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College of Nursing Ozamiz City

In partial fulfillment of the requirements in NCM 105 Related Learning Experience


Submitted to:

Mrs. Mary Ann Daan RN, MN Clinical Instructor

Submitted by: Tomboc, Edisah Sheen


General Objectives Specific Objectives Principles of Sterile Technique Roles and Functions of the ff: A. Sugeon B. Anesthesiologist/Anesthetist C. Assistant Surgeon D. Scrub Nurse E. Circulating Nurse Common Operating Room Instruments & Their Functions Dilatation and Curettage Instruments & Their Functions Parts and Pictures of an OR Gown Anatomy of Forceps Perioperative Nursing Care Pharmacology of the ff:  Propofol  Bupivacaine HCL  Sevofluorine  Medazolam  Lidocaine CEMOC and BEMOC


PRINCIPLES OF STERILE TECHNIQUE The patient is the center of the sterile field, which includes the areas of the patient, the operating table and furniture covered with sterile drapes, and the personnel wearing the OR attire. Strict adherence to sound principles of sterile technique and recommended practices is mandatory for the safety of the patient. This adherence reflects ones surgical conscience. Principles remain the same; it is the degree of adherence to them that varies. The principles of sterile technique are applied in the: 1. Preparation for operation by sterilization of necessary materials and supplies. 2. Preparation of the operating team to handle sterile supplies and intimately contact wound. 3. Creation and maintenance of the sterile field, including the preparation and draping of patient, to prevent contamination of the surgical wound. 4. Maintenance of sterility and asepsis throughout the operative procedure. 5. Terminal sterilization and disinfection at the conclusion of the operation.

Principles Sterile persons have scrubbed and are gowned and gloved; unsterile person have not. Only Sterile Items Are Used Within the Sterile Field. Some items such as linens, sponges, or basins may be obtained from stock supply of sterile packages. Others, such as instruments, may be sterilized immediately preceeding the operation and removed directly from the sterilizer to the sterile tables. Every person who dispenses a sterile article must be sure of its sterility and of its remaining sterile until used. Proper packaging, sterilizing, and handling should provide such assurance. If you are in doubt about the sterility of anything, consider it not sterile.

Gowns Are Considered Sterile Only from the Waist to Shoulder Level in Front and the Sleeves. When wearing a gown, consider only the area you can see down to the waist as the sterile area. The following practices must be observed: 1. Sterile persons keep hands in sight and at or above waist level. 2. Hands are kept away from the face. Elbows are kept close to sides. Hands are never folded under arms because of perspiration in the axillary region.

3. Changing table levels is avoided. If a sterile person must stand on a platform to reach the operative field, the area of the gown below waist must not brush against sterile tables or draped areas. 4. Items dropped below waist level are considered unsterile and must be discarded. Tables Are Sterile Only at Table Level. The result is that: 1. Only the top of a table with sterile drape is considered sterile. Edges and sides of drape extending below table level are considered unsterile. 2. Anything falling or extending over table edge, such as a piece of suture, is unsterile. Scrub nurse does not touch the part hanging below table level. 3. In unfolding sterile drape, the part that drops below table surface is not brought back up to table level. Persons Who Are Sterile Touch Only Sterile Items or Areas; Persons Who Are Not Sterile Touch Only Unsterile Items or Areas. 1. Sterile team members maintain contact with sterile field by means of gowns and gloves. 2. Nonsterile circulating nurse does not directly come into contact with the sterile field. 3. Supplies for sterile team members reach them by means of the circulating nurse who opens wrapper on sterile packages.

Unsterile Persons Avoid Reaching over a Sterile Field; Persons Avoid Leaning over an Unsterile Area. 1. Unsterile circulating nurse never reach over a sterile field to transfer sterile items. 2. In pouring solution into sterile basin, circulating nurse holds only lip of bottle over basin to avoid reaching over a sterile area. 3. Scrub nurse sets basins or glasses to be filled at edge of the sterile table; circulating nurse stands near this edge of the table to fill them. 4. Circulating nurse stands at a distance from the sterile field to adjust light over it to avoid microbial fallout over field. 5. Surgeon turns away from the sterile field to have perspiration removed from brow.

