SURGERY ROTATION PROPER OR ATTIRE

 Surgical Cap – should cover the ears

 Mask – should cover nose and mouth
OUTLINE
 Scrub Suit
I. Role of the Nurse in the Operating Room  Closed white shoes/OR slippers with shoe cover – foot
II. Proper OR Attire wear should be closed to prevent any body fluids from the
III. Basic Surgical Procedures (Sequence) client
IV. Whiteboard Format (OR)
BASIC SURGICAL PROCEDURES (SEQUENCE)
ROLE OF THE NURSE IN THE OPERATING ROOM 1. Gather the packs and instruments
o Wait for the staff’s signal that you are allowed to
prepare
 Open the pack with the presence of CI or
staff nurse
o Placed in the stockroom, if none, in the ante room
o If the procedure is the first case of the day, the
night shift usually prepares and places the
instruments and the packs in the OR assigned.
 Still check for completeness of instruments
o Packs have labels of the OR room, procedure,
surgeon, anesthesiologist, remarks, etc.
o Big pack is placed in the back table. The rest of
the packs and instruments will be placed on the
mayo table.
2. Medical handwashing
 Change the white uniform (Type C) to scrub suit (Type B) o Always bring pocket size alcohol (used if there’s
and outside shoes to inside shoes/slippers in designated no time for medical handwashing)
dressing rooms. 3. Opening of the Pack
 Bring with you your valuables (e.g. wallet) and 4. Surgical Handwashing
paraphernalia in your pocket. o After opening the pack, wait for the signal to do the
 Receive the endorsement at the nurses station (semi- surgical handwashing
restricted area) 5. Gowning and Closed Gloving
o Diretso na after surgical handwashing, no need to
DIFFERENT AREAS wait for instruction
6. Setting up of the Mayo Table and Back-up Table
 OR 5 - for minor cases only o Initial counting in the mayo table and back table
 PACU - There’s comfort room for ladies 7. Serving of the Gown and Gloves to the Surgeon
 Washroom - where you wash reusable instruments etc. 8. Serving of the Instruments
9. Counting During the Closure of the Surgical Site
 Packing Area - where you receive the endorsement
o Usually 4 counts for abdominal surgery
o it is where you dry the instruments and pack
 Initial – before start of procedure
o different sterilization machine is placed in here
 1st – before closure of peritoneum
 CSR (Central Supply Room) – a.k.a tindahan
 2nd – before closure of fascia
o it is where you can get suture, meds, delicate
 3rd – before closure of skin
instrument (e.g. sharps, needles), gloves, IVF,
10. After Care
suction tubes, cautery, and etc
 Stockroom – where the gathered pack are placed SCRUBBING AREA
 Female’s Quarter – resting place for staff  In San Pedro Hospital: all sink for water and soap are foot
 Pantry Room – eating place control.
 Sink – scrubbing area
 Ante room - where general instruments are placed (e.g. BACK TABLE
abdominal set, individual packed instruments, neuro  Big pack is placed on the back table
pack, D&C pack, pick up forceps, sterile water, extra  Other and extra instruments are placed here.
towel & foot drapes, EENT instruments OB packs, etc.)  Ex. Towels, if need extra towel, no need to rush to
stock room

BSN-3F 1
MAYO TABLE
 comes in different sizes
 adjustments are either foot control or side

PACKS
 Disposable and reusable
 Indicator tape: RED to YELLOW if autoclaved
 Date when pack was sterilized not the expiry date.
 Do NOT throw reusable packs.

OPENING OF THE PACK Additional Notes:

 Wait for the signal; done 30 min - 1hr before the surgery
 Check & read the label first  If sponges are soiled:
 Check expiration date o OS, AP, MS - drop it in the kick bucket
 Check integrity (intact, not moist/wet) o CB, PB, and Cottonoids - do not drop in the kick
 Opening of Big Pack: check the 1st flap (should face bucket. Placed in the back table in extra basin
towards the scrubbing area/sink)  If cottonoids was cut in half, add the other half to initial
 Open big instrument first counting
 On top will be the abdominal set or other basic o Ex. 10 is the initial, but surgeon want to cut one
instruments (first to use) into two, the count for cottonoids will be 11.

1. BIG PACK
 Check for integrity (if there’s tear, holes, or moist)
 No expiry date but check the date of when it is sterilized.
 1st flap should face the scrubbing area - 5 gowns and
Drapes, placed in upper corners to make space for other
materials. (In placing the gowns, consider the location of
scrubbing area/sink)
 After separating gowns and drapes, clip the pick-up
forceps at the side (table level).

2. INSTRUMENTS
 Start opening instruments from biggest to heaviest
 Instruments are placed at the center or anywhere as long
as there is space, and on top should be the Abdominal
Set.
 Drop the instruments when putting it on the table

3. SUTURE BASIN
 Suture basin should always be place in line with the
drapes; separate bigger basin (MS) from smaller basin
(PB, CB, Suture, blades) using pick-up forceps
 You can place AP anywhere in the sterile field as long as
Indicator Tape
not on top of drapes nor gowns.
CONTENTS OF THE BIG PACK
1. OR gowns (5) 4. Foot drape (1) 4. PREPARE GLOVES
2. Mayo cover (1) 5. Head drape (1)  Gloves (without wrapper) should always be placed in line
3. OR towels (5) 6. Lap sheet (1) with the gowns (near the gown is the surgeon’s gloves)
 Order of gloves: surgeon-residents-staff-student
TYPES OF SPONGES  Prepare the gloves last.
 AP (Abdominal Pack) (2) - biggest sponge; with blue  Check supplies at the back table if complete.
string
 MS (Medium Sponge) (10) - bigger than OS; also for PROCEDURE:
abdomen  Check for sterility (integrity)
 OS (Operating Sponge) (10) - mostly for superficial;  Check expiry date
from CSR  Open slowly starting at the side (outside wrapper throw in
 Blue Line - X-ray indicator to easily detect if left black bin)
inside the body  Inner wrapper:
 CB (Cherry Ball) (5) - clipped in ovum forceps; for  Hold and open apart
sponge or dissect; has x-ray detector (same with PB)  Unfold the lower portion using thumb
 PB (Peanut Ball) (10) - clipped in big Kelly  Flip (side by side), then hold using non-dominant
 Cottonoids (10) hand

