OPERATING ROOM NURSING

BY:

GERARDO A. NICOLAS RN RM MAN RPT MAEd

Suffixes

-ectomy – removal of a part from the body.

-otomy – making of an opening

-rrhaphy – repair of a part of the body

 CONDITIONS TREATED BY SURGERY

Congenital
– inborn deformities

Acquired
– conditions resulting
from trauma or
injury.

4 Basic Pathologic Conditions that require surgery

Obstruction – blockage in obstructions that are

dangerous because they block the flow of blood, air,
CSF, urine and bile through the body.
CHOLEDOCHOLITHIASIS
Perforation – is the rupture of an organ, artery
or bleb.
Erosion – break in the continuity of tissue surface
it can be caused by irritation, infection,
ulceration or inflammation. It may damage the
walls of the blood vessels resulting in serious
bleeding.
Tumors – abnormal growth of tissue that serves
no physiologic function in the body.
CLASSIFICATIONS OF SURGERY
 Location
Internal External
– inside the body. – outside the body.

HYSTERECTOMY SKIN
GRAFTING

Degree of risk to the person
Major Minor
- life threatening when major – non-life threatening,
or vital organs are involved less serious.
and those surgeries that
Lip
may involve serious Suturing
bleeding.

Cesarean
Section

Purpose endoscopy

● Diagnostic– verifies
a suspected diagnosis.

Exploratory Laparotomy

● Exploratory –
estimates the
extent of the
diseases or
injury.
 Purpose
● Curative– removes or repairs damaged tissues,
diseased or congenitally malformed organs or
tissues.
Cheiloplasty
Purpose

● Ablative
– removing diseased organs.

Appendectomy

Purpose

● Palliative
– relieves
symptoms but does
not cure the
underlying disease
process.

Tracheotomy
 Mode of Operation
Reconstructive Constructive – repair
– a partial or complete of a congenitally
restoration of a defective organ,
damaged organ or improving its function
tissue to its original or appearance.
appearance and
function. Cheiloplasty

Skin grafting
after severe
burns.

Categories of Surgeries According to Urgency

Emergency Surgery – done

immediately to save life, limb or a
part of the body.
Ex. Explore Lap, CS

Urgent Surgery – must be done

within 24-48 hours. Ex. relief of
intestinal obstruction.

Elective surgery – done at the patient's or surgeon's

convenience. It can be completed within days or
months.
! Required Surgery – done to improve patients health
or well being and is not catastrophic if omitted. Ex.
Cataract removal
! Cosmetic surgery – done for aesthetic purposes

liposuction
Cataract
removal

 On call
– any time, any date,
operation can be done.

AT RISK PATIENTS Hypertensive and ALCOHOLIC

Hypotensive

Young and Elderly

DIABETIC PATIENT

UNDER WEIGHT

overweight

dehydrated
Qualities of an Ideal OR Nurse
Works rapidly even under tension and under close supervision
of both MD and RN.
Must have a quick reaction time and make change for
unexpected changes without notice.
Must anticipate the surgeon’s needs and keeps one step ahead
of him.

Qualities of an Ideal OR Nurse

Must organize work effectively so that not a single minute
is lost, not a motion overflows.
Must work fit and smoothly as a member of a closely
functioning team.
Must be patient with those who sometimes become
impatient in a tense situation because some degree of
tension maybe present at times.

Qualities of an Ideal OR Nurse

Must possess kindness, poise, sureness and within that
short contact can allay the patient’s fears.
Must have a quiet, responsive and pleasing personality.
Must possess a genuine interest and eagerness to learn
and increase her proficiency.
Be able and willing to take on call operations without
complain.

Operating Room team

Sterile Team Unsterile team
- scrubbed, gowned and gloved - In scrub suit, mask and cap
personnel. attire only.
- Operating Surgeon - Anesthesiologist or
- Assistant to the surgeon Anesthetist
- Scrub person - Circulating nurse

Functions of Sterile personnel

 Operating Surgeon
- Pre-op diagnosis and care
- Performance of operation
- Post-op management and care
- Assumes full responsibility
- For all medical acts of judgment and
- management.

 Assistant to the surgeon

- Holds retractors in the wound to expose operative site.
- Clamp bleeding blood vessels.
- Assist in suturing during operation or closing the wound/
operative site.
- Suction body fluid/blood to provide clear view of the
operative site.

Scrub Person
- Maintain integrity of, safety, and efficiency of the
sterile field.
- Prepare and arrange instruments and supplies.
- Assist the surgeon and assistants surgeon and assistants
throughout the operation by providing sterile instruments
and supplies.

