NCM 109 OR Skills Lab

TOPICS to discuss:
 Review of Principle of Sterile Technique
 Perioperative Nursing
- Preoperative preparations (Chap 5)
 Surgical scrub (Review)
 Gowning & Gloving
- Surgical positions (Chap 6)
- Duties of Scrub and Circulating Nurse ( Chap 7)
- Surgical Instruments (Chap 8)

NCM 109 OR Skills Lab

TOPICS to discuss:
 Review of Principle of Sterile Technique
 Perioperative Nursing
- Preoperative preparations (Chap 5)
 Surgical scrub (Review)
 Gowning & Gloving
- Surgical positions (Chap 6)
- Duties of Scrub and Circulating Nurse ( Chap 7)
- Surgical Instruments (Chap 8)

1|Page
PERIOPERATIVE NURSING
Providing Holistic Nursing Care Throughout the Entire Surgical Experience
SURGERY
 It is the branch of medicine concerned with diseases and conditions which require or are
amenable to operative procedures. Surgery is the work done by a surgeon.
 "Surgery can involve cutting, abrading, suturing, laser or otherwise physically changing body
tissues and organs."

Goals of Surgery
• For diagnosis
• For preservation of life
• For maintenance of dynamic bodily equilibrium
• For prevention of infection and promotion of healing
• For alleviation of discomforts
• For correction of deformities and defects

DEFINITION OF TERMS

STERILE
 Free from living germs or microorganisms; aseptic: sterile surgical instruments.
ASEPSIS
 The state of being free of pathogenic microorganisms.
 The process of removing pathogenic microorganisms or protecting against infection by such
organisms.
SEPSIS
 a toxic condition resulting from the spread of bacteria or their toxic products from a focus of
infection; especially : septicemia
 is a severe illness caused by overwhelming infection of the bloodstream by toxin-producing
bacteria.
 is caused by bacterial infection that can originate anywhere in the body

DISINFECTANT - any chemical agent used chiefly on inanimate objects to destroy or inhibit the growth
of harmful organisms.
ANTISEPTIC - is a substance that prevents or arrests the growth or action of microorganisms either by
inhibiting their activity or by destroying them. The term is used especially for preparations applied
topically to living tissue.
STERILIZATION - the destruction of all living microorganisms, as pathogenic bacteria, vegetative forms,
and spores.
BACTERIOSTATIC -Capable of inhibiti ng the growth or reproducti on of bacteria .
- An agent, such as a chemical or biological material, that inhibits bacterial growth.
BACTERICIDAL - Capable of killing bacteria .
BACTERIOCIDES - is a substance that kills bacteria .Bactericides are either disinfectants ,
anti septi cs or anti bioti cs .

2|Page
PREFIXES & SUFFIXES
 Prefixes & Suffixes can explain the type of procedure the client will undergo:
PREFIXES
 Supra – above ; beyond
 Ortho – joint
 Chole – bile or gall
 Cysto – bladder
 Encephalo- brain
 Entero – intestine
 Hystero – uterus
 Mast/ Mammo – breast
 Meningo – membrane; meninges
 Myo – muscle
 Nephro – kidney
 Neuro – nerve
 Oophor – ovary
 Pneumo – lungs
 Pyelo – kidney pelvis
 Salpingo – fallopian tube
 Thoraco – chest
 Viscero – organ esp. abdomen
 Cardio – heart
 Hepato – liver
 Osteo – bone
 Cranio – skull/cranium
 Angio – blood vessel

SUFFIXES
 Oma – tumor ; swelling
 Ectomy – removal of an organ or gland
 Lithiasis- stone formation
 Rhapy – suturing or stitching of a part or an organ
 Scopy – looking into
 Ostomy – making an opening or a stoma
 Otomy – cutting into
 Plasty – to repair or restore
 Cele – tumor ; hernia ; swelling
 Itis – inflammation of

FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE SURGERY:

1. OBSTRUCTION – a blockage ; are dangerous because they block the flow of blood, air, CSF, urine
& bile through the body.
2. PERFORATION – is a rupture of the organ, artery or bleb.

