inside the operating theater.
o Skin lesion, cuts or any impaired skin integrity should not scrub and
be part of sterile team member because of the risk of contamination
from the procedure or giving off microorganism to the patient
o Fingernail should be maintained and should not pass from the
fingertips. Nails harbor microorganisms and may induce infections.
Nail-polished nails are not recommended.
o Jewelries and watches should be removed when entering semi-
restricted area and performing handwashing (both medical or
surgical) and application of sterile suit. These materials carries
microorganisms and may induce friction to the skin that causes more
shedding.
o Make up should be kept at minimum.
o Handwashing every patient contact or practice 5 moments of hand
hygiene.
CRITERIA FOR SURGICAL ATTIRE

o Protects from
microorganism
o Void dangerous electrostatic
properties
o Maximum skin coverage
o Hypoallergenic
o Lint-free
o Flexible materials
o Colored to reduce glaring
from lights
o Easy to wear

COMPONENTS OF APPROPRIATE ATTIRE
Body cover (Scrub Suit)

▪ Worn in the semi-restricted and
restricted areas.
▪ Must fit the body perfectly, not
too tight and not too loose.
Loose clothes can generate
aerosols and tight clothing can
cause shedding of skin.
▪ Inner shirt and drawstings
should be placed inside the
pants to prevent unsterile
contact to the sterile field.

Head Cover
▪ Worn in the semi-restricted and restricted areas
▪ Worn before the scrub to prevent the unnoticed hair fall onto the scrub
suit.
▪ Bouffant style is recommended than surgical caps as this not cover all the
hair.

Shoe Cover
▪ Worn in the semi-
restricted and restricted
areas
▪ To lessen floor
contamination.
▪ Shoe covers are subject to
change when wet and
damaged. Changing of
shoe cover should be worn
by gloves.
Photo taken from: https://blog.universalmedicalinc.com/wp-
content/uploads/sites/264/gallery/postimages/suregrip-serged-seam-shoe-covers.png
Masks
▪ Worn inside the restricted area
▪ Reusable masks are not
recommended because when
soaked, it will harbor
microorganisms.
▪ It filters microorganisms from
both exhalation and inhalation
and should be worn by covering
both mouth and nose.
▪ Fit and mold the metal layer
over the nose bridge to provide
seal.

▪ Perform hand hygiene when

manipulating mask and
removing mask.
▪ Avoid reusing of mask
▪ Change frequently (as per
hospital protocol) or when
soaked.
▪ When act as a scrub nurse,
when sneezing while wearing a
mask, take one step away from
the sterile field and turn head
away from the sterile field.

Sterile Gown
▪ Worn in the sterile field
▪ Gowns are made up of non-
woven, moisture-repellant
materials.
▪ Prevents the contamination
between the sterile team
member and to the sterile field.
▪ Water and moist resistant to
prevent strikethrough
penetration of microorganisms.
▪ The back and anything below
the sterile are not considered
sterile.
▪ The cuff of the gowns are

snugly fitted over the
wrist, however it absorbs
the sweat and makes it
unsterile afterwards.
▪ Pulling the cuff down over
the hand and utilizing a
closed-gloving method
when changing
contaminated gloves.

Surgical Gloves
▪ Worn in the sterile field
▪ Commonly used gloves are
disposable latex gloves.
▪ Watch out for latex allergies and
can cause dermatitis or
systemic anaphylaxis; use
hypoallergenic gloves to prevent
this occurrence.
▪ Gloves are placed in a folded
sterile paper

▪ Powder free gloves are advised

when has allergies to cornstarch
powder
▪ Scrub nurses should inform any
team member to change their
gloves if there is a contamination
noted.
▪ Gloved-circulating nurse will
remove the contaminated gloves
from the sterile member.
▪ Double gloving is recommended.
Wear larger size for the inner
gloves and wear the normal size for
the outer gloves.

SURGICAL HAND WASHING
ANG SCRUBBING
SURGICAL HAND WASHING ANG SCRUBBING
- Also known as surgical scrub, method of removing as

many microorganisms as possible from the skin before
donning the sterile suit.
- Scrub room
- is located beside or adjacent the operating suite and the sinks has an
automatic sensor or foot or knee-controlled faucets to prevent any breach
of contamination.
- The sink should be wide and deep to prevent splashes, therefore, an
eyewear is also advised.
- The sink should used solely for handwashing or scrubbing. This should be
used for surgical cleaning and other personal hygiene purposes.
SURGICAL HAND WASHING ANG SCRUBBING
Anti-microbial Skin Cleansing Agents properties:

o Broad spectrum
o Fast acting and effective
o Nonirritating and nonsensitizing
o Prolonged action
ANTI-MICROBIAL SKIN CLEANSING AGENTS
▪ Chlorhexidine Gluconate (Core Scrub) – it can cause
permanent corneal damage and ototoxicity. Alcohol based is
effective after 20-30 seconds of manual cleansing. It is easy to
evaporates and minimal odor. Effective to gram positive and
negative, fungal and viral agents, however, not with TB agents.
▪ Iodophors – povidone-iodine are intermediate acting
antimicrobial agents and effective against, both gram positive
and negative, TB, fungal and viral agents.
▪ Triclosan - effective against, both gram positive and negative,
TB, and viral agents but not effective with fungi. Less effective
as compared with chlorhexidine and iodophors.
▪ Alcohol – nontoxic but drying effect on the skin. If other is not
okay with the user, this can be used prior to handwashing using
soap.
▪ Hexachlorophene – most effective in suppressive action and
effective against gram positive only. It is prescription-based
agent and highly neurotoxic.
STEPS IN SURGICAL HANDWASHING
1. Remove accessories such as jewelries and watches

2. Inspect for any skin lesions or wounds
3. Check nails
4. Perform medical handwashing
STEPS IN SURGICAL HANDWASHING
5. Apply or use antiseptic scrubs.