Functions of Unsterile Personnel

 Anesthesiologist or Anesthetist
- Administers and maintain anesthesia and manages untoward
reaction to anesthesia.
Circulating Nurse
- Application of the nursing process in directing and
coordinating all nursing activities related to the care
and support of the patient.
- Creation and maintenance of a safe and comfortable
environment for the patient through implementing the
principles of asepsis.

Circulating Nurse
Provision of assistance to any member of the OR team in any
manner in which the CN is qualified. Identification of any
potential environment dangers or stressful situations.
Maintenance of communication link between events and team
members as the sterile field and persons not in the OR but
concerned with the outcome of the operation.

Circulating Nurse
Direction of the activities of the learners.
Communication links inside and outside the OR.
Charting/Organizing.

Division of Duties of Scrub and Circulating

Nurse
 Duties Circulating Nurse
Preliminary Preparations of the OR
Done before First Operation of the day.
Housekeeping duties that must be done at least
1 hour before scheduled incision time.
Duties Circulating Nurse
Remove unnecessary equipments and tables from the
OR.
Perform dusting using a damp cloth wet with
disinfectant.
OR light furniture, etc.
Disinfect the floor.
Turn on aircon.
Before each operation and

After the room is cleaned

Secondary Preparations of the OR

Place a clean sheet, arm straps and a pillow on the
OR table.
Position OR light, tables and check for proper
functioning.
Assemble and check
suction machine.
Provide a clean kick bucket.
Before each operation after the room is
cleaned

Arrange furniture according to use.

Obtain sterile instruments, sets, drapes and sterile
supplies that will be needed during operation.
Refer to surgeon's preference card for additional
supplies.
When Patient Arrives

Greet and identify the patient.

Check the patient's chart for consent and if
Preoperative preparations are carried out.
Be sure to cover the patient's hair with the cap.
Transfer the patient to OR table.
Make the patient comfortable.
During Induction of Anesthesia:

Help/ assist the anesthesiologist in positioning

the patient.
Assist the patient in assuming the position for
anesthesia.
Anticipate the anesthesiologist's needs.
 If spinal anesthesia
Place the patient in quasi fetal position, provide
pillows.
Perform lumbar prep aseptically.
Anticipate anesthesiologist's needs.
After the Patient is Anesthetized

Reposition the patient per anesthesiologist's

instruction
attach anesthesia screen and arm boards.
apply restraints on the patient.
Expose the area for skin preparation.
Catheterize the patient.
Turn on OR light.
Perform skin prep.
 During Operation

Be alert to anticipate the

needs of both sterile and
unsterile team members.
Collect soiled sponges for
counting.
Monitor blood loss
Charting Watch out for any
break in aseptic technique.
During Closure

Assist in counting sponges, needles and instruments.

Report count as to complete or incomplete.
After Operation
Assist the surgeon and assistants
in removing their gowns.
Assist with dressing.
Clean the patient.
Transport the patient to Recovery Room (RR),
Intensive Care Unit (ICU) or ward.
Endorse the patient properly.
Duties of the Scrub Nurse
Check instruments and supplies.
Do a complete scrub
Gown and Glove
Drape and Mayo Stand – mayo cover first then mayo
towel.
Count sponges, surgical needles and instruments as the
C.N stands to countercheck the counting.
Duties of the Scrub Nurse
Arrange the instruments on the mayo table and on the back
table.
ex. Mayo Table – scissors, knife/ scalpel
clamps, graspers, and army – navy.
Place blade on the knife handle. Assemble suction tip and
suction tube.
assemble the drapes according to use and ready the towel
clips.
Prepare sutures and needles according to use.
 When Surgeon Arrives After Scrubbing

Gown and glove the surgeon and his assistants as

soon as they arrive.
Assist in draping the patient according to routine
procedure.
 When Surgeon Arrives After Scrubbing

Bring mayo stand and back table in position after draping

is completed.
Drop the end of the suction tube and cautery cord for the
circulating nurse to connect to their proper attachment.
Check suction machine.
 During Operation

Provide 2 sponges on the operative site prior to skin incision.