3|Page
 3. EROSION – break in the continuity of tissue surface. It can be caused by irritation, infection,
ulceration or inflammation. It can damage the walls of blood vessels resulting in serious
bleeding.
4. TUMORS – abnormal growth of tissue that serves no physiologic function in the body.

CATEGORIES OF SURGICAL PROCEDURES

I. Purpose for the surgery
a. diagnostic
 performed to determine the origin and cause of a disorder or the cell type of a cancer
e.g., breast biopsy, exploratory laparotomy
b. curative
 performed to resolve a health problem by repairing or removing the cause
e.g., cholelithiasis, mastectomy, hysterectomy
c. reconstructive
 partial or complete restoration of a damaged organ/tissue to bring back the original
appearance & function.(mammoplasty, face-lift)
d. palliative
 performed to relieve symptoms of a disease process, but does not cure
e.g., colostomy, nerve root resection, tumor debulking, ileostomy
e. constructive
 Repairing the damaged tissue or congenitally defective organ. (multiple wound repair)
f. Exploratory
 to estimate the extent of the disease
g. ablative
 removing diseased organ that can’t wait anymore.
- emergency surgery. E.g. appendectomy

II. Urgency of surgery

a. elective
 planned for correction of a non-acute problem and should be performed for patient’s well-
being but which is not absolutely necessary for survival. Delay or omission will not cause
adverse effect
e.g., cataract removal, hernia repair, total joint replacement, repair of scars
b. urgent
 requires prompt intervention; or may be life-threatening if treatment delayed;
e.g., intestinal obstruction, bladder obstruction, kidney or urethral stones
c. emergency
 requires immediate intervention because of life-threatening consequences
e.g., gunshot wound, stab wound, severe bleeding
d. Optional Surgery
 surgery that the patient request, usually for aesthetic purposes.
e.g., Facelift, cosmetic surgery
e. Day (Ambulatory Surgery) – done on out-patient basis

III. Degree of risk of surgery

4|Page
 a. minor surgery (low degree of risk)
CRITERIA:

o generally not prolonged

o leads to a few serious complication
o involves less risk procedure without significant risk, often done with local anesthesia
e.g., incision and drainage, muscle biopsy, circumcision

b. major surgery (high degree of risk)

CRITERIA:

- poses greater risk than minor surgery – extensive

- large amount of blood loss
- vital organs may be handled or removed
- great risk of complication
- longer/ larger incision
e.g., mitral valve replacement (MVR), pancreas implant, lymph node dissection, CS, TAHBSO

IV. Extent of surgery

a. simple
 only the most overtly affected areas involved in the surgery
e.g., simple or partial mastectomy
b. radical
 extensive surgery beyond the area obviously involved; is directed at finding a root cause
e.g., radical mastectomy or prostatectomy

PERIOPERATIVE
 Period of time that constitutes the surgical experience
Includes three phases:
 Preoperative phase: the period of time from the decision for surgery until the patient is
transferred into the operating room.
 Intraoperative phase: the period of time from when the patient is transferred to the
operating room to the admission to postanesthesia care unit (PACU).
 Postoperative phase: the period of time that begins with admission to the PACU and
ends with follow-up evaluation in the clinical setting or at home

PERIOPERATIVE NURSING
 a.k.a : OPERATING ROOM NURSING
The identification of physiological & sociological needs of the client, & the
implementation of an individualized program of nursing care in order to restore or
maintain the health & welfare of the patient before, during & after surgical intervention
LEGAL ASPECTS

5|Page
  Informed consent (Operative Permit/ Surgical Consent)
 A legal document stating that the patient or any of his legally-accepted representative
voluntarily agrees to have a surgical procedure performed on the patient after all benefits,
alternatives, possible risks, complications, disfigurements, and disability have been explained
by the surgeon.