6. Scrub the fingernails using the bristled part of the scrubs.
7. Scrub the sides of each finger and the part between fingers
back and front using the nonabrasive part of the scrub.
8. Extend the fingers to wash the creases.
9. Scrub the palm and back of the hand. This process should
take 2 minutes.
10.Scrub the arms up to 2 inches above the elbow.
11.Repeat on the other hand
12.Rinse the hands and arm by a running water
TAKE NOTE:
- Surgical Handwashing last for 3 – 5 minutes;

prolonged handwashing exposes the normal
flora of the dermis and induces more risk.
- Do not go back to the part that is already
scrubbed.
- Do not move the hand and arms back and
forth when rinsing. Repeat the rinsing by
removing the hand from the running water.
- If accidentally touched the sink or any
unsterile area, repeat the whole procedure.
- Maintain the hands on a 90-degree angle and
never put your arms down.
DRYING HANDS AND ARMS
1. When drying the hands and arms,

make sure not to let the excess
water touch or drip over the
sterile items.
2. Dry hand using a sterile towel
from the packaging. Grab the
corner of the towel and dry the
hand using a circumferential
movement. Do not rub the towel
back and forth.
3. To dry the other hand, hold the
dry edge or other side of the
towel, reverse it and dry the other
hand using the same manner.
4. Dispose the towel used.
Photo taken from: Phillips, N. (2017). Berry & Kohn's

Operating Room Technique 13th Edition. Missouri: Elsevier.
GOWNING AND
GLOVING
STEPS IN GOWNING
1. Reach the opened
sterile gown at the
sterile field, be
careful not to touch
the field itself.
2. Take a step back
from the sterile
field and unto an
unobstructed area.
3. Locate the neckline
and holes for the
arms.

STEPS IN GOWNING
4. Hold inside of the gown

just below the neckline at
the level of the shoulder

STEPS IN GOWNING
5. Carefully slide the

hands inside the hole
simultaneously. Do not
let your hands get out
of the gown.
6. The circulating nurse
pulls the gown over the
shoulder and secure the
gown at the waist and
neck.

STEPS IN GOWNING
If with DISPOSABLE
GOWN:
▪ Disposable gown:
disengage the tie
within the paper tag of
the gown, hold the on
the left tie and right tie.
▪ The right tie has the
paper tag; hand over
the right tie with paper
tag to the circulating
nurse by holding only
the paper tag.

STEPS IN GOWNING
▪ While holding the left
tie, and the while
holding the right tie
by the circulating
nurse, turn towards
left. This will cover
the expose area at
the back.
▪ After turning, pull the
right tie from the
paper tag and knot
both ties.

GOWNING
GOWNING
o If the gown drops, this is now
considered unsterile. Do not
reverse the gown if it already
touches the floor or any
unsterile area.
o Do not pull the cuff, the back
of the gown is tied first
before the neckline
o If both ties fell off, the
circulating nurse will
retrieve the tie and tie
around the scrub nurse.

GLOVING:
CLOSE
TECHNIQUE
1. Open the
internal
packaging with
the paper. Expose
the paper
package until you
see the two
sterile gloves.

GLOVING: CLOSE TECHNIQUE
2. Extend the left forearm and the palm facing upward.

3. Using the cuffed RIGHT hand, place the LEFT STERILE GLOVES
upside down over the LEFT HAND that is facing upward.
4. Grab the edge of the LEFT GLOVES by the covered LEFT HAND while
holding the other of the edge using RIGHT CUFFED HAND. Put the
gloves inside by peeling or turning the gloves over the LEFT HAND
until to the stockinette of the gown. Position the fingers once inside.
5. Lift the right gloves by lifting the fingers and position it the same
manner with left hand.
6. Repeat the process using for the other hand but with left gloved
already.
GLOVING: CLOSE
TECHNIQUE

GLOVING: OPEN TECHNIQUE
oSkin to skin and glove to glove technique.

oAlthough the hand is scrubbed, it is still
considered sterile and should not touch the
external part of the gloves.
oUsed in changing gloves intraoperatively.
GLOVING: OPEN TECHNIQUE
oSkin to skin and glove

to glove technique.
oAlthough the hand is
scrubbed, it is still
considered sterile and
should not touch the
external part of the
gloves.
oUsed in changing
gloves intraoperatively.
GLOVING: OPEN
TECHNIQUE
1. With left hand, hold the
inner cuff of the right
glove. Step back from
the table and other area.
2. Insert the right hand
into the gloves and pull
it on and leaving the cuff
still turned.
3. Using the right gloved
hand, slip the fingers
under the everted cuff of
the left glove.
Photo taken from: Phillips, N.
(2017). Berry & Kohn's Operating
Room Technique 13th Edition.
Missouri: Elsevier.
GLOVING: OPEN
TECHNIQUE
4. Insert the left hand
inside the left gloves
and pull it without
touching the inside of
the gloves.
5. Pull the cuff of the
right gloved hand over
the knitted cuff
afterwards.
Missouri: Elsevier.
GLOVING: OPEN-ASSISTED METHOD
1.Get the right glove first and open it. Place the gloves facing the
palm towards the user.
2.Grab the edges of the gloves and stretch it firmly. Make sure
that the height of the gloves does not fall below the sterile field.
3.The user will insert his or her hand inside the gloves, place an
upward pressure to let the glove fit in up to the surgical gown.
4.Repeat for the other hand.

