Gowns, Drapes, Masks, Gauze Dressings, Sponges, and Pads: The types of

gowns, dressings, etc., vary somewhat, although within recent years they have
become more standardized. The method of caring for them is very much the same.
Gowns, drapes, sponges, and dressings are packed in drums or wrapped in cloth or
paper and sterilized by autoclaving. Masks are wrapped either in individual
packages or in groups of two and three. When drums are used they should be care
fully inspected before being packed, being sure that they are dry, well lined and
that the holes on the sides are open. Instead of packing several types of articles in
one drum as is generally done on the ward, one drum is used for gowns, another
for towels, another for larger drapes, one for gauze, etc. All articles are examined
for imperfections before being packed and are folded so that they may be removed
from the drum and unfolded for use with speed and without danger of
contamination. Gowns are folded so that the outside of the gown is turned inside
and are placed in the drum in such a fashion that they may be removed from the
container without touching the outside of the gown. The method of folding articles
and packing drums varies greatly but a standard system used throughout a hospital
aids efficiency. The articles should be packed loosely to allow complete penetration
of the contents by steam. A sterilometer may be placed in the center of the drum
so the nurse may check to see whether the contents of the drums are sterile. Each
drum should be labeled.

When articles are sterilized in packages, each package should be wrapped loosely,
but securely in paper or in two thicknesses of cloth, tied, and labeled.

Sutures and Ligatures: A suture is used for sewing, while a ligature is used for
tying off a blood vessel.

Suture material is classified into two large groups: Absorbable sutures which are
absorbed by the tissues during the healing process of wounds and, therefore, do
not have to be removed, and nonabsorbable sutures which are not absorbed and
have to be removed.

Absorbable Materials: Plain Catgut: A light tan colored suture made from the
intestines of sheep. It is purchased, ready sterilized, in tubes. Catgut is absorbed in
from two to eight days, depending upon the size, which varies from 00-5. Number
00 absorbs in two days and number 0 in four days, so they are used for tissues
which heal quickly, e.g., superficial ligatures. Number I absorbs in six days and is
used to tie off muscle bleeders and for sewing muscle.

Chromicized or Tanned Catgut: Catgut treated with a salt of either chromic or

tannic acid and prepared in sterile tubes. This material resists absorption longer
than plain catgut and is used where approximation is required to last from 10 to 20
days Numbers 00 and 0 are used on mucous membrane and small tendons,
numbers I and 2 for sewing fascia, peritoneum, and tying off small organs, and
numbers 3-5 for tying off larger organs such as lungs and kidneys. Chromic catgut
comes in small sizes welded on a straight or curved needle. These are called
atraumatic sutures and are used for work where diminished trauma is desired, e.g.,
intestinal work.

Kangaroo Tendon: Used for orthopedic work, for recurrent hernias, and cases
where absorption is not desired before 30 to 60 days. All absorbable materials,
unless otherwise stated on the tube, are sterilized by chemical action or by tying
the tubes in gauze and boiling.

Nonabsorbable Materials: Pagenstecher: Linen thread which has been treated

with a celluloid and rendered nonabsorbable. It comes in varying sizes and is used
chiefly for gastrointestinal work. Although nonabsorbable, it is not removed from
the tissue. It is sterilized by autoclaving or boiling.

Deknatel: A waxed, treated, nonabsorbable suture used in such operations as

herniotomy and thyroidectomy and is not removed. It is sterilized by autoclaving or
boiling.

Silk, Either Black or White: Comes in various sizes according to number and is used
mostly for suturing the skin. Silk also comes welded to a small round, curved
needle used for suturing nerves and arteries, and a small cutting needle for plastic
work. Silk may be autoclaved or boiled. If boiled, it should be wrapped around a
spool made from rubber tubing. It should not be resterilized as the process
weakens the material.

Horsehair: Used mainly for suturing the skin and is sterilized by boiling. It should
first be washed thoroughly in soap and water and then boiled in a soda solution for
ten minutes to render it free of tetanous spores.

Silkworm Gut: Unspun silk from the silkworm used for superficial retention sutures.
Strands of the gut are placed through a piece of Dakin's tube and boiled. Reboiling
weakens the material.

Dermal: A fine, plain catgut used for suturing the skin. It comes inclosed in a tube
and is sterilized by boiling or autoclaving.