PURPOSES:
 To ensure that the client understands the nature of the treatment including the potential
complications and disfigurement (explained by AMD)
 To indicate that the clients decision was made without pressure
 To protect the surgeon and the hospital against claims that unauthorized surgery has
been performed and that the patient was unaware of potential risks of complications
involved
 To protect the patient from undergoing unauthorized surgery
 Surgeon obtains operative permit (informed consent)
1. Surgical procedures, alternatives , possible complications & disfigurements or removal of body
parts are explained.
2. It is part of the nurse’s role as client advocate to confirm that the client understands
information given.
INFORMED CONSENT is necessary in the following circumstances:
 Invasive procedures, such as surgical incisions, biopsy, cystoscopy or paracentesis.
 Procedures requiring sedation or anesthesia
 A non-surgical procedure, such as arteriography, catheterization
 Procedures involving radiation

Requisites for validity of Informed Consent:

1. Adult client (over 18 y/o) signs own permit unless unconscious or mentally incompetent.
(Written permission is best and is legally acceptable)
 Signature is obtained with the client’s complete understanding of what is to occur
i. Obtained before sedation
2. If unable to sign, relative (spouse or next of kin) or guardian will sign.
3. In an emergency, permission via telephone or telegram is acceptable; have a 2 nd listener on
phone when telephone permission is given
4. Consents are not needed for emergency care if all 4 of the ff. criteria are met:
a) There is an immediate threat to life.
b) Experts agree that it is an emergency.
c) Client is unable to consent.
d) A legally authorized person cannot be reached.
5. Minors (under 18 y/o) must have consent signed by an adult (i.e. Parent or legal guardian)
6. Emancipated minor (married or independently earning his or her own living) may sign his/ her
own consent.

6|Page
 7. Witness to informed consent may be a nurse, another M.D., clerk or any other authorized
person.
8. The nurse witnessing informed consent, specifies whether witnessing explanation of surgery or
just signature of the client.

Nursing responsibility related to informed consent:

 The nurse is not responsible for obtaining the operative permit.
 The nurse should not explain the details about the surgery.
 If the patient needs additional information to make his or her decision, the nurse notifies the
physician about this.
 Also, the nurse ascertains that the consent form has been signed before administering
psychoactive premedication, because the consent may not be valid if it was obtained while the
patient was under the influence of medications that can affect judgment and decision-making
capacity.
 The main responsibility of the nurse is to ascertain or verify that the patient and/or his family
understood the information given to them about the surgery.
 Before signing an informed consent, the patient should:
 Be told in clear and simple terms by the surgeon what is to be done. The anesthesia care
provider will explain the anesthesia plan and possible risks and complications.
 Have a general idea of what to expect in the early and late postoperative periods.
 Have a general idea of the time frame involved from surgery to recovery.
 Have an opportunity to ask any questions.
 Sign a separate form for each procedure or operation.

INTRAOPERATIVE PHASE
 Giving nursing care to client undergoing surgery.
 It starts from the time the patient was admitted to the O.R. , during operation until it ends &
transferred to the PACU.
NURSING ACTIVITIES:
 Activities providing for patient’s safety.
 Maintenance of aseptic environment.
 Ensuring proper function of equipments.
 Providing surgeons with specific instruments & supplies for surgical field.
 Completing documentation.
 Positioning patient.
 Acting as scrub/circulating nurse.
PRACTICE TO ENSURE ASEPSIS