SKIN PREPPING
Skin Prepping
This procedure to prepare the skin site to

reduce the number of any microorganisms as
possible. This, however, cannot keep the skin
free from any microorganism. Also, to remove
any visible dirt, hair, oils that can interfere
with the surgery.
Skin Prepping
PRELIMINARY PREPARATION
- Mechanical cleansing – reduce the number of microorganisms on the
body by the means of bathing and shampooing.
- Hair Removal – to gain better visualization of the surgical site. The
following methods are the following:
i. Shaving – least favored method because it increases the risk of having
unwanted cuts and abrasion on the skin and might cause infections.
However, it completely removed the hair. It is done ideally 30 minutes
before the procedure for it to be considered as clean wound.
ii.Clipping – it less traumatic as compared to shaving however, this
leaves a small hair on the skin that does not affect the surgery.
iii.Depilatory Cream – chemical means of removing the hair strands on
the surgical site. These creams cannot be used in the sensitive area
such as the genitalia and might cause irritation due to the chemicals.
Skin Prepping
PREPARATION ON THE SURGERY TABLE

▪ Mechanical effect of scrubbing
▪ Antiseptic effect of the solution – these should
be broad spectrum, non toxic and non irritating,
prolonged efficacy and does not cause
hazardous effects such as electrical burning.
STEPS IN SKIN PREPERATION
1. Prepare materials needed for the cleaning. Open and ready
the items because you will not be able to do so once you
don sterile gloves.

2. Wear sterile gloves

3. Place drapes or towel over
the edges of the site. This
will serve as a mark for
cleaning.
4. Wet sponges with
antiseptic solutions and
remove remaining solution
to prevent dripping.
5. Scrub the skin from the
targeted site outward in a
circular motion.
6. Do not go back to the previous site using the same

sponge. Dispose the sponge after every stroke and use
another to repeat the circular motion.
7. Document and note for any irritation of reactions.
Indicate if it is clipped or shave and the person who
performed the skin cleansing.

TRAUMATIC WOUNDS
1. Irrigate the wound using warm sterile saline using bulb
syringes or IV line for more solution is needed.
2. Gently flush the wound to remove debris and not to
push it more inside.
3. Place a basin under the wound for the collection of the
solution that is to be disposed.
4. Once irrigated, debridement will be done.
DRAPPING
Method to cover the patient in a sterile
manner and to create an adequate sterile field
over the patient.
Draping
- Characteristics of drapes:
1. Fluid resistant to prevent strikethrough and wicking
2. Puncture resistant
3. Dark and dull colored to prevent glare and eye straining
4. Prevent sparks and combustion
5. Free of toxins
- Types of drapes:
1. Towel
2. Fenestrated sheets
3. Laparotomy sheets
4. Thyroid sheet
5. Chest sheet
Steps in Draping
1. Ensure that the area is dry because the of the risk of

wicking. Ensure proper placement and do not rush.
2. Never lean or reach the other side when draping
3. Drapes should not have contact to tables and linens
4. If improperly placed, do not readjust it but remove it. Place
a new drape for covering.
5. The gloved hand should be covered by the drape to prevent
contact with the skin.
Steps in Draping
6. The part that is below the table is contaminated. If the

sheet falls below the table, replace it.
7. Secure the drapes using clips that cannot penetrate the
integrity of the drapes.
8. In an instance that the drape has a hole, it can be covered
with another drape.
9. If debris such as hair is noted, it is removed and covered
with another drape.
Steps in
Draping

PRINCIPLES IN
ASEPTIC
TECHNIQUE
1. STERILE ITEMS ARE USED ONLY IN THE STERILE FIELD
- Sterile instruments (sets, drapes, sponges, sutures and basins) are
place only on the sterile field. Circulating nurses or related should
ensure the integrity of the packing before dropping the items on the
sterile field. When in doubt, discard and replace the sterile item.
- “When in doubt, throw it out”

2. STERILE PERSONNEL ARE GOWNED AND GLOVED
- Gowns are considered sterile from the chest to the level
of operating table (level of the surgical site) including 2
inches above the elbow.
- Self-gowning and gloving should be performed on a
different sterile area using closed-glove technique
- Stockinette cuffs of the gown are not considered sterile
once covered with sterile gloves because it has moisture
from the enclosed space.

2. STERILE PERSONNEL ARE GOWNED AND GLOVED
- Regloving should be done with another sterile membrane by the
means of open-assisted gloving technique.
- Sterile gloved hands should be put away from the face, neckline,
back and axillary region
- Avoid changing levels at the sterile field. The gown is only sterile
only down to the sterile field. If the height was changed due to
changing platforms such as foot stools, the drapes should also be
adjusted. Sterile member can only sit if the level of the operation at
achieve at the sitting level, also, all members should also sit to
maintain sterility.