BSN-3F 2
 Using pick-up forceps, pick the gloves  Invert the gloves
 Take out left glove first, followed by the right glove, and  With non- dominant hand, grip the upper lid, dominant
place gloves with thumb facing up. (right glove should be hand grasps the lower lid. With a close fist, insert
on top) dominant hand. Then unfold cuff.
 Do not lock the forceps when picking up the gloves  You can now expose your fingers in the gloves by pulling
 Once done, clip pick-up forceps at the side (once the gown down slowly. Do not expose your fingers on
surgically clean na ang scrub nurse, di na pwede mu gunit your non-dominant hand to prevent contamination. Start
sa pick-up forceps) manipulating the gloves.
 After properly wearing your gloves on the dominant hand,
SURGICAL HAND SCRUBBING proceed with your non-dominant hand
 Wait for staff or CI to tell you to do surgical hand  Once you are done, rest hands by holding the chest part
scrubbing of the gown or putting your hands on top of the sterile area
 Guard the back table while waiting of the back table.
 Surgical Brush - reusable
o one side is sponge other side is bristles SETTING UP THE MAYO TABLE
o Students: use the bristles all throughout
 Anti-septic solution - microshield soap is used in SPH
o solutions and avaguard are used by surgeons

PROCEDURE
 Keep a distance from the sink.
 Fold sleeves, wet hands up to 2 inches above elbow
 Wet brush, dispense soap, and make lather
 Brush nails in 20 circular motions followed by each finger
in 10 circular motions.
 From thumb to index finger in one stroke.
 Brush palms and back of the palms in 10 circular strokes
 Divide arm into 2 portions (wrist to mid forearm, and mid  Take the mayo cover; unfold mayo cover.
forearm to 2 inches above the elbow), and further divide  Closed end will be inserted at the cuff to avoid dangling
into 4 sections (anterior, posterior, left, and right sides). while covering the mayo table
 Lastly, the elbow since it is the most contaminated area.  Step your foot at the base of mayo table to avoid moving
10 circular strokes. it.
 Rinse brush, dispense a soap, make lather and brush the  Cover slowly while trying to unfold he cuff, move the cover
other hand forward until its parallel to the table.
 Drop brush after brushing elbow and rinse  Pull one side of mayo cover and insert the excess under
 Do not let your hands touch your scrub suit the tray.
 Get one towel and spread on top of the mayo tray. Parallel
DONNING OF STERILE GOWN to mayo tray
 Use back or butt to open the door to OR theater.  Get the abdominal set and place it on top of mayo tray
 Using the dominant hand, grab the center of the gown o it contains the basic instruments
(the gown on top)  Remove the indicator tape and place it on the anterior
 Move back, sideways, dangle portion of your gown. (will use it later)
 Dry your hands with the foot part of the gown  Remove slowly the wrapper, remove the instrument, and
 Keep gown an arm’s length away to avoid contamination set aside.
 Dry hands starting with the fingers, hands, arms, and  Make rolled towel using the wrapper of Abdominal set.
lastly elbow. One direction only. o Use indicator tape to secure the end of the towel
 Locate armholes, and wear gown, do not extend hands  Place it on the left side of mayo tray.
beyond shoulder level, let the circulating nurse fix your  Arrange the grasping instruments on top of the rolled
gown. towel
 Do not insert hands in the gown pockets, place your hand o handles rest above the rolled towel
directly on the chest area of the gown only when you  Remove towel clip and ovum forceps
already don your sterile gloves. o place towel clip with the other clips and ovum
CLOSED GLOVING forceps to the back-up table
 Hands are kept inside the gown to avoid contamination  Arrange other instruments in mayo table
 Don dominant hand first  Start initial counting together with the circulating nurse
 With your non-dominant hand, place gloves on the palm o Use the end of the thumb forceps to separate each
of the dominant hand instrument while counting
 3 principles:  Start counting with cutting instrument, then grasping
o Palm to palm, thumb to thumb, edge to edge instrument, followed by retracting instruments
 Palm of the glove is parallel to the palm,  When counting: mention the name of instrument, count,
thumb is parallel to the thumb, and the edge followed by the total number of instruments
of the cuff is in line with the edge of the o Ex. “Allis. 1, 2, 3. 3 Allis”
fingers.

BSN-3F 3
 Remove the towel clips and place four towel clips on the 3. Exposing/Retracting – are used to hold back the wound
side of mayo table and the rest on back-up table edges, structures, or tissues, to provide exposure of the
 Get the ancillary instruments: suction tubing attached with operative site.
the tip, followed by cautery attached with the tip (include o Ex. Richardson Retractors
the tip in the counting), and one towel clip on the top of it SERVING OF THE GOWN AND GLOVES TO THE
 Place all the drapes on top. SURGEON
 Prepare four towels, unfold and fold 1/3; folded towel
 Once the surgeon is inside the operating room, offer the
facing toward you, and place each on top of drapes in a
sterile towel or the gown so that he/she could dry hands
cascading manner.
 Grab the gown with both hands and offer the foot part to
 Do initial counting of the rest of the instrument in the back-
the surgeon by unfolding the gown (foot part: dangling).
up tables, followed by needles, MS, OP, AP. Place it in
 Make sure your hands is in the middle part of the gown to
cascading manner
avoid contaminating your gloved hands from the surgeon.
CONTENTS OF THE ABDOMINAL SET  Once the surgeon is starting to dry hands, locate the
 Fine curve (12)  Ovum forceps (1) anterior part of the gown
 Straight clamp (6)  Blade handle #4 (2)  Place hand inside the shoulder portion to expose the
 Big curve/kelly (6)  Long tissue forceps w/o teeth (1) armhole
 Allis (3)  Tissue forceps w/o teeth (2)  Serve the gown to the surgeon
 Babcock (3)  Tissue forceps w/ teeth (2)
 Once halfway, you can release and ask the CN
 Needle holder (2)  Adson w/ teeth (1)
(Circulating Nurse) to tie the back portion of the gown.
 Army navy (2)  Adson w/o teeth (1)
 Towel clip (7)  While the CN nurse is tying, start preparing the gloves of
the surgeon
o Serve the right glove first
o Unfold the cuff and check if there’s holes by
inflating
o After which, make a smaller cuff using four fingers
inside and thumbs abducted
o When ready, face the surgeon; keep feet apart or
1 foot forward. This will serve as a support
o Make sure the thumb and palm are facing the
surgeon
o Say “right glove doc”
o While surgeon is inserting his/her hands, exert a
slight upward pressure on the cuff; release the
gloves slowly.
CLASSIFICATION OF INSTRUMENTS  Do the same thing for the other gloves
1. Cutting/Dissecting - Used to cut or separate tissues
o Blade holder number 7 - (stab knife) blade number SERVING OF INSTRUMENTS
11 DRAPING THE PATIENT/ MAKING A STERILE FIELD:
o Blade holder number 4 - blade numbers 20, 21, 22  Cover the area with sterile drapes.
o Blade holder number 3 - blade numbers 10, 11, 15  Serve the OR towels one by one
o Sharps  Serve the towel clips
 Metzenbaum - cut delicate or soft tissue  Serve the drapes
 Mayo Scissors - cut hard tissues 1. Foot drape – start draping the most contaminated
 Suture scissors - cut sutures part
2. Grasping/Clamping - specifically designed for holding 2. Head drape
tissue or other materials 3. Lap sheet
o are divided in the following categories:  Serve ancillary instruments
a) hemostats o Suction tubing
b) occluding clamps o Cautery
c) graspers and holders
d) forceps or pick-ups POSITION THE TABLES:
o Allis forceps - grasp hard tissue
 Mayo table
o Babcock forceps - hold delicate tissues/ soft tissue
o Placed by the leg part of the pt
o Other examples:
 Back up table
 Kelly
o Beside the mayo table
 Mosquito
 Medium Curves
 Straight Clamp
 Ochsners
 Tissue forceps w/o teeth (a.k.a thumb
forceps)
 Tissue forceps w/ teeth