7|Page
 1. DISINFECTION- implies the destruction of pathogenic microorganisms, except spores, by physical
or chemical means
2. STERILIZATION- the process of completely ridding material or tissue to live microorganisms,
leaving no viable forms including spores. All items (instruments, supplies, equipment, etc.) that
come in contact with the sterile field and the wound must be sterile.
 The three most commonly used method of sterilization employed in the operating
room or central supply include:
A. Saturated Steam Under Pressure – utilizes the Autoclave for sterilizing materials and
articles.
 Usually operated at 250 F or 121C, (15lbs pressure per square inch)
B. Gas Chemical Sterilization – Ethylene oxide gas is used to sterilize items that are
vulnerable to heat or moisture.
 Usually cycles 3-7 hours employed.
C. Liquid Chemical Sterilization – a 2% activated aqueous glutaraldehyde solution (e.g.
Cidex) is the agent often employed when liquid chemosterilization is desired.
 Instruments and other items must be completely immersed in the solution for 10
hours to achieve sterilization.
 Disinfection is effective if the instrument is submerged for 10 minutes. All times
must be thoroughly rinsed sterile distilled water before use.

Asepsis and Aseptic Practices in the Operating Room

 The goal of asepsis and aseptic practice in the operating room is to prevent the contamination
of open surgical wounds
 The patient is the center of the sterile field, which include the areas of the patient, the operating
table and the furniture covered with sterile drapes and the personnel wearing the OR attire.
 Strict adherence to sound principles of sterile technique and recommended practices is
mandatory for the safety of the patient.
 This adherence reflects one’s surgical conscience. Principles remain the same; it is the degree of
adherence to them that varies.
BEFORE AN OPERATION
 It is necessary to sterilize and keep sterile all instruments, materials, and supplies that come
in contact with the surgical site.
 Every item handled by the surgeon and the surgeon's assistants must be sterile.
The patient's skin and the hands of the members of the surgical team must be thoroughly
scrubbed, prepared, and kept as aseptic as possible.
DURING THE OPERATION
 The surgeon, surgeon's assistants, and the scrub nurses must wear sterile gowns and gloves
and must not touch anything that is not sterile.
 Maintaining sterile technique is a cooperative responsibility of the entire surgical team.
 Each member must develop a surgical conscience, a willingness to supervise and be
supervised by others regarding the adherence to standards.

Principles of Sterile Techniques:

8|Page
 1. Only sterile items are used within the sterile field.
 Every person who dispenses a sterile article must be sure of its sterility and of it’s
remaining sterile until used.
 Proper packaging, sterilizing and handling should provide such assurance.
 If you are doubt of the sterility of anything, consider it not sterile. Known or
potentially contaminated items must not be transferred to the sterile field

2. Gowns are considered sterile only from waist to shoulder level in front and the sleeves.
 The following practices must be observed
 Sterile persons keep hands in sight and at above waist level.
 Hands are kept away from face. Elbows are kept close to the sides. Hands are never
folded, underarms because of perspiration in the axillary region.
 Changing table level is avoided. If a sterile person must stand on a platform to reach
the operative field, the area of the gown waist must not brush against sterile tale or
drape areas.
 Items dropped below the waist level are considered unsterile and must be discarded.

3. Tables are sterile only at table level. The result is that:

 Only the top of a table with sterile drape is considered sterile. Edges and side of
drape extending below the table level is considered unsterile.
 Anything falling or extending over table edges, such as piece of suture is unsterile.
Scrub nurse does not touch the part hanging below the table level.
 In unfolding sterile drape, the part that drops below the table surface is not brought
back up to the table level.

4. Person who are sterile touch only sterile items or areas; person who are not sterile touch
only unsterile items or areas.
For example:

 Sterile team members:

 Maintain contact with sterile field by means of gowns and gloves.
 Reach supplies by means of circulating nurse who opens the wrapper on sterile
packages.
 Stand back at a safe distance from the operating table when draping the patient.
 Pass each other back to back or face to face.
 Turn back to a non sterile person or area when passing.
 Ask non sterile individual step aside rather than risk for contamination.
 Faces sterile area to pass it.
 Stay within and around the sterile field. They do not walk around or go outside the
room.
 Non sterile circulating nurse or persons:
 Does not directly come it contact with the sterile field.
 Maintain at least one foot distance any area of the sterile field.
 Face and observe a sterile area when passing it to be sure they do not touch it.
 Never walk between two sterile areas, e.g. between sterile instrument tables.