3. TABLES ARE STERILE ONLY AT THE TABLE LEVEL
- Only the top level of the table is considered sterile and covered with
sterile drape. The edges are considered contaminated. Mayo table
can be placed over the sterile field provided that it is draped with
sterile cover, however, the other side of the Mayo table should not
be manipulated or contacted.
- Any equipment that fell off and left hanging from sterile table is
considered contaminated.
- When unfolding sterile equipment, it should be away from the
sterile away and prevent manipulation of drapes.
- Sterile materials can be clipped using a non-perforating clip to
prevent slipping away from the table.

4. STERILE PERSONNEL ARE ONLY FOR STERILE FIELD
- Sterile items are should only touch the sterile field
- Circulating nurse should not touch the sterile field
- Opening of sterile materials should be done using
sterile technique.

5. UNSTERILE PERSONNEL SHOULD
NOT CROSS STERILE FIELD
- The circulating nurse should not
reach over the sterile field.
- When transferring sterile solution,
simply pour the solution over the
sterile basin without touching it. All
the solution should be dispensed in a
single time; reserved or recapped
sterile solution is now considered
unsterile. This is applicable for both
sterile solution and medications.
- The unsterile solution can be used a
way of cleaning the skin after the
surgical dressing and undraping
- The basin should be placed at the
edge of the sterile table and the
circulating .
- Sterile light handles should be placed
after the patient was draped.

5. UNSTERILE PERSONNEL SHOULD
NOT CROSS STERILE FIELD
- Open sterile package using the
margins of from the packages
and should not practice tearing
the whole packaging. Heat seals
of the packaging is the
borderline between sterile and
unsterile
- Flipping the items may cause the
items to fall out of the sterile
field
- Medications inside the vial
should be aspirated by the
circulating nurse and transfer it
to sterile medicine with the
needle removed, cup near at the
edge of the sterile table.
- Prevent parallel aspiration of
medication as it poses
needlestick injury.

6. STERILE FIELD SHOULD BE CREATED NEARLY TO THE TIME OF USE
- Since, there is no standard time when to initiate sterile field, it must
be set up prior to the procedure.
- If the table is not going to be utilized, covering the sterile field with
a sterile drape can be done.
- Covering should be done in a horizontal manner and applying a
second cover horizontally that cover the first drape.
- When removing, the top drape should go first without touching the
first drape, then followed by the bottom drape.
7. STERILE AREAS SHOULD ALWAYS IN VIEW

- Maintain sterile area by observing sterile field and prevent any
possible break of sterility.
8. STERILE PERSONNEL SHOULD BE ON THE STERILE AREA
- Changing of place should be done in a back to back method. The
nurse goes around the back other surgical sterile member by
rotation and facing their backs
- Sterile team should turn their back whenever an unsterile member
passes. Ask the unsterile team to move aside.
- Sterile team must always face the sterile field and do not loiter
outside the field.

9. STERILE PERSONNEL LIMIT CONTACT TO STERILE FIELD
- Prevent leaning to sterile tables and on the patient.
10. UNSTERILE PERSONNEL AVOID STERILE AREAS
- Keep at least 1 foot (30 cm) from the sterile field
- Make sure not to touch it
- Do not cross sterile field
11. DESTRUCTION OF THE INTEGRITY OF THE BARRIERS
- Strikethrough – soaking of barrier from sterile to unsterile side or
vice versa
- Sterile packages should be stored in a dry place and handled with
clean and dry hands
- If the sterile field is soaked, it may be covered with another sterile
drape
- Prevent physical penetration of the packaging
12. MICROORGANISM SHOULD BE LIMIT
- Skin cannot be sterilized however, it can be washed using antiseptic
solutions to remove resident flora
- Instruments and gloves that touch the skin should be removed and
replaced with another. It cannot touch both skin and inner tissues
- The surgical wound site should be dressed in a sterile manner
before removing the overall drape on the patient.
- Organs such as gastrointestinal site is considered contaminated
and cannot be sterilize, however, it measures should be done to
prevent spreading the microorganism
- Movement of the materials should be limited because it may affect
the air turbulence.
- Minimize droplet producing activities such as talking and coughing
Spaulding’s Law
- CRITICAL – items that will be used inside the bloodstream, tissues and
mucous membrane.
– Cleaning and Sterilization are required
– Example: surgical instruments, catheters, implants and needles
- SEMI CRITICAL – intact skin or mucous membrane. These are items
safe to handle using bare hands
– Cleaning and High Level Disinfection are required
– Example: respiratory therapy equipment, anesthesia equipment,
gastrointestinal scopes
- NONCRITICAL – items that will contact intact skin.
– Intermediate or Low- level disinfection is enough
– Example: blood pressure cuff, furniture, linens, bedpans, utensils
STERILIZATION OF INSTRUMENTS
Decontamination Disinfection
To clean inanimate Destroying most of the
objects and noncritical pathogens except spores
surfaces by physical or using physical or
chemical means. chemical means.
Levels of Disinfection:
1. High-level disinfection – destroys all bacteria, viruses and fungi.
Spores may be destroyed depending on the contact time. This
should be used when an item cannot be sterilizes such as
endoscopes.
a. Examples: Aqueous Acids, Banicide, Cidex OPA, Sporox
Hydrogen Peroxide, Formaldehyde
2. Intermediate-level disinfection – kills most bacteria, viruses and
fungi on non-critical items but does not affect spores. It also
inactivates mycobacterium tuberculosis.
a. Examples: Alcohol (Isopropyl/Ethyl)
3. Low-level disinfection – removes vegetative bacteria, fungi and
least resistant viruses on non-critical items such as HIVs.
a. Examples: Ammonium, Chlorine
Methods of Disinfection:
1. Chemical Disinfection – Indicated for materials that cannot
be heated.
2. Physical Disinfection:
- Boiling Water – boiling the water until 100 degrees Celsius
will destroys the pathogen except the spores.
- Pasteurization – high level disinfection that is indicated for
reusable respiratory devices and anesthesia breathing
circuits by hot water decontamination with chlorine
agents
3. Ultraviolet Irradiation – UV rays at wavelengths of 240 to
480 nm. This can be used in surgical environments to
decrease the airborne microorganism to low level, however,
this can cause skin irritation.
STERILIZATION
- Eliminates all pathologic and non-pathologic microorganisms