Fascia Lata (in tubes): Derived from the ox and is used for recurrent hernias when
it is impossible to use human fascia. The tubes are sterilized by placing in a
chemical solution for 20 minutes.
Metal Clips, Silver Wire, and Bone Wax: Various sizes of metal clips are used for
skin sutures. Silver wire and bone wax (sterilized beeswax) are used in orthopedic
work, the silver to wire bone together and the bone wax to control bleeding from
bone. The metal clips and wire are sterilized by boiling and the bone wax by a
chemical agent.

Needles: There are many kinds of needles on the market and each surgeon has his
preference. Some surgeons change the type of the needle to fit the tissues being
sewed. while others use one kind of needle for practically all their work. The nurse
needs to find out the preference of each surgeon and prepare the type he uses.
Needles come in all sizes and shapes, t t they may be generally classified into
straight and curved needles, those with a cutting edge, and those with a round
edge. As a rule, straight, cutting edge needles are used for surface work, while
curved needles with a round edge are used for the deeper layers. Unless special
type needles are requested, a suggested list for a laparotomy is as follows:

2 straight skin needles for suturing the skin.

2 medium curved skin needles for superficial tension sutures.
2 large curved skin needles for deep tension sutures.
2 large Mayo needles for suturing muscle tissue.
2 medium Mayo needles for suturing the peritoneum.
2 small Mayo needles for suturing fascia.
2 straight intestinal needles.
2 small curved intestinal needles.

Needles are sterilized by boiling, autoclaving, or a chemical solution.

Drains and Packing: A drain is some material inserted into a wound to provide an
exit for toxic materials, blood, and serum. Practically all drains are made from
rubber tubing, rubber sheaths, gutta percha, and gauze. Because gauze readily
adheres to the wound and causes pain when removed, it is usually covered with
some other substance, rubber being most commonly employed. A common type of
drain is the cigarette drain, made of a rubber sheath with gauze packing running
through the lumen in the form of a wick. A small Penrose drain, composed of
rubber with no packing, is used to drain off serum in such cases as thyroidectomy.
Some other types of drains employed are plain rubber dams, catheters, mushroom
catheters, Dakin's tubes, and perineal tubes. Mayo tubes and T-tubes are
frequently used to drain gall ducts and the gallbladder. Whenever a drain is needed,
a sterile safety pin is prepared to insert through the outer end of the drain and
prevent it slipping into the wound. Drains are sterilized by boiling.
Gauze packing is used in sizes from 1/4 inch to 3 inches in width. The packing is
placed in the wound and only a small amount is removed at one time. This process
keeps the wound open, allowing the lower layers to heal first, meanwhile leaving an
opening for drainage.

Medicated gauze, particularly iodoform gauze, is sometimes used for packing. This
cannot be sterilized and so the gauze drain is medicated under sterile conditions.
Vaselined gauze is placed around wounds where there is considerable drainage in
order to prevent irritation of the adjacent skin areas.

Instruments: A dissecting tray, which contains instruments necessary to open and

close an area, is the fundamental tray used in all operations. Other instruments are
added, depending upon the type of operation performed and the surgeon's
preference. Dissecting trays vary somewhat in different hospitals, but a suggested
list of instruments is as follows:

1 knife to make the skin incision. This knife is discarded after the incision is made.
1 knife for cutting tissues under the skin.
1 straight scissors.
1 curved scissors.
1 suture scissors.
2 mousetooth forceps—to pick up tissues for suturing, etc.
2 anatomical forceps (smooth) to pick up delicate tissues, such as the peritoneum.
6 small curved Kelly clamps—to clamp off superficial arteries.
6 small straight Kelly clamps—to clamp off superficial arteries.
6 medium curved Kelly clamps—to clamp off vessels in the muscle layers.
6 Allis clamps.
6 Kocher clamps.
1 probe.
1 grooved director.
1 set of aneurysm needles for ligature carriers.
2 rake or prong retractors.
2 smooth retractors.
1 needle holder.
2 sponge sticks
4 towel clips

Electrical and Mechanical Appliances: Various appliances such as a Cameron

light, suction machine, and cautery, are ,used frequently. The nurse needs to
become familiar with the type of appliance employed in her institution. She should
know the use of the machine, how to test it before using, the method of handling
during an operation, the care of the machine after it has been used and should
understand the mechanical principles involved. They should be available for use at
a moment's notice.