BSN-3F 4
 AFTER CARE

REMOVAL OF GOWNS AND GLOVES

 The anterior portion is considered contaminated this time;
keep contaminated side inside.
 Ask the circulating nurse to untie the back portion of the
gown
 Grab the anterior portion of the gown and pull it.
Maneuver the gown while pulling and keep contaminated
Position of Tables side inside.
 Roll the gown and place it in soiled hamper (yellow
SURGICAL PAUSE
cellophane)
 Initiated by the circulating nurse
 Remove the gloves using glove to glove and skin to skin
 Done before the incision to confirm: contact
o Right patient, right procedure, right site
 Dispose the gloves into the yellow bin
 Prayer
 Do medical handwashing
 Circulating nurse will document the time of:
 Copy your cases first in Jotdown notebook
o Time in
o Date
o Induction of anesthesia
o Time of the procedure
o Cutting time (start of operation)
o Full name of patient
o Specimen out
o Case number
o Operation ended
o Surgeon
o Refer the time from the wall clock
o Anesthesiologist
o Proposed procedure
COUNTING DURING THE CLOSURE OF SURGICAL SITE
o Post-op procedure
 Responsibility of both circulating and scrub nurse o Copy the back portion of accounting clearance
 Performed to prevent injury of the patient from retained o Final procedure and patient
foreign object/s o Final diagnosis
 For protection of the patient, personnel, and the  Exhibit booklet
institution. o Date of procedure
 4 COUNTS (especially if abdominal) o Time surgery started
a) Initial counting (before the procedure starts) o Initials of the patient (first name, MI, last name)
o Serve as a basis for counting during the o Case number
closure of surgical site. o Procedure
o Sequence: Instrument, needles, sponges o Staff nurse who supervised the surgery
(INS) o Clinical instructor (signature)
o Not reported o Get the signature of the OR staff (SN or CR) based
b) 1st counting (before the closure of peritoneum) on your role
o Sequence: Sponges, needles,
instruments (SNI) WHITEBOARD FORMAT (OR)
o Report to surgeon if complete  Filled-out by the Circulating Nurse
c) 2nd counting (before the closure of fascia)  There is a small whiteboard in each room
o Sequence: SNI
 Data is gathered when the patient enters the OR since
o Report to surgeon if complete
the circulating nurse helps in receiving the patient
d) 3rd counting (before the closure of skin)
o Sequence: SNI
o Report to surgeon if complete
 Start in the sterile field (patient), Mayo table, then Back-
up table

HOW TO REPORT?
“Excuse me Dr. *surgeon* and the rest of the surgical team,
the *1st, 2nd, 3rd and Final* counting of sponges, instruments,
and needles is complete.”
Note: ang asterisk naga depend unsa na counting imong ireport.
If first then 1st counting of SIN (bawal shortcut) is complete. Format of the Whiteboard

 Always wait for the acknowledgement of the surgeon

(thank you). If there is no response, report again.
 Only the circulating nurse will report to the surgeon.

BSN-3F 5
  Example naay AP sa site (patient) so SN
BEFORE THE PROCEDURE will point and say “AP 1” then mutanaw sa
mayo table. If walay AP sa mayo table,
proceed to the back table. Icount if meron
isa sa back table.
o If the SN will count on the field, say “UP”
 Ex. SN: “AP 1, 2. 2 APs up”
 After SN counts, CN will write on the small table.
o Lahat na isabi na “up” ilagay under sa SN. If
“down” ang imention then write it under CN.

