CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

1. Principles of Asepsis
 Only sterile items are used within the sterile field.
 Sterile persons are gowned and gloved.
 Tables are sterile only at table level.
 Unsterile persons touch only sterile items or areas, while unsterile persons touch only unsterile items or areas.
 Unsterile persons avoid reaching over the sterile field, while sterile persons avoid leaning over an unsterile field.
 The edges of anything that encloses sterile contents are considered unsterile.
 The sterile field is created as close as possible to the time of use.
 Sterile areas are continuously kept in view.
 Sterile persons keep well within the sterile field.
 Sterile persons keep contact with sterile areas to a minimum
 Unsterile persons avoid sterile areas.
 Destruction of the integrity of the microbial barrier leads to contamination.
 Microorganism must be kept to an irreducible minimum.

2. Duties and Responsibilities of an Operating Room Nurse

Before Operation
a. Instrument and Suture Nurse
 Gather the following sterile things ready for use
 Prepare Sterile and Instrument packs to be used
 Prepare possible additional Instruments to be used for the case (i.e. Suction Tape, Army Navy Retractor, Suction)
 Inspect the container with concentrated disinfectants and all sharps are already soaked.
 Adjunct mayo stand with tray and covered
 Cover OR table with a clean cover OR sheet
 Test electrical necessities, Bp apparatus, IV paraphernalia(IV stand, IV tubings, tourniquet, cotton balls with alcohol, plaster, scissors, armband)
either screen or anesthetics, screw the patient head cover, kelly pad, footstool etc.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

b. Circulating Nurse
 Helps the instrument nurse in preparing all the things needed for the care
 Complete and Prepare Skin Prep
 Receiving patient from Surgical Ward:
o Take note for arrival time
o Ask the patient’s full name
o Read the label of IVF
o Ask when was the last intake of food and water
o Inspect if jewelries and dentures are present
o Check for signed consent
o Received special endorsement like blood of patient's blood type screen and cross matched, pending laboratory and due medications.
 Empty all pails before the start of the operation
 Collect necessary stock and equipment
 Assist with counts and records
 Help scrub nurse with setting up the theater

Before actual cutting and during operation

a. Instrument and Suture Nurse
 Do surgical scrubbing of the hands and arms, gowning and gloving observing strict asepsis.
 Prepare and arrange the instruments, suture and supplies accordingly with the most care that the principle of asepsis will not be broken.
 Assist the surgeon during the entire procedure by anticipating their needs
 Count sponges, instrument and needles ( which might be needed in the field) together with the circulating nurse
 Notify the surgeon and staff nurses on duty for any missing sponge/tiny object or instruments before the closure of the wound
 Assist the surgeon/ assistant surgeon in dressing the wound immediately after the operation.

b. Circulang Nurse
 Anticipate the need of the sterile team
 Count and recount sponges and instruments (which might be added to the field) together with the scrub nurse recount them before the closure of
the wound (fintial count)

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

 Closely observe for breaks in the aseptic technique

 Maintain the cleanliness and orderliness of the room
 Upon arrival in the Operating room, endorse the patient and all the things brought from the ward to the OR nurse
 Attached the patient to the cardiac monitor and start taking v/s as your baseline.
 Note the time of the following:
a. induction of anesthesia
b. intubation of the patient under general anesthesia
c. Follow up of IVF
d. Cutting time
e. if blood started
f. instrument and sponges count
g. specimen out
h. closing of wound
If patient is caesarian section take note the time of the following:
a. baby`s out
b. placenta out
c. kinds of placenta
 Received any specimen remove from the patient and PROPERLY label it. Keep the specimen.
 Help the instrument nurse in preparing all the things needed
 Proceed to the scrub area for surgical scrubbing of hands and arms.