IV. IMMEDIATE PREPARATION FOR OPERATION

Topic Preview
1. Preparation of the operating room
2. Selection and preparation of equipment
3. Technic of "scrubbing"
4. Preparation of aseptic fields

At least four nurses are needed to prepare and assist with any major operation. For
convenience we will give these nurses titles, although the terms used are colloquial.
Both the "instrument nurse" and "suture nurse" are dressed in sterile gown, gloves,
etc., and directly assist the surgeon during the operation. The "utility nurse" is
unscrubbed and remains in the operating room during the entire procedure to wait
upon those who are scrubbed. The "ether nurse" receives the patient, cares for him
in the anesthetizing room and places him on the operating table. She also has
charge of all duties which take one from the immediate operating vicinity.

Before preparing for an operation, all nurses involved should become familiar with
the operating schedule, noting the type and order of operations, the kind of
anesthesia to be used and the surgeons operating. Dressing rooms and lockers
should be equipped and ready for use.

Preparation of the Operating Room: The entire operating room should be

spotlessly clean. Walls and furniture are dusted with a damp cloth or washed. Sinks
and floors are cleaned. The furniture and equipment should be arranged to permit
the greatest amount of efficiency. The details of arrangement will differ depending
upon the environment, equipment, and type of operation. The operating table
should be placed where the maximum amount of light can be obtained. The room
should be well ventilated but in such a fashion that there is no draught on the
patient.

Selection and Preparation of Equipment: Usually each nurse has definite

preparatory duties for which she is responsible but in general the following
preparation is necessary : All materials needed for the schedule should be selected
and brought to the operating room before the nurse begins to "set up." Materials
kept in the room should be checked to make sure there is an adequate supply. The
anesthetizing room is prepared for the patient. Scrubbing materials are placed by
the "scrub-up" sinks. Mechanical appliances are tested. Specimen jars are made
ready. Water tanks are checked to see that there is plenty of sterile hot and cold
water. Basins are selected, placed in the basin sterilizer and boiled for at least 20
minutes. A chemical solution is made and knives, needles, scissors, and other
articles which need to be sterilized in this manner are placed in it and left for 20
minutes. Instruments are selected, tested to see that they work properly and
easily, and placed in the instrument sterilizer to boil. Sutures are chosen and
sterilized.

Technic of "Scrubbing": Although the technic of scrubbing varies in different

hospitals, the purpose is always the same—to make the hands and arms as clean as
possible. The method consists of two processes, a thorough scrubbing with soap
under running hot water and the use of some kind of disinfectant. A suggested
procedure is as follows:
1. PREPARATION FOR SCRUBBING:
a. Either a short sleeved operating room dress is worn or else sleeves
are rolled up three inches above the elbow.
b. Fingernails should be short, evenly filed and free from polish.
c. A cap is worn which completely covers the hair.
d. A sterile mask is placed over the nose and mouth to prevent bacteria
from being expelled on the sterile field and wound.
e. All articles used for scrubbing, brushes, orangewood sticks, etc., are
sterile.
2. THE SCRUB-UP PROCEDURE:
a. Clean the fingernails.
b. Dip the fingertips in 3 1/2 per cent iodine and allow it to dry.
c. Rinse both hands and arms completely under running hot water,
holding the fingertips up and allowing the water to drain off the
elbow.
d. Wet the brush with green soap solution and beginning on the outside
of the thumb, with a circular motion, scrub each finger as though it
had four sides.
e. Rinse completely.
f. Start at the fingertips and scrub the palm of the hand with a circular
motion to the wrist. Scrub the back of the hand in the same fashion.
Rinse again.
g. Start at the wrist, scrub the arm with a circular motion, advancing
toward and including the elbow. Rinse.
h. Scrub the other hand and arm in the same manner.
 i. Clean underneath the nails with an orangewood stick.
j. Repeat the procedure from step "c," this time omitting the elbow.
k. Scrub the fingertips of each hand for one minute.
l. Rinse completely under running water.
m. Rinse completely with alcohol

The entire scrub should take ten minutes.

n. Dry the hands and arms on a sterile towel.
o. Put on sterile gown and gloves.

A three-minute scrub is all that is necessary between cases providing technic has
not been broken, or the previous case was not septic.

Preparation of Aseptic Fields: The various pieces of furniture, such as gown

table, supply table, Mayo stand, saline table, and basin racks, are draped with
sterile sheets and pads to create and maintain an aseptic field. The method of
draping will vary, depending somewhat upon the type of drapes and furniture used.

V. ARRANGEMENT OF INSTRUMENTS, BASINS, AND OTHER MATERIAL

After the instruments have been sterilized they are removed from the sterilizer,
dried with a piece of sterile gauze and arranged on the trays and tables. All special
instruments are placed on the general supply table. Those forming the basic
dissecting tray are always arranged in the same manner, so that everyone is
familiar with their placement. They should be placed in the order of use, usually
beginning with the right side of the tray and working toward the left. Like
instruments should be kept together. The handles should point toward the operator.
If extra instruments are needed during the operation they may be secured from the
reserve table, but do not clutter up the tray with more than is needed. Other
materials are arranged on tables and trays where they will be ready and convenient
for use.