Pass the first knife for the skin to the surgeon's needs.
Pass instruments in a decisive and positive manner.
watch out for signals and keep instruments as clean as
possible.
During Operation
Notify C.N. if you need additional instruments as clean as
possible.
Keep two clean sponges on the field.
Save and care for tissue specimen according to hospital
policy.
Maintain sterile technique and
watch for any breaks.
 During Operation
Step away from sterile field of contaminated.
Change gloves when pricked by needles.
Do not turn your back from sterile field.
Keep sterile field as dry as possible
Discard soiled sponges from a sterile field.
Keep talking to a minimum.
 During closure
Count sponges, needles and instruments with C.N.
Always ready your sutures, clamp, forceps, and
straight scissors.
Have a clean damp sponge ready to clean the
incision site.
Have a dressing and
antiseptic ready.
Assist in application of
pressure dressing.
 After Scrub Person Scrubs
Fasten the back of the scrub person's gown.
Open package of the sterile supplies.
Assist the scrub nurse in counting the sponges,
needles and instruments. write the figure on the white
board.
After Surgeon and Assistants' Scrub

Assist with gowning.

Observe for sterile technique during draping.
Assist the scrub nurse in moving the mayo stand and
back table
Focus OR light
Position kick buckets on
the operating side.
Connect suction tube
to suction machine.
 Types of Consent
General Consent Informed Consent/
- Signed upon admission Operative Permit
- Authorizes the physician in - Signed before the
charge and hospital staff to procedure is performed.
render such treatment or - For specific procedures,
perform such procedures, as that can possibly injure the
the physician deems patient.
advisable.
- Applicable only to routine
duties carried out.

3 Division of OR Suite

Unrestricted
area

Semi-restricted
area

Restricted area
Unrestricted/ Unsterile Area
this area is isolated by doors from the main
hospital corridor.
Semi-restricted/ Semi-sterile Area

OR attire is required. This area includes peripheral

support areas and access corridors to the OR.
Restricted/ Sterile Area
marks are required to supplement OR attire. Sterile
procedures are carried out in this room.
Dressing Rooms and Lounges
Clothes changing areas must be provided for both men
and women. Access is from an unrestricted area to
change from street clothes to OR attire before entering
the semi restricted areas or vice versa.
Scrub Room
for surgical scrubbing and must be provided adjacent
to each OR.
Furniture and other equipments

OR Table/ Operating Table – divided into bed, body and

leg sections.
Instrument Tables
Mayo Stand/Table Small tables

placed just above and for patient’s preparation

across the patient serves equipments.
to bring near the operative Ex. Skin Prep
field.
Other Equipments
Anesthesia machine and tables for anesthesiologist’s
equipments.
Other Equipments
Sitting stools and standing flat forms or foot stools.
IV stands
Other Equipments
Suction Machine, bottles and tubing.
Linen bumper
Kick buckets in wheeled bases
 Operating Room Attire
Consists of body covers such as
scrub suit, head cover, mask and
scrub shoes.
Purpose:
To provide effective barriers
that prevents the dissemination
of microorganism to the
patient.

Points to Remember:
Only approved, clean OR attire must be worn within the
restricted area of the OR.
OR attire is not worn outside the OR suite.
Eyeglasses should be wiped with the tissue wet with antiseptic
solution to prevent cross contamination.
Personal hygiene must be emphasized.

Points to Remember:
No unauthorized person should be permitted in the OR.
Personnel with skin diseases or wounds must never be
allowed to scrub.
Jewelry and nail polished should not be worn inside the OR.

Components of attire:
Body Cover – must be done
before entering a restricted or
semi restricted areas.

● Head Covers – cap protects the

garment/ body cover from
contamination by hair.
Shoe Covers/ Scrub ● Mask – must be worn in
Shoes – must be worn to restricted area to contain or
prevent spread of filter microorganisms
microorganisms. expelled from the moth and
nasopharynx by coughing.
 Gloves – a pair of
sterile gloves completes
the attire for sterile
team members.

● Gown
– a sterile gown is worn over the
scrub suit to permit the wearer
to come within the sterile field.

Criteria for Attire:

Effective barrier for microorganisms
Resistant to blood and aqueous fluid abrasion to prevent
penetration by microorganism.
Designed for maximal skin coverage.
Hypoallergenic, cool and comfortable.
Pliable material to permit freedom to movement.
Easy to don and remove.

Surgical Scrubbing
The process of removing as many as microorganisms as possible
from the hand and arms by mechanical washing and
chemical antisepsis before participating in an operation.
 Purpose:
To decrease the number of microorganism on the skin.
To keep the population of microorganism minimal during the
operative procedure by suppression of growth.
To reduce the hazard of microbial contamination of the operative
wound by skin flora.

Preparation for Surgical Scrubbing:

Skin integrity of hands and arms must be
intact.
Remove all finger jewelry because it
harbors microorganism
Be sure that all hairs are covered by
headgear because they are potential
foreign body inside the operative
wound
Preparation for Surgical Scrubbing:

Adjust mask snugly and comfortably on

the nose and mouth

Adjust eyeglasses comfortably in relation

to mask.