 Time in – pag enter ng patient

 VS can be seen on the monitor when the gadgets are
already attached to the patient.
 Fill out the sponges, needles, instruments based on the
 After CN writes under SN, compare the total (on the table)
quantity pag count during the initial counting. If wala sa
to the initial number (during initial counting; can be seen
initial counting then leave blank.
on the left side of the board). If same, it means complete
o Ex. 2 AP sa initial counting then put 2 sa tabi ng
ang sponge. If complete, CN will say “2 APs” then icheck
AP
yung number sa initial counting na side.
o Lahat ng na count during the initial counting isulat
sa whiteboard
 If meron pa ibang instruments na wala nakasulat sa
whiteboard then iadd lang. Put a space in-between
instruments (red square ang space).
 Final Script:
o CN: “AP”
o SN: “AP up. 1, 2. 2 APs up”
o CN: *write 2 APs on whiteboard then write the total
then compare to initial counting. If complete,
icheck sa initial counting na side* then say “2 APs
 Time inducted – administration of anesthesia
check”
 Another example (MS 10):
COUNTING DURING CLOSURE
o CN: “MS”
o SN: “MS up. 1 (sa patient), 2 (sa mayo table), 3, 4,
5, 6 (sa back table). 6 MS up”
o CN: *using the pick-up forceps, count the MS in
the kick bucket one by one* “MS down. 1 (then
transfer), 2 (then transfer), 3, 4. 4 MS down”
 There are 2 kick buckets. When counting,
itransfer sa pikas kick bucket para sure ang
pag count and dili libog
o CN: *writes on the table then compare the total to
initial counting. If complete, check* “10 MS check”
 Circulating nurse initiates the counting.  Only count the accountables.
o Ex. the circulating nurse will say “mag counting na  The table is only for the sponges. If needles and
ta” or “mag 1st counting na ta.” There is no formal instruments na icount, icheck lang didto sa side.
format when counting, pag report lang meron.  If na check na lahat, go back to the accountables before
 If mag initiate na si CN ng counting, the SN will get the reporting. Recheck the board basin nay wala naapil ug
ovum forceps then hand it to the CN. count. If complete, report to the surgeon (excuse me dr
o CN will use ovum forceps in counting soiled surgeon and the rest of the surg team etc.)
sponges in the kick basin/bucket.  Do not erase the check marks since it will serve as a
 The circulating nurse (CN) will only mention the sponge, guide that the counting is finished. If 2nd/3rd counting na
needles, or instruments then the scrub nurse (SN) will itabi lang ang check.
count. o Ang sa table lang pwede ierase after reporting.
o Scrub nurse will count starting from the site. Start
with the patient going to the mayo table then lastly
the back table. SN will only focus on the sterile
field.
o Ex. CN will say “AP”, and then the scrub nurse will
proceed to count the AP.
o SN will check the patient, then the mayo table then  Example wala nay AP during the 2nd, the SN will say “no
lastly the back table. APs up” then the CN will proceed to check the kick basin.

BSN-3F 6
 Example: nagpa add ng ATR after the 1st counting.
o Since dili man ierase ang check, just add “+2” sa
tabi ng check then put the total.
o Ex. +2 = 4  [check ng 2 counting]

REFERENCES

I. Notes from RLE Skillslab PPT and

Recording

BSN-3F 7
 OR ATTIRE
Operating room attire Personal protective devices
○ Scrub suit ○ Surgical eye protection devices
○ Sterile gown ○ Surgical face mask
○ Head cover ○ Sterile gloves
○ Shoes
Basic surgical procedures (sequence):
1. Gather the packs and instruments (30-1hr before the cutting time; not allowed without the presence of the CI or staff)
○ Usually placed in the stock room
○ Night shift prepares all the packs and instruments that will be used the following day (elective cases)
○ If there is no pack prepared in the stock room, look in the anteroom (between OR 3 and 4; usually OB cases and ENT)
○ Small packs and instruments are placed on the mayo table
○ Big packs should be placed on the back table
2. Medical handwashing (sometimes alcohol na lang)
3. Opening of the pack
4. Surgical hand scrubbing (wait signal coming from the CI or staff)
○ Make sure you are properly wearing cap and mask
5. Gowning and closed gloving (diretso na; no instruction)
6. Setting up of the mayo table and back-up table (diretso na; no instruction)
○ Initial counting (initiated by the scrub nurse bc they know the equipment that they prepared)
7. Serving of the gown and gloves to the surgeon
8. Serving of instruments
9. Counting during the closure of the surgical site
○ Usually 4 counts (abdominal surgery):
■ Initial (before the procedure starts)
■ 1st (before closure of the peritoneum)
■ 2nd (before closure of the fascia)
■ 3rd (before closure of the skin)
10. After care

Content of the BIG pack: Types of sponges:

1. OR gowns (5) ● AP - abdominal pack (2)
2. Mayo cover (1) ● MS - medium sponge (10)
3. OR towels (5) ● OS - operating sponge (10)
4. Foot drape (1) ● CB - cherry ball (5)
5. Head drape (1) ● PB - peanut ball (10)
6. Lap sheet (1) ● Cottonoids (10)

Content of the abdominal set:

● Fine curve (12) ● Blade handle (2)
● Straight clamp (6) ● Long tissue forceps w/o teeth (1)
● Big curve/kelly (6) ● Tissue forceps w/o teeth (2)
● Allis (3) ● Adison w/teeth (1)
● Babcock (3) ● Adson w/o teeth (1)
● Needle holder (2)
● Army navy (2)
● Towel clip (7)
● Ovum forceps (1)
 RETURN DEMONSTRATION SCRIPT
GREETINGS: Good morning, ma’am Magno, I am Ellanie Inayangan student nurse and for this morning I will be return demonstrating the basic
surgical procedures.
When entering the OR, I will immediately change my white uniform into a scrub suit, then I will change my outside shoes to inside shoes and I
will wear my mask and surgical cap in the dressing room. I will make sure to bring my valuables and paraphernalia and place it in my pocket.
After changing into my OR attire, I will be receiving my endorsement in the packing area
I will be performing the opening of the major pack. In SPH, We are allowed to open the major pack 30 mins to 1 hour before the cutting time
provided there are a signal coming from the staff that we can open the pack. So let’s say there is a signal coming from the staff, we may now
gather the packs and instruments (packs are found in the stockroom and anteroom).
After gathering the packs and instruments, I will do my medical hand washing - to deter the spread of microorganisms and afterward, I can go
back to the Operating Theater. Then before opening the packs and instruments in the OR theater, make sure your CI or a staff nurse is there
that will supervise you.