VI. PREPARATION OF THE PATIENT

Topic Preview

1.Placement of patient on operating table:

a. Dorsal position
b. Dorsal lithotomy position
c. Trendelenburg position
d. Jackknife position
e. Modified Sims position
General preparation of the patient, his removal to and acceptance in the
anesthetizing room has been discussed in Chapter VI.

Placement of the Patient on the Operating Table: The patient may be placed
on the table either before or after administering anesthesia. The arrangement of
the table varies with different operations. Every nurse in the operating room should
know the various positions used and how to manage the table to secure these
positions with ease and rapidity. Several important points -should be kept in mind.
The patient should be as comfortable as possible. The part to be operated upon
must be exposed and easily accessible, but unnecessary exposure should be
avoided. There should be no pressure upon nerves or interference with the
circulation or respiration. Patients have been known to develop paralysis due to
continuous pressure on a nerve while under anesthesia. Many of the backaches
during the postoperative period are due to rough handling and uncomfortable
positions while on the operating table. More patients complain of pain in the back of
the neck after a thyroidectomy than of pain in the incision. Many postoperative
discomforts cannot be avoided, but thoughtful consideration will help eliminate
unnecessary ones.

A few of the most commonly used positions are as follows:

Dorsal Position: The patient lies on his back in a horizontal recumbent position
with the arms extended at the sides and held in place by a drawsheet. A restraining
strap is placed over the knees. This position is used for all laparotomies. It may be
varied, e.g., an armboard is added when a radical mastectomy is performed, and a
small, hard pillow placed under the neck elevates the area for thyroidectomy.

Dorsal Lithotomy Position: This position is used for rectal and vaginal operations.
The arms are folded across the chest while the legs are flexed on the abdomen and
held in place by stirrups. The buttocks should be even with or slightly overhanging
the edge of the table. Shoulder braces help maintain the position. In all perineal
cases a Kelly pad is placed on the table before the patient is transferred from the
stretcher.

Trendelenburg Position: Practically all pelvic operations require this position,

which by gravity keeps the intestines out of the pelvis. The patient is placed first in
the dorsal position with the bend of the knees directly over the break of the table.
The arms are held in place at the sides. Shoulder braces are used. The table is then
tilted, so the pelvis is higher than the head.

Jackknife or Modified Knee Chest Position: Rectal cases are often performed
with the patient in a modified knee chest position. The patient lies on his abdomen,
with the hip Joint over the break of the table. Shoulder braces and other methods
of support should be used, as this position is uncomfortable and difficult to
maintain.

Modified Sims Position: Modified Sims position is used for chest and kidney
operations. Sandbags help to support the patient and keep him in position.

While the patient is being placed on the operating table and anesthetized, the
surgeon and his assistants are scrubbing and preparing for the operation. After they
have been assisted into sterile gown and gloves, the patient receives the final part
of the preparation.

VII. THE OPERATION

Topic Preview
1. Chemical skin disinfection and draping
2. The instrument nurse
3. The suture nurse
4. "Utility" or "circulating" nurse
5. "Ether" nurse

Chemical Skin Disinfection and Draping: Some of the most commonly used skin
disinfectants are tincture of iodine, mercuro- chrome, and picric acid, although each
surgeon has his preference. The disinfectant chosen should be able to penetrate the
surface of the skin, kill organisms living on the skin, and dry rapidly. If iodine is
used, great care should be taken to prevent burning. Most surgeons paint first with
iodine and then with alcohol.

After the area has been disinfected, sterile towels are placed around it. Then the
larger drapes are applied, forming a complete sterile field.

The surgeon and assistant step into position, the instrument trays, saline stands,
and other necessary equipment are moved into place and the operation begins.

Duties of the Instrument Nurse: The main duty of the instrument nurse is to
assist the surgeon by placing in his hand the instrument needed. Some of the
points to keep in mind are as follows:
1. Place the handle of the instrument in the surgeon's hand in such a manner
that the instrument is- in position for use. Movements should be quick,
quiet and sure. Unnecessary movements should be avoided.
2. Anticipate the surgeon's needs.
3. Do not give more than one clamp at a time.
 4. After an instrument has been used, clean it and place on the tray in its
former position. Replace instruments on the tray from the reserve table as
necessary.
5. Always keep the tray neat and the towel under the instruments dry and
clean.
6. As soon as the peritoneum is opened remove all loose sponges-from the
tray.
7. Either the instrument nurse or the suture nurse keeps the surgeon supplied
with warm laparotomy pads and sponges. Whoever has charge of this
should verify the pad and sponge count before the peritoneum is closed and
at the end of the operation.