After the Operation

a. Instrument and Suture Nurse
 Undertake count of sponges and instruments with circulating nurse and correlate with the pre-surgery findings.
 Informs the surgeon regarding count result.
 Assist the surgeon for suturing the surgical incision.
 Apply the dressing over the surgical site.
 Clears away instrument and equipment.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

b. Circulating Nurse
 Assist the scrub nurse for patient dressing.
 Helps in removing and disposing the drapes.
 Helps to prepare the patient for transporting to the recovery room.
 Assist the scrub nurse, taking the instrumentations to the service (washroom).
 Make arrangement for preparation of theater for the next case.
3. The Sponge and Instrument Count
General Count Information

 The “surgical count” is the responsibility of the scrub and circulating nurses. If there is no scrub nurse, the circulating nurse and the surgeon or another
perioperative nurse/technician conducts the “count”.
 All sponges, sharps, sutures, designated miscellaneous items and instruments used on the sterile field during a counted surgical procedure are x-ray
detectable. Exceptions are made when necessary items are not offered as radio-opaque by the manufacturer.
 All items are counted and recorded upon dispensation during the operation.
 Items counted and recorded as they are counted before proceeding to the next item.
 Interruptions in the count process are avoided
 Once the count is initiated items are not removed from the theatre including garbage and laundry until the final count is complete
 Counts are visibly observed and audibly counted concurrently by the scrub and circulating nurse
 The scrub nurse directs the count
 Sequence of count is sponges, sharps, sutures, designated miscellaneous items and instruments
 Items of instruments with multiple parts are counted as 1 item with the number of parts in brackets e.g. 1(3)
 Items removed from the sterile field are contained and visibility displayed
 A mark (/ or X) through an item indicates that the item has been handed off the sterile field and is no longer an active part of the count
 Relief of Personnel Counts
o A sponge, sharp, suture, designated miscellaneous item and instrument count is done upon permanent relief of the scrub nurse. All efforts are
made to count instruments when appropriate or possible to do so.
o A sponge, sharp, suture, designated miscellaneous item is done upon permanent relief of the circulating nurse
o The aforementioned counts are verified by incoming staff prior to the original staff exiting the room.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

 Sponges
 Counted in units of issue
• Pull tabs to ensure security
• Separate
• Count twice initially, at time of dispensing, removal from sterile field and closure.
• Count additional packages away from already counted sponges on the back table; once counted, all like sponges are kept together.
• During surgery, discarded sponges are counted out and placed a separate bucket in the units of issue
• At closure, direction of count is sponge bucket, back table, mayo stand, operative field
• Sponges left in an incision as packing when leaving the OR are identified by type, counted and documented in the appropriate section in the
Operative Record (Articles Inserted)
• Sponges removed from an incision upon entry into the OR are counted and noted in the appropriate section in the Operative Record. (Articles
Removed)
• Packages containing incorrect numbers of sponges are bagged with the outer wrapper and removed from the OR immediately.

 Needles
• Suture needles, free (eyed) needles, and injection needles are identified separately
• Counted in units of issue – all needle packages are opened and number verified at time of count
• Count once (twice upon discretion of the nurses involved)
• Injection needles with multiple parts are counted as 1 item with the number of parts in brackets e.g. 1(2)
• When removed from the sterile field are contained and visibly displayed.

 Designated Miscellaneous Items

• Cautery Tip
• Suture Reel
• Scratch Pad
• Marking Pen
• Small Endoscopic Parts (rubber caps including caps reducer, rubber seals)

 Instruments
• Clearly separate instruments
• Like instruments may be counted in multiples of 2 or 3
• Instruments broken during surgery are accounted for in their entirely

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

• Do not spread instruments over the mayo tray or table until they are counted
• In thoracic spinal and abdominal spinal procedures involving a large quantity of complex instrumentation where an instrument count cannot be
done with accuracy and confidence, an appropriate x-ray is taken prior to closure of the cavity. The x-ray is read by the surgeon or designate prior
to the completion of the surgery. Note: A sponge, sharp, suture and designated miscellaneous item count is always done

 Closure Counts
• A sponge, sharp, suture and designated miscellaneous item count is done at the closure of a cavity within a cavity
• A sponge, sharp, suture, designated miscellaneous item and instrument count is done upon closure of the first layer depending on the cavity
entered
• A sponge, sharp, suture and designated miscellaneous item count is done at the closure of skin
• Direction of closure count is: items off the sterile field → back table → mayo stand → operative field
• The scrub nurse systematically moves across the back table in one consistent direction (may be either R→L or L→R)
• Results of all counts are announced audibly to the surgeon. The circulating nurse receives verbal acknowledgement from the surgeon.