6. Scrub nurse drapes a nonsterile table toward self-first to protect gown. 7. Scrub nurse stands back from nonsterile table when draping it to avoid leaning over an unsterile area.

Edges of Anything That Encloses Sterile Contents Are Considered Unsterile. Boundaries between sterile and unsterile areas are not always rigidly defined, for example, the edges of wrappers on sterile packages and caps on solution bottles are unsterile. The following precautions should be taken: 1. In opening sterile packages, a margin of safety is always maintained. Ends of flaps are secured in hand so they do not dangle loosely. The last flap is pulled toward the person opening package thereby exposing package contents away from nonsterile hand. 2. Sterile persons lift contents from packages by reaching down and lifting them straight up, holding elbows high. 3. Steam reaches only the area within the gasket of a sterilizer. Instruments trays should not touch the edge of the sterilizer outside the gasket. 4. Flaps on peel-open packages should be pulled back, not torn, to expose sterile contents. Contents should be flipped or lifted upward and not permitted to slide over edges. Inner edge of the heat seal is considered the line of demarcation between sterile and unsterile portion. 5. If a sterile wrapper is used as a table cover, it should amply cover the entire table surface. Only the interior and surface levels of the cover are considered sterile. 6. After a sterile bottle is opened, contents must be used or discarded. Cap cannot be replaced without contaminating pouring edges. Sterile Field Is Created as Close as possible to Time of Use. Degree of contamination is proportionate to length of time sterile items are uncovered and exposed to the environment. Precautions must be taken as follows: 1. Sterile tables are set up just prior to the operation. 2. It is difficult to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended.

Sterile Areas Are Continuously Kept in View. Inadvertent contamination of sterile areas must be readily visible. To ensure this principle: 1. Sterile persons face sterile areas. 2. When sterile packs are opened in a room, or a sterile filed is set up., someone must remain in the room to maintain vigilance.

Sterile Persons Kept Well within the Sterile Area. Allow a wide margin of safety when passing unsterile areas and follow these rules: 1. Sterile persons stand back at a safe distance from the operating table when draping the patient. 2. Sterile persons pass each other back to back. 3. Sterile person turns back to nonsterile person or area when passing. 4. Sterile person faces sterile area to pass it. 5. Sterile person asks nonsterile individual to step aside rather than risk contamination. 6. Sterile persons stay within and around a sterile field. They do not walk around or go outside room. 7. Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons.

Sterile Persons Kept Contact with Sterile Areas to a Minimum. The following rules are observed: 1. Sterile persons do not lean on sterile tables and on the draped patient. 2. Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate, they do so without proximity to nonsterile areas. Unsterile Persons Avoid Sterile Areas. A wide margin of safety must be maintained when passing sterile areas by following these rules: 1. Unsterile persons maintain at least one foot (30cm) distance from any area of the sterile field. 2. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it. 3. Unsterile persons never walk between two sterile areas, e.g. between sterile instrument tables. 4. Circulating nurse restricts to a minimum all activity near sterile field.

Destruction of Integrity of Microbial Barriers Results in Contamination. Integrity of a sterile package of sterile drape is destroyed by perforation, puncture or strike-through. Strike-through is soaking of moisture through unsterile layers or vice versa. Ideal barrier materials are abrasion resistant, impervious to permeation by fluids or dust that transport microorganisms. The integrity of a sterile package, its expiration date, and appearance of process monitor must be checked for sterility just prior to opening. To ensure sterility: 1. Sterile packages are laid on dry surfaces. 2. If sterile package becomes damp or wet, it is re-sterilized or discarded. A package is considered nonsterile if any part of it comes in contact with moisture. 3. Drapes are placed on a dry field. 4. If solution soaks through sterile drape to nonsterile area the wet area is covered with impervious sterile drape or towels. 5. Packages wrapped in muslin or papers are permitted to cool, after removal from the sterilizer to avoid condensation and resultant contamination. 6. Sterile items are stored in clean dry areas. 7. Sterile packages are handled with clean dry hands. 8. Undue pressure on sterile packs is avoided to prevent forcing sterile air out and pulling unsterile air into the pack.

