*insert notes sa fb live lecture*

FB LIVE LECTURE

4 Main Principles of Aseptic ● Know what is sterile

Technique ● Know what is not sterile
● Keep the two apart
● Remedy contamination immediately.

I. Supplies a. All articles to be sterilized should be clean and free from foreign particles, hair,
dust, or discharge of any kind.
b. All materials must be sterile before it comes in contact with a sterile area.
Sterilized articles become unsterile when they come into contact with any
unsterile object or material.
c. Dressings and supplies once removed from the sterile container are
considered contaminated.
d. Covers of containers, corks from bottles etc., when removed and placed on an
unsterile surface, should be placed with the sterile side up so as to prevent
contamination from the unsterile surface. When held in, they should be held
with the sterile side down. This helps to keep air contamination to a minimum.
e. If in doubt as to the sterility of an article, it should be considered unsterile. If in
doubt, leave it out.
i. If a sterile – looking package is in a non-sterile area, it should be
considered unsterile.
ii. If the actual timing of an autoclave load is uncertain, it should be
autoclaved and re-timed.
iii. If an unsterile person brushes a sterile table, the table should be
considered unsterile.
f. Wrappers on sterile packages should be of a double thickness and of sufficient
size so that the package may be opened without contamination or
contaminating rather any part of the contents of the package.
g. Sterile packages should have identifications as to sterility and contents.
i. Sterile and unsterile articles should not be stored together.
ii. Sterile packages should be dated and marked with a moist heat
indicator to denote sterility. (proper labeling of the packer: name of
instrument, date packed, expiry date (2 weeks autoclaved); name of
the one who packed the instrument; the orderly who autoclaved the
pack.
h. The edges of anything that encloses sterile contents are considered unsterile.
i. In opening sterile packages, the ends of flaps are secured in the hand
so they do not dangle loosely.
ii. The last flap of a sterile package is pulled towards the person opening
the package thereby exposing package contents away from the
non-sterile hand.
iii. Flaps on peep-open packages should be pulled back not torn. To
expose sterile contents.
iv. If a sterile wrapper is used as a table cover, it covers the entire table
surface; only the interior and surface level of the cover is considered
sterile.
i. Tables are sterile at table level only.
i. The linen which falls over the side of the table should be discarded.
ii. If a suture falls over the side of the table, it should be cut off at table
height or discarded completely.
iii. Sterile tables are to be covered by peeling back the sterile cover. It is
dragged up from below the table level.
j. Wet areas are to be considered contaminated. Moisture may cause
contamination.
i. If a solution soaks through a sterile area to an unsterile area, the
sterile area becomes contaminated.
ii. A damp area on a sterile table should be covered with an adequate
amount of sterile linen.
 iii. Draping should be done over a dry area only. If an area is wet from
preparing the patient, a dry unsterile sheet is put down before placing
the sterile drapes.
iv. Petroleum jelly and lubricating jelly should be put on a towel or sponge
on the sterile table. Wet ampoules and suture packages and tubes
should be kept in a container.
v. Moist sponges or packs should be kept in a basin or on a dry towel.
vi. Sterile packages should be laid on clean dry surfaces only.
vii. The linen should be put away only if it is cool and dry. Warm packages
become damp from steam condensation when in contact with a cold
shelf.
k. Sterile drapes or towel clips should not be removed once they are placed.
i. Once a clip is placed through sterile drape, it reaches an unsterile
layer below and on being removed, it passes from the unsterile area
back through the sterile area.
l. Special precautions must be used when operative areas are considered
grossly contaminated.
i. Any infected tissue or purulent fluid is considered contaminated.
ii. The contents of the large intestines and the rectum are considered
contaminated.
m. Equipment should not be transferred from one case to another after the initial
incision has been made.
i. Nothing from the table can be used on another case or placed with
sterile articles not coming from the same case