Adjust water to comfortable

temperature.
Method of Surgical Scrubbing
Time Method Brush Stroke Method
allotting a prescribed length allotting prescribed number of
of time. strokes to each sides of the
hands.
Principle involved
Surgical scrubbing starts from the cleanest area to the
dirtiest area. (fingers, hands, arms and elbows 3 inches
above)
Prerequisites to Surgical Scrubbing

Wear scrub suit, put on mask cover all hair with a cap.
Remove jewelries
Fingernails must be short and no nail polish.
Hands must be free from wounds.
Eyeglasses must be washed and secured.

 Scrub Room
– area wherein surgical scrubbing is done.
Equipments for Surgical Scrubbing
Antimicrobial Solution – contained in a liquid soap
dispenser near the sink often operated by foot pedal.
Deep sink with foot or knee controls for water
Nail cleaning tool-file or orange stick.
Surgical scrub brushes

 Procedure: Time scrub method

Wet hands and forearms under running water, holding

the hands above the level of the elbows so that the
water runs from the fingertips to the elbows.
Apply 2-4 mL of antiseptic solution to the hands. Use firm
rubbing circular motion to wash the palms and the back
of the hands, wrists and forearms, interlace the fingers
and thumbs and move the hands back and forth.

Clean the nails with a file or an orange stick. Rinse hands and
arms under running water while keeping the hands higher than
the elbows.
Get a sterile brush and rinse it under running water. Apply
antiseptic on the brush. Start brushing the fingernails, back and
the palm of the hand, forearm and the elbow while allotting a
prescribed time of brushing for each part.
At the end of the scrub dry your hands with a sterile towel
beginning at the tip of the fingers to the elbow. Rotate the
towel and repeat the procedure on the other hand. Proceed to
put on a sterile gown.
Time allotted:
Left hand – 1 minute Left hand – 1 minute
Left arm – 1 minute Right arm - 1 minute
Left elbow – ½ minute RINSE BRUSH
RINSE BRUSH Right hand - 1 minute
Right hand - 1 minute Right arm - 1 minute
Right arm - 1 minute RINSE HANDS, ARMS AND
Right elbow – ½ minute BRUSH
RINSE HANDS, ARMS AND Left hand – ½ minute
BRUSH Right hand – ½ minute
RINSE HANDS, ARMS AND
BRUSH AND PROCEED TO
OR

BRUSH STROKE METHOD

● Follow the procedure of time method from nos. – 1-5 except
that instead of allotting time, you’re going to allot
prescribed no. of strokes for each part.
Prescribed no. of Strokes
Left hand: Nails – 20 stroke across nails.
Fingers – 10 strokes to each side
Hand – 10 strokes to each side
Left arm – 6 strokes to each side
Left elbow – 6 strokes
RINSE BRUSH
Repeat the above procedure to your right hand.
RINSE HANDS, ARMS AND BRUSH

 Prescribed no. of Strokes

Left hand – nails – 10 strokes, fingers – 5 and hand - 5
Left arm – 3 strokes to each side.
RINSE BRUSH
Repeat above for right hand then rinse hands, arms and
brush.
Left hand – nails – 5 strokes, fingers – 3 and hand – 3 then
brush then rinse
Repeat above for right hand then rinse hands, arms and then
discard brush, rinse hands, arms. Turn off the faucet then
proceed to OR.

Gowning and Gloving

The sterile gown is put on after the surgical scrubbing.
The sterile gloves are put on immediately after
gowning.
Purpose:
Sterile gowns and gloves are worn exclude skin as
possible contaminant and to create a barrier between
sterile and unsterile areas.
Gowning
Reach down to the sterile package and lift the folded
gown upward.
Move one step backward for safety margin while
gowning.
Gowning
Holding the folded gown, carefully locate the neck
band.
Unfold the gown and be careful not to touch the outside
portion of the gown.
Gowning
Slip both hands into the arm holds simultaneously.
Gowning
The circulating nurse brings gown shoulders by
reaching inside the shoulder and arm seams. The gown
is pulled out the lowering the sleeves extended to both
hands. The back of the gown is securely tied or
fastened at the neck and waist.
Closed Gloving Technique
❑Using the left hand, while keeping it within the
cuff of the left sleeve, pick up the right glove.
❑ Place the palm of the right glove against the

palm of the right hand. Glove fingers must be

pointing toward the wearer.
Closed Gloving Technique
Secure
Secure hold
hold the
the lower
lower portion
portion ofof the
the cuff
cuff of
of the
the
right
right glove
glove with
with right
right hand
hand that
that is
is still
still hidden
hidden
inside
inside the
the sleeves.
sleeves. Secure
Secure upper
upper portion
portion of of cuff
of
cuff
the
ofglove
the glove
with with
your your
left hand.
left hand.
Closed Gloving Technique
Slip/slide your right hand into the right glove.
Arrange sleeve and glove with your left hand.
Do the same procedure in donning the left
glove.
Removing gowns and gloves:
the gown is removed first before the gloves.
Sterile Field
– any area covered with a sterile drape.
Principle of Sterile Technique
Only sterile items are used within the sterile field.
If you are in doubt about the sterility of anything,
consider it unsterile.