including spores. This is the only method in destroying all
microbial life. This method can be done either physical or
chemical means.
Methods of Sterilization:
1. Thermal (physical) – steam with pressure, hot air/dry
heat, autoclaving
2. Chemical – ethylene oxide (EO) gas, ozone gas. Hydrogen
peroxide plasma
3. Radiation – X-ray (ionizing) and Microwave (nonionizing)
STERILIZATION
Autoclaving
o Most common and best method
of sterilization; works like a
pressure cooker that uses steam
and pressure to achieve the
temperature.
o Temperature reaches to 100
degrees Celsius to destroy the
spores.
o Advantages:
o destroys pathogens, nontoxic and
lesser duration for about 20
minutes
o Disadvantages:
o items must be heat resistant and
does not sterilization oils and
powders.
Photo taken from: https://microbeonline.com/autoclave-

principle-procedure-types-and-uses/
STERILIZATION
Ethylene Oxide (EO)
o Indicated for items that are
sensitive to heat or moisture.
o EO is highly flammable and
explosive and the EO residues
poses hazard to personnel expose
to it.
o Advantages:
o effective for heat sensitive items, and it
does not damage the item by erosion;
used for commercially pack sterile
items.
o Disadvantages:
o complicated and long process,
Photo taken from:
expensive, repeated EO can increase its
https://ww1.steris.com/healthcare/products/sterility
residues; inhaled EO can irritate the -assurance-and-monitoring/chemical-
mucous membranes and carcinogenic. indicators/verify-ethylene-oxide-integrator-strips/
STERILIZATION
Hydrogen Peroxide Plasma
Sterilization
o Highly sporicidal even at a low
temperature and concentration.
o Converts the hydrogen peroxide
into plasma or vapor,
o Indicated for metal and nonmetal
surgical devices.
o Advantages:
o dry and non-toxic; byproducts are
safely evacuated; corrosion does not
occur to moisture sensitive items.
o Disadvantages:
o metal tray blocks waves and cannot be Photo taken from:
used; not compatible with cellulose https://www.steris.com/healthcare/knowledge-
(cotton fibers, paper), nylon becomes center/sterile-processing/hydrogen-peroxide-
brittle. sterilization
INSTRUMENT PACKAGING
- Permits the penetration of sterilizing agents and its release

upon finishing.
- Withstand the physical condition of the packaging and
maintain its integrity
- Provide impermeable barrier from microorganism and
other particle post sterilization.
- Cover the items completely and sealed properly.
- Proper identification of contents and indicators.
STERILIZATION INDICATORS
- Mechanical Indicators
- measure the temperature, pressure and time. Place on the
equipment itself.
- Chemical Indicators
- used internally and placed together with the items.
Commonly used chemical indicator is the tape that darkens
when sterilized.
- Biologic Indicators
- most accurate indicator because it works when the
microorganism is dead. Commonly used indicator is by using
cultures and done once a month. If there is a positive culture,
the sterilization is malfunctioning.
ENDOSCOPIC SURGERY
- Examination of a body or cavity using an optical
system
- Essential Elements of Endoscopy
1. Access Portal – Natural orifice of functional stoma
- Natural orifice
- Puncture or incision
2. Working space – fluid, gas or positional expansion to accommodate
instruments
- Structural working space – abdomen
- Expansion media – Fluids, Gas, Air, Balloon expansion between tissue
planes
3. Illumination – fiberoptics or incandescent bulb
- Fiberoptic Light – connected to coated glass fibers encased in a plastic
sheath
- Others: incandescent bulb, indirect lights (used with specula, vaginal, nasal
or anal)
ENDOSCOPIC SURGERY
4. Vision – direct or indirect viewing of camera
- Scope
▪ Rigid – straightforward scope with no
accessory ports.
▪ Rigid hollow – additional side ports for
oxygen and anesthetics
▪ Flexible – multidirectional scope that
can be manipulated to gain better
visualization
- Camera – video, monitor and wireless
capsule endoscopy
- Microscope attachments – permits study of
the abnormal tissues
- Ultrasonic imaging – ultrasound transducer
at the end of the endoscope to visualize
heart, liver, pancreas and kidney
- Radiographic assisted – fluoroscopy guided

ENDOSCOPIC SURGERY
5. Manipulation – tissue grasping, debulking
and dissection
- Instrumentation – dissectors, graspers,
snares, spatulas, clamps, needles
- Suturing, stapling and clipping
6. Capture – collection of specimens
- Grasper and snares can be used to
remove tissues
- Pouches with drawstrings can be used
via the trocar to collect the specimen
7. Evacuation – remove gases, plume of fluid
- Evacuated using suction irrigators and
should not be expelled to the room
because of its biologic particles.
8. Closure – suturing, stapling or minimize the
portal