 Count Discrepancy
• When count discrepancy occurs
 Recount
 Notify surgeon
 Surgeon checks incision
 Search laundry, garbage, drapes, floor etc.
• If discrepancy continues
 Patient x-ray is taken in the operating room prior to the patient leaving the room
 Incorrect count is noted on Operative Record
 Results of the x-ray is documented on the Operative Record
 Incident report is completed

 Exceptions
• When counts, particularly instrument counts, cannot be done with complete accuracy and confidence due to large amount of complex
instrumentation, speed of closure or the emergency nature of the surgery:
 An x-ray is taken
 The x-ray is read by the surgeon prior to closure of the patient

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

 An incident report is completed

 A sponge, sharp, designated miscellaneous item (SSM) count is not performed when the incision is deemed to be of a size that does not
present a risk of SSM loss.
 An instrument count is not performed when a cavity is not entered or the incision/cavity is deemed to be of a size that does not present a risk
of instrument loss.

4. Careful Methods of Counting

 Counting should be performed by two persons, such as the scrub and circulating nurses, or with an automated device, when available. When there is
no second nurse or surgical technician, the count should be done by the surgeon and the circulating nurse. If a count is interrupted, it should be started
again from the beginning. Ideally, the same two persons should perform all counts. When there is a change in personnel, a protocol for transfer of
information and responsibility should be clearly delineated in hospital policy.
 Sponge count (e.g. gauze, laparotomy sponges, cotton swabs, dissectors): An initial sponge count should be done for all non-exempt procedures. At a
minimum, sponges should be counted before the start of the procedure, before closure of a cavity within a cavity, before wound closure (at first layer of
closure) and at skin closure.
 When available, only X-ray-detectable sponges should be placed in body cavities. Sponges should be packaged in standardized multiples (such as 5 or
10) and counted in those multiples. Sponges should be completely separated (one by one) during counting. Packages containing incorrect numbers of
sponges should be repackaged, marked, removed from the sterile field and isolated from the other sponges. Attached tapes should not be cut. Non-X-
ray-detectable gauze used for dressing should be added to the surgical field only at skin closure.
 When sponges are discarded from the sterile field, they should be handled with protective equipment (gloves, forceps). After they have been counted,
they should be organized so as to be readily visible (such as in plastic bags or the equivalent) in established multiples. Soiled dissecting sponges (e.g.
peanuts) should be kept in their original container or a small basin until counted.
 Sharps count (e.g. suture and hypodermic needles, blades, safety pins): Sharps should be counted before the start of the procedure, before closure of
a cavity within a cavity, before wound closure (at first layer of closure) and at skin closure. Suture needles should be counted according to the marked
number on the package. The number of suture needles in a package should be verified by the counters when the package is opened. Needles should
be contained in a needle counter or container, loaded onto a needle driver or sealed with their package. Needles should not be left free on a table.
 Instrument count: Instruments should be counted before the start of the procedure and before wound closure (at first layer of closure). Instrument sets
should be standardized (i.e. same type and same number of instruments in each set) and a tray list used for each count. Instruments with component
parts should be counted singly (not as a whole unit), with all component parts listed (e.g. one retractor scaffold, three retractor blades, three screws).
Instruments should be inspected for completeness. All parts of a broken or disassembled instrument should be accounted for. If an instrument falls to
the floor or is passed off the sterile field, it should be kept within the operating room until the final count is completed. No instrument should be removed
from the operating room until the end of the procedure.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

5. Surgical Skin Preparation ( provide Drawing)

Shoulder and Thigh Abdomen

Upper Arm
On operative Remove hair from 3”
On operative side, remove above nipples to
side, remove hair hair from toes to
from fingertips to upper thighs,
3” (7.6 cm) including pubic area.
hairline and
above umbilicus
center chest to
center spine, and from midline
extending to iliac front to midline
crest and back, including
including the pubis.
axilla.

Forearm, Chest Lower A

Elbow, and
Remove hair Remove
Hand
from chin to iliac above u
On operative crests and to midthigh
side, remove midline of back pubic
hair from on operative s femoral
fingertips to midline
shoulder. back;
Include axilla herniopl
unless surgery embolec
is for hand. costal m
down to

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

Ankle and Foot

Hip
On operative side,
On operative side, remove hair from toes
remove hair from toes to 3′above knee.
to nipples and at least
3” beyond midline
back and front,
including pubis.