Principle of Sterile Technique

Gowns are considered sterile ONLY from the

waist to shoulder level in front and themselves.
Sterile persons keep hands in sight and at or
above waist level.

Principle of Sterile Technique

Hands are kept from the face and never held

under the axillaries region.
Changing table levels are avoided.
Items dropped below waist level are considered
unsterile.

Principle of Sterile Technique

Tables are considered sterile only at table level.
Anything that extends below the table level is
considered unsterile.
In unfolding sterile drape, the part that drops
below the table level is considered unsterile.

Principle of Sterile Technique

Sterile persons touch only sterile items or areas,

unsterile persons touch only unsterile items or areas.
Unsterile persons should not directly get in contact
with the sterile field. Use sterile transfer forceps.

Principle of Sterile Technique

Unsterile persons a void reaching over a sterile field

and sterile persons avoid leaning over an unsterile
field.
In pouring into a sterile field and sterile persons
avoid leaning over the basin to avoid over reaching.

Principle of Sterile Technique

The scrub nurse should set the basin or glasses to be
filled at the edge of the sterile table.
Surgeons turn away from the sterile field and to
have perspiration removed from the brow.

 Principle of Sterile Technique

Sterile persons keep well within the sterile area.
Sterile persons pass each other back to back.
Sterile persons turn back to non-sterile person or
area when passing.

Principle of Sterile Technique

Unsterile persons avoid sterile areas.
Unsterile person should maintain at least 1 foot
distance from any sterile area.
Unsterile persons never walk between 2 sterile
areas.

Principle of Sterile Technique

Sterile field is created as
close as possible to the
time of use.
Sterile areas are
continuously kept in view.
Destruction of integrity of
the microbial barriers
results in contamination.
Microorganisms must be
kept to a minimum.

Operative Positions
Supine
most natural position of the body at rest
patients lies on his back with arms secured on the
sides, legs are straight and parallel in line with head
and spine.
Modifications:
for procedure of face
and neck
for shoulder procedure
Operative Positions

Dorsal recumbent
for vaginal procedures
Modified Recumbent/ Frog-legged
Operations in the groin region
or lower extremity.

Arm extension – for breast, axillary, or hand

operation.
Operative Positions
Trendelenburg's Position
patient lies on his back and the head of
table is tilted about 45 degrees downward.
For procedures in the lower abdomen.
Operative Positions
Reverse T Position
Patient lies in his back and head is tilted
upward.
Foot board is used to prevent sliding.
For thyroidectomy, gallbladder procedures
and biliary tract.
 Operative Positions
Fowler's Position
Body section is raised
45 degrees.
For cranial procedures.

Sitting Position
Same as in Fowler's but
the torso is in upright position.
For neuro surgical procedures.
Operative Positions
Lithotomy Position
Patient's buttocks rests along break between
body and leg section of the table.
Legs are raised simultaneously by two persons
and placed over the stirrup in each side of the
table.
For vaginal, perineal, rectal procedures.
Operative Positions
Prone Position
Patient lies on his abdomen.
For neurosurgical procedures.
Kraske Position
Patient is in supine until
anesthetized then turned into prone
position by rolling/ rotation.
hips must be over at the center of
the table (break) between body and
leg sections.
Head is turned to one side
and supported by a donut. Both
legs and upper part of the table is
lowered.
For rectal surgery
Operative Positions
Knee-Chest Position
For sigmoidoscopy.

Lateral Position
The patient is anesthetized in supine
position then turned to the unaffected side.
For operation of the kidneys.
Operative Positions

Sim's Position
a modified lateral position, the patient lies
on the left side with the upper leg flexed at hip
and knee the lower leg is straight.
For the examination of the rectum for the obese
patient.
Theories Involve
Maslow’s Hierarchy of Human Needs
Stages of Illness

Symptom Assumption of
experience the sick role

Medical care
contact

Recovery or Dependent
Rehabilitation client role