Microorganism Must Be Kept to an Irreducible Minimum. Perfect asepsis in an operative field is an ideal to be approached; it is not absolute. All microorganisms cannot be eliminated, but this does not obviate necessity for strict sterile technique. It is generally agreed that: 1. Skin cannot be sterilized. Skin is potential source of contamination in every operation. Inherent body defences usually can overcome the relatively few organisms remaining after patients skin preparation. Organisms on the hands and arms of the operating team are a hazard. All possible means are used to prevent entrance of microorganisms into wounf. Preventive measures include:

a. Transient and resident flora is removed from skin around operative site of patient and the hands and arms of sterile team members by mechanical washing and chemical antisepsis. b. Gowning and gloving of operating team is accomplished without contamination of sterile exterior of gowns and gloves. c. Sterile gloved hands do not directly touch skin and then deeper tissues. Instruments used in contact with skin are discarded and not reused d. If glove is pricked or punctured by needle or instrument, glove is changed immediately. Needle or instrument is discarded from sterile field. 2. Some areas cannot be scrubbed. When the operative field includes the mouth, nose, throat, or anus, the number of microorganisms present is great. Various parts of the body, such as the gastrointestinal tract and vagina, usually are resistant to infection from flora that normally inhabits these parts. However, the following steps may be taken to reduce the number of microorganisms resent in these areas and to prevent scattering them: a. Surgeon makes an effort to use a sponge only once, and then discards it. b. Gastrointestinal tract, especially the colon, is contaminated. Measures are used to prevent spreading this contamination. 3. Infected areas are grossly contaminated. The team avoids spreading the contamination. 4. Air is contaminated by dusts and droplets. Environmental control measures are necessary.


A. Surgeon Although the surgeons most obvious responsibility is to perform the operative procedure safely and correctly, there are other responsibilities to the patient both before and after surgery. Like all members of the operating room team the surgeon must be properly attired. The surgeon will visit the patient prior to induction of anesthesia and, if needed, assist with positioning of the patient. A proper scrub with the approved drying, gowning, and gloving techniques must also be done. The surgeon may assist with draping the patient and will check or assist with placement of suction, cautery, Mayo stand, etc. The surgeon is responsible for being certain that all team members are aware of what is needed during the procedure and that all necessary equipment and instruments are available. If the surgeon is to give the anesthetic (local, nerve, block, or regional) it will be given either prior to scrubbing or after the patient has been draped. At completion of the operation the surgeon secures the dressings in place. After the anesthesiologist gives permission, the surgeon should assist in moving the patient onto the postanesthesia recovery stretcher. The surgeon may then accompany the patient to the postanesthesia recovery room or may go to the postanesthesia recovery room directly to write the postoperative orders.

B. Anesthesiologist or anesthetist The anesthesiologist or anesthetist is the person who administers the anesthetic to the patient. The anesthesiologist must be properly attired before entering the operating room, although a scrub is not done. This person is responsible for being ceratain that all equipment and supplies necessary for the induction of anesthesia are available and then checks the patient and the chart for any last minute changes, such as special requests from the patient or additional laboratory tests. A blood pressure cuff and other monitoring devices are then placed on the patient as needed. At the proper time, the anesthesiologist administers the anesthetic to the patient and determines when the surgeon or circulating nurse may proceed with positioning and preparing the operative site. The anesthesiologist often helps to position the patient properly.

The surgeon generally checks with anesthesiologist before incision made. During the procedure the anesthesiologist monitors the patients vital signs and is responsible for keeping the surgeon aware of the patients condition. The anesthesiologist gives fluids and blood transfusion needed during surgery, and if tourniquets are used, is responsible for informing the circulatory nurse of the time for the next patient to be premedicated. The anesthesiologist determines when the patient may be moved to the postanesthesia recovery stretcher after the surgical procedure has been completed. This person usually checks the patients airway and vital signs before taking the patient to the postanesthesia recovery room. Postanesthesia recovery room personnel are given all necessary information, such as a report on the patients condition both at present and during the operation, and the type of surgery performed. C. Assistant Surgeon The primary responsibility of the assistant is to help the surgeon in any way requested. The assistant must be properly attired. After performing a hand scrub, including proper drying, gowning, and gloving procedures, the assistant may help with draping the patient and with the final placement of equipment and supplies. During the procedure this team member gives any assistance as requested by the surgeon. At the completion of the procedure the assistant may close the incision and help with the placement of dressings. After the anesthesiologist gives permission the assistant helps to move the patient to the postanesthesia recovery stretcher and may accompany the patient to the postanesthesia recovery room and write the postoperative orders. D. Scrub Nurse As a member of the scrub team, the scrub nurse must be properly attired, scrubbed, gowned, and gloved. However, before scrubbing, the nurse assists the circulator in the preparation of the operation room if necessary. The scrub nurse must be familiar with the procedure to be done and with the supplies and equipment needed. After completing the proper scrubbing, gowning, and gloving procedures the scrub nurse set up the black table, Mayo tray and prep stands, Spongers, needles,