9|Page
  Movement within and around the sterile area kept to minimum to avoid contamination
of sterile items or a person.
 Sitting or leaning against a non sterile surface is break in the technique. If the sterile
team is sits to operate, they do so without proximity to the non sterile areas.

5. Unsterile persons avoid reaching over a sterile field; sterile persons avoid leaning over
unsterile area.
 For example:
 Unsterile circulating nurse reach over a sterile field to transfer sterile items.
 In pouring solution into a sterile basin, circulating nurse hold only lip of the bottle
over basin to avoid reaching over sterile area.
 Circulating nurse stands at a distance from the sterile field to adjust light over it to
avoid microbial fall out over field.
 Surgeon turns away from the sterile field to have perspiration remove from brow.
 Scrub nurse drapes a non sterile table towards self first to protect gown.
 Scrub nurse stands back from non sterile table when draping it to avoid leaning over
unsterile area.

6. Edges of anything that encloses sterile content are considered unsterile.

 The following precaution should be taken:
 In opening sterile packages, a margin of safety is always maintain. Ends of flaps are
secured in hand so they do not dangle loosely. The last flip is pulled toward the
person opening package thereby exposing package content away from non sterile
hand.
 Sterile person lifts contents from packages by reaching down and lifting them straight
up, holding elbow high.
 Flaps on peel open packages should be pulled back, not torn, to expose sterile
content. Content should be flipped or lifted upward and not permitted to slide over a
edges. Inner edges of the heat seal is considered the line of demarcation between
sterile and non sterile person.
 If a sterile wrapper is used as a table cover, it should be apply over the entire table
surface. Only the interior and surface level has the cover are considered sterile.
 After sterile contents must be bottle in open, contents must be used and discarded.
Cap cannot be replace without contaminating pouring edges.
7. Sterile field is created as possible to time of use. Degree of contamination is proportionate
to the length of time sterile items are uncovered and exposed to the environment.
 Precaution must be taken as follows:
 Sterile tables are set up just prior to operation.
 It is difficult to uncover table of sterile contents without contamination. Covering
sterile tables later used is not recommended.
8. Sterile areas are continuously kept in view.
 To ensure this principle:
 Sterile persons face sterile areas.
 When sterile packs are opened in a room, or sterile field is set up, someone must
remain in the room to maintain vigilance.

10 | P a g e
 9. Destruction of integrity of microbial barriers results in contamination. Integrity of sterile
package or sterile drape is destroy by perforation, puncture or strike through (soaking of
moisture through unsterile layers to sterile layers or vice versa). Ideal barrier materials are
abrasion resistant, impervious to permeation by fluids or dust that transport
microorganism. The integrity if sterile package, its expiration date and appearance of
process monitor must be checked for sterility just prior to opening.
 To ensure sterility
 Sterile packages are laid on dry surfaces
 If sterile packages becomes damp or wet, it is re-sterilized. A package is considered non
sterile if any part of it comes in contact with moisture.
 Drapes are placed in dry surface.
 If solution soaks through sterile drape to non sterile area, the wet area is covered with
impervious sterile drape.
 Undue pressure on sterile packs is avoided to prevent forcing sterile air out and pulling
unsterile air into pack.
10. Microorganism must be kept to an irreducible minimum. Perfect asepsis in an operative
field is an ideal to be approached. It is not absolute. All microorganism cannot be
eliminated, but this does not preclude necessity for strict sterile technique.
 It is generally agreed that:
 Skin cannot be sterilized. Skin is a potential source of contamination in every
operation. Organisms on hands and arms of the operating team are a hazard. All
possible means are used to prevent entrance of microorganisms into the wound.
Preventive measures include:
 Transient and resident floras are removed from skin around operative site of
patient and the hands and arms of sterile members by mechanical washing and
chemical antiseptics.
 Gowning and gloving of operating team is accomplished without contamination
of sterile exterior of gowns and gloves.
 Sterile gloved hands do not directly touch skin and then deeper tissue.
Instrument used in contact with the skin are discarded and not reused.
 If glove is pricked or punctured by needle or instrument, glove is changed
immediately. Needle or instrument is discarded from a sterile field.
 Some areas cannot be scrubbed. When the operative field include mouth, nose,
throat, anus, GIT and vagina, the number of microorganisms are present are
great. However, the following steps may be taken to reduce the number of
microorganism present in these areas and to prevent scattering them:
Surgeon makes an effort to use a sponge only once, then discards it.
GIT, specially colon, is contaminated. Measures are used to prevent spreading
this contamination.
 Infected areas are grossly contaminated, the team avoids spreading the contamination.
 Air is contaminated by dust and droplets. Environmental control is necessary.