OPENING OF THE MAJOR PACK

Opening of the Major Pack Sequence (back table)
➔ Check the indicator type
◆ (Making sure that it is the right pack)
◆ Read the lable
◆ Make sure the pack underwent the sterilization process
➔ check expiration date,
➔ check integrity of the pack holes, moist, tears
➔ Check for the FLAP, should be facing toward the scrubbing area

Procedure
1. In the opening of the big pack, place the sterile pack on the back To ensure placement of the gowns and drapes after opening the pack. The
table with the cuff towards the scrub room. gowns are usually positioned near the scrub room to avoid overreaching.
2. Open the pack gradually following the direction of the folded cuff. The folded cuff serves as a line of demarcation between the sterile and
1st flap - use hand; grasp on top unsterile portion of the pack.
2nd flap - use hand, insert in the cuff
3rd flap - hold the edge of the wrapper (Open together with the
C.N.)
Last flap – use 2 hands, spread hands and open it towards you.
3. Open and remove the sterile pick-up forceps from its wrapper. The sterile pick-up forceps will be used to manipulate anything that is
Throw wrapper in the black trash can within the sterile field.
4. With the use of the sterile pick-up forceps, position the drapes and Allows enough space at the center of the table where all necessary
gowns (scrub room) on opposite upper corners of the table. instruments will be placed.
Content of the BIG pack:
● OR gowns (5) for surgeon, assistant to the surgeon,
anesthesiologist, scrub nurse and circulating nurse
● Mayo cover (1)
● OR towels (5) 4 towels to drape the patient and 1 will be
used on top of the mayo cover
● Foot drape (1)
● Head drape (1)
● Lap sheet (1)

After placing the drapes, clip the pick-up forceps on the side of the backup
table on table level.
5. We will now start opening the instruments. Unwrap the following To open the pack easily for aseptic removal of instruments and sponges.
using the banana peel technique and place it on the back table
without causing contamination:
a. Big and heavy individually packed instruments like the
retractors (balfour, beaver, richardson) and should be
placed at the center
b. Abdominal set over the retractors
c. Cutting instruments
d. Accessory instruments
e. Suture basin ( Big and small round basin), place in line
with the drapes, seperate with the use of forcep
f. Suture book - For NON - ATR needles
Major suture book - 12
Minor suture book - 10
6. Open the pack of MS (medium sponge) and place it one by one in Counting each sponge as you place it in the round basin ensures
the big round basin using the sterile pick up forceps. completeness before the start of the surgery.
if you need 10 MS and kulang ang meron sa pack, go to the
 Anteroom and check canesther; inform the staff)
7. Open and drop the surgical blades in the small round basin. Provides protection from accidental injury during the preparation of the
Smaller basin - Put ATR needles instruments.
8. Last to prepare is the surgical gloves— these is placed in line with Ensures sterility of the gloves and promotes organization.
the gowns
● Check expiration date, integrity, and size
● Circulating nurse will also put packs in the OR table like
the gloves because they’re the one who knows the sizes
of the gloves of the doctor and other staff; they also put
suture, sharps, cautery, and accessory
● Make sure black bin is beside you, you will throw your
trash/packs
● When opening gloves:
○ Get the gloves and open it on the side then to the
center.
○ Take out the 2nd wrapper w bare hands and open it
halfway
○ With the wrapper, using your thumb, slide down the
lower flap (do not include the upper flap to prevent
the gloves from slipping)
○ Fold the wrapper in the middle
○ Using Non dominant hand to hold the wrapper
○ And using the Dominant hand to use the pick up
forceps. In holding the pickup forceps, Thumb -
insert it with one ring finger. The middle finger in the
other ring finger and lastly, the pointing finger at the
center of the scissors.
○ Use forceps to pick up gloves making sure to pick it
up at the center of the gloves and not the edges
○ Pick up the left gloves first and placed it on the back
up table in line with the gowns
○ Keep in mind that we should not lock the forcep
once you will get the gloves in the wrapper because
sometimes there are teeth in the forceps so it will
cause breakage to the gloves
○ Thumb of the glove should be facing up (left) and on
top place the right glove.
○ Arrangements of gloves in the table: surgeon,
assistant to surgeon, staff, and student nurse
○ You can only interchange the arrangement (left or
right glove) if you are already done with gloving
9. Keep close watch on the open sterile items at all times. Ensures sterility of all the items.
● Wait until there is a signal coming from the CI or staff
nurse that we can proceed in doing surgical handwashing

SURGICAL HAND SCRUBBING

Definition: surgical hand scrubbing is a vigorous and lengthy cleaning of the skin of the hands and forearms with water, antiseptic agent and scrub/
sponge to create friction. It is called counted – stroke scrub.

Purpose: so there are 3 purposes of surgical hand scrubbing

1. To remove dirt and skin oil from the hands and lower arms.
2. To reduce the count of microorganisms count to as near zero as possible.
3. It is done before you do surgical gloves and gown
Reminder:
● We have to make sure to wear cap and mask properly and tighty because we are going to spend a lot of time in the OR and we cant adjust our
caps and mask inside once we are done gloving and gowning
● Also, don't forget to fold sleeves especially for gentlemen before hand scrubbing
● Equipment:
○ surgical cap
○ surgical mask
○ antimicrobial soap
○ plain scrub brush
○ sink with foot, knee or elbow control and high faucet
 Procedure
1. Check for completeness of supply. Prevents having to stop to obtain those materials needed.
Check if the faucet is functioning
2. Remove all pieces of jewelry, including the wedding ring. Jewelry harbors microorganism
3. Trim nails if needed. No nail polish or artificial nails should be worn Microorganisms collect in chipped nail polish and under artificial or long
fingernails
4. Wear a surgical cap and a disposable mask. Provides a barrier to reduce the spread of microorganisms from the hair or
respiratory tract.
5. Stand before the sink keeping the body away from it. The sink is considered to be contaminated.
6. Turn on the faucet and adjust the pressure using the foot, knee or Frees hands from touching anything this time. The water should remain
elbow control. running.
Water splashed from the contaminated sink may come in contact with your
uniform, thus,
contaminating it.
7. Holding your hands above your elbow, wet the skin from the Since the hands will be the cleanest area once the scrub is completed it
fingertips down to the elbow. (2 inches above elbow) follows the principle
of allowing water to flow from the cleanest to the most contaminated area.
8. Wet and apply approximately 1 tsp of antimicrobial soap on the Soap emulsifies skin oils and contaminants and facilitates their removal.
palm using foot, knee or elbow control and work up a lather
9. When using a pre-packaged scrub brush-sponge pad, open tihe Once the scrub has begun, the brush is never put down until the scrub is
package, remove the nail cleaner and clean the nails and discard. complete as it would then be contaminated
Remove the brush and discard the wrapper. Do not put down the
brush once the scrub has begun.
If the brush or sponge is not impregnated with the cleaning agent,
moisten the brush or sponge and dispense the soap into it.