instruments, etc., are counted as required by hospital policy. All instruments and supplies must be checked against the surgeons card to be sure that everything is available. The scrub nurse the assists the surgeon and assistant to the surgeon into their gowns, and gloves. After patient is brought into the operating room, anesthesized, positioned and the operative site is prepped, the scrub nurse drapes the operative site. The nurse assists the surgeon throughout the procedure as required. Many times the surgeons need can be anticipated; for example, when the surgeon is using scalpel or scissors, the use of clamps should be anticipated. The nurse should listen carefully to what the surgeon is saying. At the completion of the surgery, the scrub nurse and the instruments must remain sterile. The scrub nurse is responsible for cleaning uo the back table and preparing for between surgery clean-up. As the patient leaves the room, the scrub nurse gets all of the instruments ready for terminal cleaning. The gown and gloves can then be removed as the nurse prepares the room for between-surgery clean-up.

E. Circulating Nurse Although the circulating nurse does not scrub, a good handwashing technique must be carried out and proper operating room attire must be worn. The circulator is responsible for the overall running of the operating room before, during, and after the operative procedure. One of the most important duties is to assure that sterility is maintained at all times. In addition, the circulating nurse is responsible for preparing the operating room, assisting the scrub nurse, caring for the patient before and after he is taken into the operating room, assisting the anesthesiologist, positioning the patient and preparing the operative site, assisting the scrub team before and after surgery, caring for the patient immediately after surgery, and cleanin up the operating room after the procedure has been completed.


PERIOPERATIVE NURSING CARE SURGERY is a unique experience of a planned physical alteration encompassing three phases:

1. PREOPERATIVE PHASE  Begins when the decision to have surgery is made and ends when the client is transferred to the operating table.  The nursing activities associated with this phase include assessing the client, identifying potential or actual health problems, planning specific care based on the individuals needs and providing preoperative teaching for the client and support people. 2. INTRAOPERSTIVE PHASE  Begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit (PACU), also called post anesthetic room or recovery room.  The nursing activities related to this phases include a variety of specialized procedures designed to create and maintain a safe therapeutic environment for the client and the health care personnel.

3. POSTOPERATIVE PHASE  Begins when the admission of the client to the postanesthesia area and ends when healing is complete.  During the postoperative phase, nursing activities include assessing the clients response (physiologic & psychologic) to surgery, performing interventions to facilitate healing and prevent complications, teaching and providing support to the client and support people, and planning for home care. The goal is to assist the client to achieve the most optimal health status possible.

Types of Surgery According to Purpose 1. Diagnostic confirms or establishes a diagnosis. Ex. Biopsy of a mass in a breast 2. Palliative relieves or reduces pain or symptoms of a disease; it does not cure. Ex. Resection of nerve roots 3. Ablative removes a diseased body part. Ex. Cholecystectomy removal of gallbladder 4. Constructive removes function or appearance that has been lost or reduced. Ex. Breast implant 5. Transplant replaces malfunctioning structures. Ex. Hip replacement

According to the Degree of Urgency 1. Emergency Surgery is performed immediately to preserve function or the life of the client. Ex. Surgeries that control internal haemorrhage or repair a fracture. 2. Elective Surgery is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the clients life. Ex. Hip replacement surgery

According to the Degree of Risk 1. Major Surgery involves a high degree of risk, for a variety of reasons. It may be complicated or prolonged, large losses of blood may occur, vital organs may be involved or postoperative complications may be likely. Ex. Organ transplant 2. Minor Surgery normally involves little risk, produces in a day surgery. Ex. Breast biopsy