MEMBERS OF THE SURGICAL TEAM and its functions

11 | P a g e
Sterile Team Members-
These are the member who scrub their hands and arms, and don sterile gown and gloves. They are the
ones who work within the sterile field.

A. SURGEON:
 Perform the operative procedure safely and correctly
 Responsible of being certain that all members are aware of what is needed during the procedure
and all necessary equipments and instruments are available
 If the surgeon will give the anesthesia, it will be given prior to scrubbing or after the patient has
been draped
 Secures dressing in place
 After the anesthesiologist gives permission the surgeon assist in moving the patient to OR
 Captain of the surgical team
 Determines the specific site for operation

B. ASSISTANT SURGEON/ FIRST ASSISTANT

 Primary responsibility is to assist the surgeon in a way requested
 Can help draping the client and with the final placement of equipment and supplies
 Helps maintain the visibility of the surgical site, control bleeding, close wounds, and apply
dressing
 Handles tissues and instruments
 At the completion of the procedure the assistant may close the incision and help placement with
the dressing
 Helps also to move patient to OR
 Documents the operating techniques used during surgery

C.SCRUB NURSE
 sets up sterile tables
 prepares sutures, ligatures, equipment
 anticipates items/equipment needed
 counts needles, sponges, instruments before closure
 As the surgical incision is closed, the scrub person and the circulator count all needles,
sponges, and instruments to be sure they are accounted for and not retained as a foreign body
in the patient
 SPECIMEN SECURING/LABELING/SENDING

UNSTERILE TEAM MEMBERS-

These are the team member who do not enter the sterile field. They work around the sterile field and
help maintain and protect the sterile field.

Anesthesiologist/Anesthetist
 Interviews/ assess the patient before surgery
 Selects and administers anesthesia
 Intubates the patient prn
 Manages problem related to the administration of anesthesia
 Supervises patients condition throughout the surgical procedure (V/S, ECG, O2 sat)
12 | P a g e
  Heads the surgical team
 Oversee the positioning of the patient
 Reassesses the patient’s physical condition immediately prior to initiating anesthesia
 Responsible to give information on patient condition before, present and during operation, type
of surgery performed.
 Gives fluids, BT
 Determines when patient may be moved to PACU
 ABC before transfer

Circulating Nurse/Assistant Circulator

 Manages OR
 Assess the patient upon receiving to the OR
 Verifies the correct client
 Protects patient’s safety – monitor activity of surgical team
 Verify consent
 Coordinate with the team
 Ensure cleanliness, proper temp., humidity and lighting, availability of supplies
 Monitors aseptic practices
 Count sponges, needles and instruments
 Most important is to assure sterility is maintained
 Carry of patient before and after operation
 Assisting the anesthesiologist
 Positioning patient
 Assist the scrub team
 Serving as communication link between the sterile team members and other personnel (the
patients family, X-ray, Pharmacy, Lab, etc.).
 Cleans up the OR after procedure

13 | P a g e
14 | P a g e