Duties of the Suture Nurse: The main duty of the suture nurse is to prepare and
hand sutures and ligatures to the surgeon.

Preparing Catgut: Catgut comes in a solution which will irritate the eyes and
cause gloves to deteriorate, so when breaking the tube, both the eyes and gloves
should be protected. This can be done by first shaking the catgut down to one end
of the tube, then turning the tube over so the solution runs to the other end. Place
a piece of gauze over the tube and break away from you. Discard the gauze and
tube. Rinse the catgut in warm saline. Catgut comes in 36-inch strands. These
pieces are cut into half lengths (18 inches) for suturing a wound when continuous
stitches are taken. If interrupted stitches are used, one quarter lengths are
sufficient. After the catgut has been cut it is rinsed again, and threaded in the
needle or placed on the suture table.

Threading the Needles: In threading a curved needle, thread away from the
point; that is, from the concavity to the convexity. Pull the suture far enough
through the eye that it doesn't pull out, then place the needle on the needle holder.

Handing the Suture to the Surgeon: Before handing the suture to the surgeon
dip it again in saline (this makes the third rinse). Hand the needle holder to the
surgeon so that he grasps it by the handle and,it is in position to use. Do not let the
end of the suture drag over the table but hand it to the assistant surgeon at the
same time you hand the operator the threaded needle. Always have a duplicate
suture prepared for use.

Duties of the "Utility" or "Circulating" Nurse: The "utility" nurse should be

within easy access to the instrument and suture nurses throughout the entire
operation. She should not leave the room for any reason while the operation is in
progress. Some of the duties for which she is responsible are as follows:
1. Wait upon the "scrub nurse," furnishing her with additional supplies, hot
saline, etc.
 2. See that all necessary supplies are on hand and prepare as far as possible
for the next case.
3. Keep the operating room in order the floor mopped, sponges picked up,
etc.
4. Collect, label, and dispose of specimens.
5. Keep the sterilizer filled with boiling water.
6. Adjust the suction apparatus, cauery, etc.
7. Prepare the scrub sinks, brushes, and dishes for the next case.

Duties of the "Ether" Nurse: All duties which take one from the immediate
operating vicinity are performed by the "ether" nurse. Some of these are listed
below:
1. Prepare stretcher, warm blankets, and gown for the removal of the patient
from the operating room to the ward.
2. Prepare adhesive straps needed to keep the dressings in place.
3. Remove all emptied drums, wrappers, glove cases, etc., from the room.
4. Send for and prepare the next patient scheduled for operation.
VIII. AFTER THE OPERATION
Topic Preview
1. Care of the patient
2. Preparation for the next operation
3. Clean-up at end of operating schedule

Care of the Patient: After the dressings have been applied, the patient is removed
from the operating table to the stretcher. Great care should be taken to prevent
injury to the patient. He should be placed on the stretcher in such a manner as to
permit relaxation of the body and prevent strain on the operative area. The head is
usually turned on one side so that mucus and vomitus may drain easily from the
mouth. An emesis basin and gauze wipes are placed at the head of the stretcher.
To prevent chilling, a dry warm gown is placed on the patient and he is covered
with warm blankets. The patient should be accompanied to the ward by the
anesthetist or doctor (SEE: Chapter VIII).

Preparation for the Next Operation: If another operation is to be performed

directly following this one, instruments are washed and resterilized, the surgeon
and scrub nurses rescrub for three to five minutes, gowns and gloves are changed
and new sterile fields are prepared.

Clean-up at the End of the Operating Schedule: The furniture is undraped and
rearranged. All unused sterile supplies are replaced. Empty drums, wrappers, used
oxygen tanks, etc., are removed from the room. Refuse is looked over carefully and
all instruments, gloves, etc., which may have fallen in the sponge pails are
removed. Some institutions save soiled gauze sponges and dressings to be used
later as "washed gauze." Gloves are washed and cared for. Instruments are soaked
in cold water to remove the blood, then washed in hot, soapy water, scoured,
rinsed, dried, and replaced in the instrument cabinets. Those instruments having
joints and screws are oiled. The entire room is tidied, cleaned, and placed in order.