Missouri: Elsevier.
COMPLICATIONS OF ENDOSCOPY
- Perforation – trauma from the rigid scopes and sharp

trocars and causes bleeding
o Management: prevent injury to these instruments while
holding the other devices and positioning the patient
- Bleeding – may came from biopsy site, pedicle of a polyp
and site of incision.
o Management: watch out for blood pooling
COMPLICATIONS OF ENDOSCOPY
- Hypothermia – Carbon dioxide is colder than body temperature,

therefore preserving body heat by the means of blankets should be
done
- Preperitoneal Insufflation – CO2 can insufflate inside the preperitoneal
tissues if the Veress needle is not inserted properly.
- Gas embolism – absorption of gas into the vascular system can cause
cardiac dysrhythmias. If happened, stop the CO2 flow, hyperventilate
the patient and position the patient at left lateral position and the
anesthesiologist can insert a central line t gain access to the right
atrium and aspirate the air.
- Incidental iatrogenic injury – the body frame of the equipment can
cause pressure on to the body. Brachial plexus can happen if improper
placement was done.
GENERAL CONSIDERATION FOR
ENDOSCOPY
- Monitor for any drug reactions from anesthetic agents.
Respiratory depression and hypotension can happen.
- Topical anesthetic agent can be applied over the nasal, oral,
pharyngeal area before induction of endoscope.
- Apply mouthpiece to prevent damage in the oral cavity
such as teeth, gums and lips. If with dentures, remove the
dentures.
- Carbon dioxide is used to flush the hydrogen and methane
gases inside the intestines to prevent explosion.
- Endoscopes should be smooth. Any irregularities can
induce trauma to the lining by introduction of the scopes.
MINIMALLY INVASIVE SURGERY ROOM
- Uses small incision and fiberoptic lighting with camera and

video and instruments for tissue manipulation
- Contains equipment for puncture and natural orifice
endoscopy and video monitors
- Capable of turning into open procedure if in case of
emergency
ROBOTIC ASSISTED SURGERY
- Provides a stables laparoscopic telescope/camera holder with a bed
mounted camera arm and controlled by a voice-actuated computer.
- Components:
1. Environmental controlled platform - The voice actuated came from
the surgeon who wears a microphone and directs the aim and
direction of the endoscope. The machine is trained by the surgeon’s
spoken words.
2. Functional peripheral equipment – all equipment such as light
source, insufflator, electrosurgery unit, irrigator, aspirator, image
recorded can be manipulated by the surgeons on food pedal or
command into the headset.
3. Master console and Instruments manipulating robot – the surgeon
manipulates three to four articulated arms with joysticks while
observing its precision with a 3D binocular laparoscope and
camera.
- Advantages:
1. Great precision as compared with
human hands.
2. Freedom of motion without tremor
or fatigue
- Disadvantages:
1. Costly or expenses, learning curve
and training
2. Reduces the floor area due to size of
the machine
3. Lacks tactile sensitivity as compared
to open surgeries.
- Virtual Reality
• Stimulating real-life motion, time
and space.
• Computer generated images that
mimics the real-life situation
• The surgeon-in-training practices
and simulation procedure with
handling a real patient.

HEMEOSTASIS
THERMOREGULATION
- Core temperature – temperature of internal body that has a range of

36.8 – 37.7 degrees Celsius
- Intraoperative Hypothermia – occurs under anesthesia, the
temperature lowers due to the effect of anesthetic effects to prevent
production.
- Convection, evaporation, conduction and radiation aggravates the loss
of body temperature.
- Hyperthermia – occurs when premedicated, dehydration,
anticholinergic effects (sweating) hypermetabolic crisis (malignant
hyperthermia) or fever from sepsis. This should be monitored by
thermometer.
SURGICAL POSITIONS
GOALS OF POSITIONING
1. Better visualizations of the site

2. Easier and convenient accessibility
3. Maintain body alignment
4. Sustain neuromuscular and skin integrity
5. Manage cardiovascular and pulmonary
dysfunctions
SURGICAL POSITIONS
SUPINE POSITION
- dorsal position, natural position when at rest
- palms extend alongside the body, legs are
straight and parallel with head and spine.
SUPINE MODIFICATIONS
Trendelenburg position
• upper torso is lowered and
feet are raised. Decreased
the lung expansion due to
gravity
• Indication: lower abdomen
or pelvis because of better
visualization
• Contraindicated: increased
intraocular and intracranial
pressure
Reverse Trendelenburg position

• Head is elevated and feet is
lowered; promotes better
respiratory clearance
• Indication: upper torso, neck
and shoulder

Lithotomy
• Buttocks are place on the back and
the legs are placed on the stirrups
(usually 90 degrees) and adjusted
the height according to the
patient’s legs and maintain
symmetry. Ensure stirrups are on
the same height and safety belts
are applied. Adjustment of the legs
should done simultaneously to
prevent any straining and
hemodynamic instability.
• Indication: urologic procedures

Semi Fowlers
• Lawn chair position; the head
of bed is raised to 45 degree
angle; improves chest
expansion
• Indication: cranial and nasal
surgeries
• Complication: air embolus,
pelvic pooling, hypotension,
pressure injury

SURGICAL POSITIONS
PRONE
- Lies the body on their abdomen.
- Before positioning, the patient is anesthetized in a
supine position on a stretcher then logrolled to the
surgical bed and assuming the prone position with his
or her arms placed on the side.
- Indication: Spinal or rectal surgeries
PRONE MODIFICATIONS
Jackknife (Kraske)
• Hips are raised at a 90 degree
angle and lowering the trunk; arms
are extended on arm boards and
flexed and palm down; head is
placed on the side and supported
by a pillow or donut.
• Indication: Hemorrhoidectomy
• Complication: embolism due to
blood pooling at the head; limited
respiration due to pressure on the
diaphragm