Knee and Lower

Leg Knee and Lower
Leg
On operative side,
remove hair from toes On operative side,
to groin. remove hair from toes
to groin.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

6. Sutures
a. Definition- a medical device used to hold body tissues together after an injury or surgery. Application generally involves using a needle with an
attached length of thread. A number of different shapes, sizes, and thread materials have been developed over its millennia of history.
b. Sizes

c. Classification of sutures

- The sutures are generally classified according to

whether the material is natural or synthetic, the material
in the body is absorbable or non-absorbable and the
suture structure is monofilament or multifilament.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

- Suture types are collagen, synthetic absorbable and non-absorbable. These are as follows:
 Type I- Monofilament, twisted or braided silk or synthetic fibers.
 Type II – Cotton or linen fibers or coated natural or synthetic fibers in which the coating contributes to suture diameter without adding
strength
 Type III – Metal sutures in monofilament or multifilament construction.
Absorbable vs Non-Absorbable
 Absorbable Sutures -Absorbable sutures are broken down by the body via enzymatic reactions or hydrolysis. The time in which this
absorption takes place varies between material, location of suture, and patient factors. Absorbable sutures are commonly used for deep
tissues and tissues that heal rapidly; as a result, they may be used in small bowel anastomosis, suturing in the urinary or biliary tracts, or
tying off small vessels near the skin.
 Non-Absorbable Sutures- Non-absorbable sutures are used to provide long-term tissue support, remaining walled-off by the body’s
inflammatory processes (until removed manually if required). Uses include for tissues that heal slowly, such as fascia or tendons, closure of
abdominal wall, or vascular anastomoses.
Synthetic vs Natural
Suture materials can be further categorised by their raw origin:
 Natural – made of natural fibres (e.g. silk or catgut). They are less frequently used, as they tend to provoke a greater tissue reaction.
However, suturing silk is still utilised regularly in the securing of surgical drains.
 Synthetic – comprised of man-made materials (e.g. PDS or nylon). They tend to be more predictable than the natural sutures, particularly in
their loss of tensile strength and absorption.
Monofilament vs Multifilament
Suture materials can also be sub-classified by their structure:
 Monofilament suture – a single stranded filament suture (e.g nylon, PDS*, or prolene). They have a lower infection risk but also have a poor
knot security and ease of handling.
 Multifilament suture – made of several filaments that are twisted together (e.g braided silk or vicryl). They handle easier and hold their shape
for good knot security, yet can harbour infections.

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

Types of Sutures

7. Types of surgical Incision ( Provide Drawing)

 Kocher’s incision- classically used for open cholecystectomy.

 Midline incision- most common incision for laparotomy and also for various
abdominal surgeries.
 Gridiron incision (Mc Burney’s incision)- classically used for appendectomy
 Lanz incision- typically used to perform appendectomy.
 Pfannenstiel incision- incision of choice for Caesarean section and Abdominal
Hysterectomy.
 Rutherford-Morisson incision (Oblique Muscle- cutting incision)- can be used for a
right or left sided colonic resection, caecostomy or sigmoid colostomy.
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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

8. Contents of Operating Room Pack

 Content of Linen Pack:
 Laparatomy Sheet (1)
 Drape Towel (4)
 Draw Sheet (2)
 Surgeon’s Gown (4)
 Nurse’s Gown (1)
 Mayo Tray Towels (3)
 Mayo Tray Cover (1)

9. Part of the forceps ( Provide Drawing)

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

10. Arrangement of instruments in the tray (provide drawing)

a. Types of tissues and appropriate needle

 Tough Tissue (a)- cutting needle (ex. skin, tendon, fascia, mucuous membrane, cervix, tonsil, nose, tongue)
 Median Tissue (b)- rough/cutting needle (ex. mons, peritoneum, muscles)
 Softer Tissue (c)- round needle (ex. viscera such as the lining subcutaneous tissue of the abdominal wall)

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

(a) (b) (c)

b. Abdominal Tissue- skin, subcutaneous, fascia, muscles, peritoneum

c. Graspers
• Straight Forceps • Curved Forceps

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

• Allis Forceps • Babcock Forceps

d. Sharps
 Knife
 Surgical Scissor
 Metzenbaum
 Needle Holder- round, cutting, trocar
e. Tissue forceps
 Toothed Forceps
 Non-toothed forceps
f. Retractors

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

11. Major Gynecology Instrument set (provide Picture)

12. Minor set (provide drawing)

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 CEBU TECHNOLOGICAL UNIVERSITY

In consortium with

CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

Name: Wenna Mae F. Abendan ID no.: 19003 Section: B

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