10. Using the brush, make 20 circular strokes on the nails (starting The scrubbing action loosens resident bacteria and contaminants, thus
with the less dominant hand). facilitating their removal.
Using bristles Circular motion mechanically removes microorganisms.
11. Scrub all skin surfaces using circular strokes: The scrubbing action loosens resident bacteria and contaminants, thus
a. each finger (10 circular strokes each) facilitating their removal.
b. Palm (10 circular strokes each) Circular motion mechanically removes microorganisms.
c. back of the hand (10 circular strokes each)
d. forearms (divide into 2 then 10 strokes on each of the 4 parts of
the first half of the forearm then another 10 strokes on each 4
parts of the second half of the forearm paying extra attention to the
elbow)
Maintain 90 degree angle
12. After scrubbing the less dominant hand, rinse the brush and The brush contains lather that may contain microorganisms. Rinsing will
transfer it to the other hand. remove the lather from the brush.
13. Continue the procedure on the dominant hand following steps 8 to
10.
14. When the scrub is finished on the dominant hand, drop the brush
on the sink
15. With the use of foot, knee or elbow control, turn on the faucet and To avoid contamination of your hands.
rinse the arms starting from the fingertips to the elbow. Water should flow from the area of least contamination to the area of most
contamination.
16. Turn off the water using the foot, knee or elbow control To avoid contamination of your hands.
Maintain position of hands (upperward and above the waist level;
in front of the body)
Make sure to let the water drip

After we are done with surgical hand scrubbing, we can now proceed with the donning of a sterile gown and closed gloving.

DONNING A STERILE GOWN AND CLOSED GLOVING

● The nurse must wear a sterile gown in the Operating Room, so sterile objects can be comfortably handled with less risk of contamination. A nurse
assisting a physician with an invasive procedure in a treatment room may also wear a sterile gown. A gown is applied after surgical handwashing
and after the nurse has donned a mask and surgical cap. He/She either picks a gown from a sterile field or has a gown assistant hand him/her one.
● The entire surface of the gown is not considered sterile. Only the area form the anterior waist to the collar including anterior sleeves is sterile

Procedure
1. After performing surgical hand scrubbing. Scrubbing eliminates microorganisms from the surface of the hands.
2. Enter the swing door of the OR using the back or the butt. After surgical hand scrubbing, the hands are rendered to be surgically
clean. Therefore, I should not touch any part of the OR door.
3. Stand on the side of the table where the sterile gowns are Contact of outer surface of gown with a dirty or clean surface would result
positioned. Grasp one sterile gown with the dominant hand and in contamination of the gown
stand in an area where the gown may be opened without risk of
contamination. (step back and side ways)
4. Hold the sterile gown away from the body. Hold the bottom part of If a sterile OR towel is not available, the bottom part of the gown can be
the gown with the other hand to be used in wiping the dominant used in wiping the hands, making sure that it will not swing or come in
hand. Bend a little (forward and distance) while wiping each finger, contact with a portion of your body, thus, causing it to be contaminated.
 hand, wrist, forearm to the elbow extending about 2 inches.
Make sure that the gown is not swinging to prevent contamination.
Ang nagamove is ang arm hindi ang gown
5. Do the same procedure on the non- dominant hand, this time the
dominant hand holds the bottom part of the gown to wipe the non-
dominant hand, to the forearm, running through the elbow and 2
inches beyond that.
6. Raise up the gown a little higher to locate the armholes. The non- Racing the gown a little higher facilitates easier location of the armholes
dominant hand grasps the armholes by inserting the fingers and prevents the risk of touching the floor.
securely while bringing it up and lowering the bottom part of the
gown
7. Slip the hands inside the armholes while the gown is held away Extension of arms straight ahead keeps the sterile outer surface of the
from the body. Keep the hands at shoulder level and allow it to gown in view and reduces risk of contamination.
unfold with the inside of the gown toward the wearer.
8. Push the hands and forearms into the sleeves of the gown. Since closed gloving technique will be used, keeping the hands at the
Advance the hands only to the proximal edge of the cuff. (sideways proximal edge of the cuff will prevent contamination to the sterile gloves
pag stretch) during donning.

Call for the circulating nurse to pull the gown over the shoulder Working from behind the scrub nurse prevents contamination by the
touching only the inner aspect of the gown and tie the strings of the circulating nurse.
gown.

Since we are done with the gown, we will now proceed to closed gloving.
We have 3 principles to follow in doing closed gloving
1. Palm to palm
2. Thumb to thumb
3. Edge to edge
So let us proceed, the first step is:
9. Lift the first glove and grasp it through the fabric or sleeve. Place Cuff of the glove facilitates easier handling of the glove.
the glove palm down along the forearm of the matching hand, with
thumb fingers pointing toward the elbow. Glove cuff lies over the Only sterile items come in contact with each other.
gown wristlet.
Dominant hand first
10. Hold the glove cuff securely by the hand on which it is placed. Prevents the hands from contaminating the sterile gloves.
Sleeve to cover the gown wristlet entirely.
11. As the cuff is drawn back onto the wrist, fingers are directed into Provides a closed sterile method of donning gloves.
their cots inglove, and the glove is adjusted to the hand.
12. Use the gloved hand to position the remaining glove on the Provides a closed sterile method of donning gloves.
opposite sleeve in the same fashion. Place the glove cuff around
the gown cuff. Draw a second glove onto your hand, and pull the
cuff into place and adjust the fingers of gloves.
Non dominant hand
13. After donning the sterile gown and gloves, position or place the Gloved hands are held above the waist or at the level of the sterile table to
gloved hands at the chest or on the sterile top of the back table. prevent it from becoming unsterile.