PRONE MODIFICATIONS
Knee Chest
• Extension is attached to
the foot part, the table is
flexed at the center. Leg
section is lowered and
legs flexed at right angle
• Indication:
Sigmoidoscopy and
lumbar laminectomy
Photo taken from: https://en.wikipedia.org/wiki/Knee-

chest_position#/media/File:Diseases_of_the_kidneys,_ureters_and_bladder,_with_
special_reference_to_the_diseases_of_women_(1922)_(14763493624).jpg
SURGICAL POSITIONS
LATERAL POSITION
- Lateral decubitus or sims position
- Anesthetized supine on the operating table and turn to
unaffected side. The ankle and foot are of the upper leg
are supported to prevent foot drop. Arms are placed on
a padded arm board. Cervical part should be aligned
with the spine and supported by a pillow.
LATERAL MODIFICATIONS
Lateral Chest
• Exposes the upper
thoracic cavity and
easier visualization;
arms are extended on
a double arm board
• Indication:
thoracotomy

LATERAL MODIFICATIONS
Lateral Kidney
• The flank region is
positioned over the
operating table
elevator and turned
into the unaffected
side.
• Indication: kidney
surgery

SURGICAL INCISIONS

SURGICAL INCISIONS
• Midline Incision
– either upper abdominal or lower abdominal or both going around the
umbilicus that extends from xyphoid process up to suprapubic region. It avoids
the umbilicus to prevent cutting the structures. Using midline incision
prevents to encounter numerous blood supply and nerve endings. The muscles
can be separated and retracted easily for visualization and easier to close.
• Paramedian Incision
– type of vertical incision and lateral to the midline on either side of upper or
lower abdomen. It allows the surgeon to access and visualize internal
structures and minimizes trauma and nerve injuries. This incision is indicated
for biliary and pancreatic procedures.
• Subcostal Upper Quadrant Oblique Incision
– a right or left oblique incision originating from the epigastric and extends
laterally. It provides good cosmetic results however it has a limited
visualization. This incision is indicated for biliary procedures.

SURGICAL INCISIONS
• McBurney’s Incision
– oblique incision that provides visualization at the appendix and intended
for appendectomy.
• Thoracoabdominal Incision
– the patient is positioned laterally from either left or right side. Incision
made from xyphoid process upto seventh to eight intercostal space. This
incision is indicated for esophageal varices and hiatal hernias.
• Midabdominal Transverse Incision

– start at either left or right and slightly above or below the umbilical area.
This is indicated for transverse colostomy and/or delivery of infants.
SURGICAL INCISIONS
• Pfannestiel Incision
– creates a curvilinear transverse incision across the lower abdomen.
This incision is indicated for pelvic and urologic organs.
• Inguinal Incision (lower oblique)

– oblique incision of either right or left inguinal regions from pubic to
anterior iliac crest. This incision is indicated for herniorrhaphy.
ANATOMIC AND PHYSIOLOGIC CONSIDERATION
1. Respiratory – diaphragmatic movement are essential to promote airway
patency and chest expansion.
2. Circulatory – blood pooling on the lower extremities can cause thrombus
formation. When elevated, this is a decrease tissue perfusion; changing
position must be done carefully to prevent changes in the blood pressure and
stress in the heart.
3. Peripheral Nerves – pressure can cause decrease tissue perfusion and
damages the nerves. Improper and prolonged positioning compresses the
nerves.
4. Musculoskeletal – muscle strains due to prolonged position of surgery. Limit
hyperextension of joints which can increase the postoperative pain and may
contribute to additional injury such as fractures in elderly patients.
5. Skin and underlying tissue – Pressure sores due to prolonged position
especially to bony prominences. Wrinkled sheets and edges can also
contributes to pressure sores.
FUNCTIONS, DUTIES, AND
RESPONSIBILITIES OF
OPERATING ROOM
NURSES
DUTIES OF CIRCULATING NURSE
• After the patient arrives in the OR:

- Greets & identifies patient.
- Check’s patient’s chart for pertinent information, orders & consent.
- Assist patient in moving into the operating table.
- Checks that the patient’s hair is covered with cap, apply restraints & strap
over legs & arms.
• After the scrub nurse scrubs:
- Fastens the back of the scrub persons’ gown
- Opens packages of sterile supply
- Pours solution into the basin
- Counts sponges, sharps, & instruments with the scrub nurse
• During induction of anesthesia & patient is anesthetized:

- Stays in the room & assist the anesthesiologist
- Helps in positioning the patient after induction of anesthesia
- Places cautery pad, exposes appropriate area for skin preparation
- Performs skin prep as ordered
After surgeon & assistant scrub:
• Assists with gowning.
- Observes for any breaks in technique during draping.
- Assists scrub person in moving mayo stand & instrument table into
position.
- Focuses overhead operating light on site of operative field.
- Sets foot stools for team members who need them.
- Positions kick buckets on each side of the OR bed.
- Connects suction & electrocautery as ordered.
• During induction of anesthesia & patient is anesthetized:

- Stays in the room & assist the anesthesiologist
- Helps in positioning the patient after induction of anesthesia
- Places cautery pad, exposes appropriate area for skin preparation
- Performs skin prep as ordered
After surgeon & assistant scrub:
• Assists with gowning.
- Observes for any breaks in technique during draping.
- Assists scrub person in moving mayo stand & instrument table into
position.
- Focuses overhead operating light on site of operative field.
- Sets foot stools for team members who need them.
- Positions kick buckets on each side of the OR bed.
- Connects suction & electrocautery as ordered.
• During operation:
- Be alert for any breaks in aseptic technique
- Stays in the room.
- Keeps discarded sponges carefully collected, separated
& counted.
- Assist in monitoring urine output & blood loss.
- Knows condition of the patient at all times.
- Prepares & labels specimens for transporting to the lab.
- Completes patient’s chart.
• During closure:
- Counts sponges, sharps & instruments with the scrub nurse.
- Assists the anesthesiologist in extubation
- Send for RR stretcher or ICU bed.
- After operation is completed:
- Opens neck & back closure of gown of surgeons & assistants.
- Assist with dressing.
- Sees that patient is clean.
- Helps to move patient to stretcher or bed.
- Endorses patient to RR or ICU.
DUTIES OF SCRUB NURSE
• Before the surgeon arrives:
- Scrubs completely, dons gown & wears gloves.
- Drapes table as necessary.
- Counts sponges, sharps & instruments with circulating nurse.
- Prepares instruments & items on mayo table.
- Puts blades on knife handles & prepares suture in sequence.
• After surgeon & assistants scrub:
- Gowns & gloves the surgeon & assistants.
- Assists in draping the patient according to routine procedure.
- Brings mayo table into position over patient after draping is
completed.
- Attach suction tubing & electrocautery.
• During operation:
- Hands towels & towel clips for fastening drapes.
- Passes skin knife to surgeon & hemostat clamps to assistant.
- Watches field & try to anticipate the surgeon’s needs.
- Passes instrument in a decisive & positive manner.
- Place ligature in surgeons hand.
- Keeps two clean sponges in the field.
- Saves all tissue specimens.
- Maintains sterile technique.
- Counts sponges, sharps, & instruments with circulating nurse when
the surgeon starts to close the incision.
• After the operation:

- Assists in dressing the wound
- Cleans the patient of any betadine or blood
- Helps move patient to stretcher/bed
- After care of the room
- Washes/cleans used instruments in the
instrument room & prepares them for
sterilization
Thank You!
References
E-Textbook
• Bonilla, S., Carsula, R., Belardo, J. E., & Balisi, M. L.
(2009). Manual of Perioperative Nursing: Reference
and Reviewer. Quezon City: C&E Publishing, Inc.
• Phillips, N. (2017). Berry & Kohn's Operating Room
Technique 13th Edition. Missouri: Elsevier.
• Potter, P., Perry, A., Stockert, P., Hall, A., & Ostendorf,
W. (2017). Fundamentals of Nursing Ninth Edition.
Missouri: Elsevier.
• Silvestri, L. A. (2017). Saunders Comprehensive Review
for the NCLEX-RN® Examination, Seventh Edition.
Missouri: Elsevier.

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PERIOPERATIVE

• Area to change the patient clothes from street

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

STERILE TEAM – these members perform surgical asepsis

Infection related to surgical operation is life

“Absence of microorganism that

- The surgical bed should be at the working

- Sterile – free from any microorganism

These are ways to protect

▪ AIRBORNE – particles smaller than 5mm carries airborne

- To effectively provide barriers

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

- Whenever in the sterile field,

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

o Dressing rooms should be in an unrestricted area, where the personnel

o Personnel who has an acute infection should not be allowed to work

CRITERIA FOR SURGICAL ATTIRE

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

Body cover (Scrub Suit)

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

▪ Perform hand hygiene when

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

▪ The cuff of the gowns are

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

▪ Powder free gloves are advised

Photo taken from: Phillips, N. (2017). Berry & Kohn's Operating

- Also known as surgical scrub, method of removing as

Anti-microbial Skin Cleansing Agents properties:

1. Remove accessories such as jewelries and watches

5. Apply or use antiseptic scrubs.

- Surgical Handwashing last for 3 – 5 minutes;

1. When drying the hands and arms,

Photo taken from: Phillips, N. (2017). Berry & Kohn's

Photo taken from: Phillips, N. (2017). Berry & Kohn's

4. Hold inside of the gown

Photo taken from: Phillips, N. (2017). Berry & Kohn's

5. Carefully slide the

Photo taken from: Phillips, N. (2017). Berry & Kohn's

Photo taken from: Phillips, N. (2017). Berry & Kohn's

Photo taken from: Phillips, N. (2017). Berry & Kohn's

Photo taken from: Phillips, N. (2017). Berry & Kohn's

Photo taken from: Phillips, N. (2017). Berry & Kohn's

2. Extend the left forearm and the palm facing upward.

Photo taken from: Phillips, N. (2017). Berry & Kohn's

oSkin to skin and glove to glove technique.

oSkin to skin and glove

Photo taken from: Phillips, N. (2017). Berry & Kohn's

This procedure to prepare the skin site to

PREPARATION ON THE SURGERY TABLE

Photo taken from: Phillips, N. (2017). Berry & Kohn's

2. Wear sterile gloves

6. Do not go back to the previous site using the same

Photo taken from: Phillips, N. (2017). Berry & Kohn's

1. Ensure that the area is dry because the of the risk of

6. The part that is below the table is contaminated. If the