SETTING UP OF THE MAYO TABLE and BACK UP TABLE

Procedure
1. Pick up the sterile mayo cover, unfold, and insert the gloved hand To prevent contamination of the sterile gloved
in the cuff of the drape while holding the edges of the bottom of the hand from the unsterile mayo table.
mayo cover.
2. Slip the mayo cover over the frame of the mayo stand. (A wide To create a sterile area for the instruments.
margin is maintained between the cover and the lower portion of
the scrub person’s gown).
3. Unfold the cover to extend over the upright support of the stand. Sterile drapes should be placed on the patient, furniture, and equipment to
Pull to one side, and then tuck the excess under the mayo tray. be included in the sterile field to prevent transfer of microorganisms.
4. Get one towel and cover the top of the mayo table. To establish an aseptic barrier that minimizes the passage of
microorganisms.
5. Get the Abdominal set and place it on the mayo table top. Remove
the indicator tape (place it on the chest). Unwrap the set slowly.
Remove loose instruments first; place them on the top portion of
the mayo table. The remaining loose instruments such as the ovum
forceps with the tissue clips are held securely while removing the
wrapper.
6. Roll the wrapper neatly and secure each end with a rubber band. Provides organization of the instruments in the mayo table.
Place the rolled wrapper on the left side of the mayo table and
position the Grasping instruments’ handles over the roll. (rolled
sheet)
7. Arrange the loose instruments like knife handles, retractors and
 tissue forceps in its proper place.
8. Unlock the towel clip and pull out the ovum forceps from the
handles of the instruments.
9. Place the ovum forceps at the back table while the towel clip is
positioned with the rest of the instruments on the rolled towel.
10. Mount the blades on the knife handles with the use of the needle
holder.
11. The scrub nurse informs the circulating nurse that he/she is ready To reduce the incidence of retained sponges and instruments during
to count. (Initial counting). INS Sequence surgery.
12. Picks up one of the tissue/Addison forceps and uses the tip of the
handle in counting the instruments. Start the counting by stating
the name of the instrument and its quantity.
13. Separate 7 towel clips. Get 4 towel clips and position them
diagonally on one side or opposite side of the scalpels.
14. Place the 3 towel clips at the back table. Get the ancillary To facilitate organization throughout the draping of the patient.
instruments. Attach the suction tip to the tubing as well as the tip
of the cautery to the cautery pencil. Get one towel clip and place it
on top. get 1 towel clip to secure later the ancillary instruments
15. Bring the drapes (foot, head and lap) to the mayo table and place it
over the instruments and accessory items.
16. Take the remaining 4 towels and unfold each towel with the folded
portion facing up. Arrange the towels in a cascading manner.
17. Continue initial counting in the back table. Continue with
instruments and arrange, count the atraumatic suture (Count ATR
first on the small basin and then NON-ATR on the suture book
using an instrument), count the sponges. (INS arrangement)
18. Wait for the surgeon to signal the start of the procedure by draping
the patient.

SERVING SURGEON’S GOWN AND GLOVES

Equipment: sterile gown and gloves
Procedure
1. The scrub person lifts up the folded sterile gown and unfolds it, This portion of the gown will be used to dry the hands of the surgeon and
hands to the surgeon the lower portion of the gown (making sure later, this will
that the hand is at a distance, about halfway through the unfolded be considered as unsterile since it is below waist level.
gown).

If a towel is available, the scrub person serves the towel by

unfolding it, holding the top portion while the surgeon grabs the
other end.
2. The sterile gloved hand is inserted at the anterior shoulder portion To prevent contamination.
of the gown exposing the open armholes towards the surgeon.

3. The gown is held until the surgeon’s hands and forearms are in the
sleeves of the gown.
(The circulating nurse then assists the gowned individual by pulling
the gown onto the shoulders, adjusts the back and ties the cords).
4. The scrub nurse grasps the glove under the everted cuff. Checks Checking for holes will ensure that the gloves to be used by the surgeon
for holes by inflating the gloves. are sterile. Inflating will also facilitate easier insertion
- From opening; slide hands to inflate
Stretching the gloves will allow the surgeon to insert his/her hand without
- After cheking, Make a smaller cuff, insert small portion of the
touching the scrub person's gloves.
thumb, invert and stretch, insert forefingers, abduct the thumb The scrub person protects own gloved fingers by holding them beneath
the cuff of the glove, and their thumbs by holding them away from the
partly-gloved hand

5. If you’re ready; inform the surgeon “Right glove Doc” OFFER RIGHT HAND FIRST, BECAUSE YOU DON’T KNOW THE
DOMINANT HAND OF THE SURGEON

6. Serves the dominant glove with the palm and thumb facing towards
the surgeon’s hand.
7. Exerts a slight upward pressure on the cuff while the surgeon
inserts his/her hand into the glove using firm downward thrust.
8. Pull the cuff over the wristlet of the gown while the surgeon slips
his/her hand well into the glove.
9. The procedure is repeated to don the other glove.

SERVING THE INSTRUMENTS (TO MAKE STERILE FIELD)

● Serve OR towel
● Secure with the towel clips (Serve the remaining 4 one by one)
● Serve the foot, head and lap sheet (Unfold 1 portion and serve)
 ● Serve Ancilliary instruments
● After al is served, position the mayo table in the leg part of the patient with the back up table
○ CN: Will position the kick basin near the scrub nurse
● Surgical pause (correct patient, correct surgery, correct site)
○ A pause performed immediately before incision is made to re-confirm that the correct: patient is on the table, surgery is to be
performed, side/site will be operated on
○ Universal protocol
○ Circulating nurse initiates time out
○ This form is to be signed by the surgeon, anesthesiologist and the circulating nurse
○ PRAYER is done after surgical pause
● Give MS
● Give scalpel

COUNTING DURING THE CLOSURE OF THE SURGICAL SITE

● sponges, needles, instruments
● are performed to prevent patient injury from a retained foreign object
● Accurate counting and recording is essential for the protection of the patient, personnel and the institution
● Usually 4 counts (usually abdominal):
○ Initial (before the procedure starts; before the cutting time or the start of the surgery) — IN S arrangement
○ 1st (before closure of the peritoneum) — SNI
○ 2nd (before closure of the fascia) — SNI
○ 3rd (before closure of the skin) — SNI
● Jotdown notebook (ward) and ballpen for circulating nurse (stay at the back or basta anywhere not near the sterile table)
● Start counting from the knife then going to grasping then army navy and down to tissue forceps (outside to inside) PAIKOT
● In counting use one pick forceps like adson w/o teeth or thumb forceps (use the handle to count the tip of the instrument)
● Sequence of counting:
○ Initial counting - instruments, needles & sponges (INS)
○ During closure of the surgical site - sponges, needles, & instruments (SNI)
○ Reporting - S, N, I or S, I, N

Sample:
Initial counting

SN: scapel 1,2. 2 scapel Sample dialog:

CN: 2 scapel noted ● “Excuse me, Dr. [surgeon], Dr. [anesthesiologist] and the
SN: 1 metz scissors rest of the surgical team, our 1st counting of the sponges,
CN: 1 metz scissors noted needles, and instruments, is complete”
SN: 1 mayo scissors ● “Excuse me, Dr. ___, Dr. ___ and the rest of the surgical
CN: 1 mayo scissors noted team, our 2nd counting of the sponges, needles, and
SN: 1 suture scissors instruments is complete”
CN: 1 suture scissors noted ● “Excuse me, Dr. ___, Dr. ___ and the rest of the surgical
SN: towel clips (count 1-7). 7 towels clips team, our 3rd and final counting of the sponges, needles and
CN: 7 towel clips noted instruments, is complete”
SN: fine curve (count 1-12). 12 fine curve ● “Welcome doc”
CN: 12 fine curve noted
SN: straight clamps (count 1-6). 6 straight clamps
CN: 6 straight clamps noted
SN: big curve (count 1-6). 6 big curve
CN: 6 big curve noted
SN: Allis (count 1-3). 3 allis
CN: 3 allis noted
SN: babcock (count 1-3). 3 babcock
CN: 3 babcock noted
SN: needle holder (count 1-2). 2 needle holder
CN: 2 need holder noted
SN: Army Navy (count 1-2). 2 army navy
CN: 2 Army navy noted
SN: 1 long thumb
CN: 1 long thumb noted
SN: thumb forceps (count 1-2). 2 thumb forceps
CN: 2 thumb forceps noted
SN: tissue forceps (count 1-2). 2 tissue forceps
CN: 2 tissue forceps noted
SN: adson w/o teeth 1
CN: 1 adson w/o teeth noted
SN: adson w/ teeth 1
CN: 1 adson w/ teeth noted
 (shown above: back table; counting = instruments, needles, sponges)

Example of what would be on the whiteboard; circulating nurse must

ensure that everything in their jotdown notebook reflects on the
whiteboard, and everything on the whiteboard will reflect on the
intraoperative checklist

AFTER CARE
● Attend sharps first
● Remove the blade from the holder and discard it in the sharps receptacle (near the anesthesia machine); make sure that the suture is not
included either
● Do not discard non-atr (reusable)
● Sure all instruments, take everything from the mayo table and place in basin; rinse and
● soak it in a disinfectant solution for 15 mins and rinse it again
REMOVING THE GOWN AND GLOVE
● Request the circulating nurse to untie
● Grab the chest part then pull
● Contaminated side inside
 ● Roll
● Place in the soiled hamper
○ PUT AT THE YELLOW CELLOPHANE
● Glove to glove
● Skin to skin
● Medical handwashing

FOLDING OF GOWN
● Anterior part- posterior part
● Insert hands sa may shoulder part – inline with the axilla
● Foot part of the gown/ lower part
● Face sideways
● Unfold half

Last: OR and DR separate jotdown notebook: date, full name of pt, case number, time of the procedure, type of procedure (kung ano talaga naperform),
copy post op diagnosis, name of surgeon and anesthesiologist, name of staff nurse dapat RN talaga (hindi sa OR technician; pwede sa scrub
nurse/circulating nurse)
Exhibit notebook: date, time, initial of patient (first name, middle initial, last name), surgical procedure, signatures

1. Opening of the major pack

➢ The first flap of the pack should be facing the scrubbing area
◆ Ex: if the scrubbing area is located at the right side: gowns are found at the upper right side of the table and drapes are found at
the upper left side of the table
➢ Do not insert under the flop. Just grab the cloth and pull.
➢ Then start to open the pack in the back up table AWAY, LATERAL, TOWARDS YOU
➢ When opening the big pack you have to maintain the sterility in the sterile field
2. Open the pick up forceps pack and arrange the equipment inside the big pack according to its use. By using pick up forceps to maintain sterility
Content of the BIG pack:
● OR gowns (5) surgeon. Assistant to the surgeon, anesthesiologist, scrub nurse and circulating nurse
● Mayo cover (1)
● OR towels (5) 4 towels to drape the patient and 1 will be used on top of the mayo cover
● Foot drape (1)
● Head drape (1)
● Lap sheet (1)
➢ Separate the gowns and the drapes using the pickup forceps
➢ For the drapes, grasp the lap sheet and move it to the side, for the gowns ensure that it faces the surgical hand scrubbing
➢ Afterwards arrange the instruments open first the BIG INSTRUMENTS like the retractors (balfour, beaver, richardson) and should be
placed at the center, and then abdominal set over the retractors, then the small instruments (extra forceps)
➢ Next, we have to open the suture basins – this is placed in line with the drapes
○ Smaller suture basin = surgical blades and suture tip of the cautery
○ Bigger suture basin = MS (if you need 10 MS and kulang ang meron sa pack, go to the Anteroom and check canesther;
inform the staff)
3. Last to prepare is the gloves— this is placed in line with the gowns
● Check expiration date, integrity, and size
● Circulating nurse will also put packs in the OR table like the gloves because they’re the one who knows the sizes of the gloves of the doctor
and other staff; they also put suture, sharps, cautery, and accessory
● Make sure black bin is beside you, you will throw your trash/packs
● When opening gloves:
➢ Get the gloves and open it on the side then to the center.
➢ Take out the 2nd wrapper w bare hands and open it halfway
➢ With the wrapper, using your thumb, slide down the lower flap (do not include the upper flap to prevent the gloves from slipping)
➢ Fold the wrapper in the middle
➢ Using Non dominant hand to hold the wrapper
➢ And using the Dominant hand to use the pick up forceps. In holding the pickup forceps, Thumb - insert it with one ring finger. The
middle finger in the other ring finger and lastly, the pointing finger at the center of the scissors.
➢ Use forceps to pick up gloves making sure to pick it up at the center of the gloves and not the edges
➢ Pick up the left gloves first and placed it on the back up table in line with the gowns
➢ Keep in mind that we should not lock the forcep once you will get the gloves in the wrapper because sometimes there are teeth in the
forceps so it will cause breakage to the gloves
➢ Thumb of the glove should be facing up (left) and on top place the right glove.
➢ Arrangements of gloves in the table: surgeon, assistant to surgeon, staff, and student nurse
➢ You can only interchange the arrangement (left or right glove) if you are already done with gloving

Stay and guard the sterile field and wait until there is a signal coming from the CI or staff nurse that we can proceed in doing surgical handwashing