II. Personnel a. Clean clothing must be worn by all operating room personnel.
i. Clean scrub dresses are worn by all female personnel; clean scrub
suits are worn by all male personnel. This should be changed daily or
more often if necessary.
ii. Hair should be covered completely by a cotton head piece.
iii. Operating room attire should not be worn outside of the operative area.
iv. Shoes should be kept clean.
b. Gowns are considered sterile only from the waist to shoulder level, in front and
the sleeves.
i. Sterile persons keep hands in sight and at or above waist level.
ii. Hands are kept away from the face with elbows close to one side.
iii. Arms are never folded because there may be perspiration in the
axillary region.
iv. Items dropped below waist level are considered unsterile and must be
discarded.
c. Persons who are sterile touch only sterile items or areas; persons who are not
sterile touch only unsterile items or areas.
i. The sterile team members maintain contact with the sterile field be
means of sterile gowns and gloves.
ii. A sterile person should allow wide margin of safety when passing
unsterile areas.
iii. Supplies for sterile team members reach them by means of the
circulating nurse opening the wrappers on sterile packages.
iv. When draping tables or patients, care must be exercised to avoid
touching unsterile areas.
d. Unsterile persons avoid reaching over a sterile field; sterile person avoids
leaning over an unsterile area.
i. The circulating nurse never reaches over a sterile field to transfer
sterile items.
ii. In pouring solution into a sterile basin, the circulating nurse holds only
the lip of the bottle over the basin to avoid reaching over unsterile
area/field.
iii. The circulating nurse stands at the distance from the sterile field to
adjust the light over it to avoid microbial fall out over the field
iv. The surgeon turns away from the sterile field to have perspiration
removed from his/her eyebrows.
 v. The scrub nurse sets basins or glasses to be filled at the edge of the
sterile table; the circulating nurse stands near this edge of the table to
fill them.
vi. The scrub nurse drapes a non-sterile table toward her first to protect
her gown.
vii. The scrub nurse stands back from a non- sterile table when draping it
to avoid leaning over an unsterile area.
viii. Sterile persons do not lean over unsterile wall.
e. Sterile persons keep well with in the sterile area.
i. All personnel should face sterile areas. When passing other persons
use back-to-back and front-to-front technique.
ii. A sterile person turns his or her back to a non-sterile person or area
when passing.
iii. Sterile persons stay within the sterile field. They do not wander around
or go outside the room.
f. Skin cannot be sterilized. It should be made as clean as possible.
i. The patient’s skin over the operative area is shaved and cleansed, and
is then prepared in surgery.
ii. All personnel scrub their hands and arms thoroughly before sterile
gowning and gloving.
iii. Nurses and doctors gown and glove without touching the outside of the
gown and gloves with their skin.
iv. The knife used for the initial incision is discarded from the sterile field.
g. Sterile persons keep contact with sterile areas to a minimum.
i. They do not handle instruments and supplies unnecessarily.
ii. They do not lean on sterile tables and on a draped patient.
iii. They do not brush against sterile tables or draped areas.

INCISION ● A cut or wound of the body tissue.

○ To know the extent and the area to be prepared.
○ To prepare the gadgets necessary for positioning the patient.

For the Scrub Nurse

A. Knowing the incision
○ To serve as guide for draping the operative site.
○ To have the correct instruments and supplies available.
○ To be able to assist the surgeon effectively and efficiently.

● Considerations in the Choice of Incision

○ Type of Surgery (Anatomical Location)
○ Maximum exposure
○ Ease and speed of entering (for emergency surgery)
○ Possibility of extending the incision
○ Maximal postoperative wound strength
○ Minimal postoperative discomfort

Anatomical Location of the Abdomino-Pelvic Organs Using the Nine Regions of

the Abdomen
● Right Hypochondriac Region
○ Main right lobe of liver
○ Gallbladder
○ Common Bile Duct
○ Part of the hepatic flexure
● Epigastric Region
○ Part of the esophagus
○ Part of the stomach
○ Part of the duodenum
○ Part of the liver
○ Body of the Pancreas
● Left Hypochondriac Region
 ○ Fundus of the stomach
○ Tail of the pancreas
○ Spleen
○ Part of the splenic flexure
● Right Lumbar Region
○ Right kidney
○ Upper portion of the right ureter
○ Fallopian tube and ovary
○ Ascending colon
● Umbilical Region
○ Transverse
○ Duodenum
○ Jejunum
● Left Lumbar Region
○ Left kidney
○ Upper portion of the left ureter
○ Left fallopian tube and ovary
○ Descending colon
● Right Iliac Region
○ Appendix
○ Cecum
○ Lower portion of the right ureter
○ Part of the ileum
● Left Iliac Region
○ Sigmoid colon
○ Lower portion of the ureter

SKIN PREPARATION ● Is the removal of as many bacteria as possible from the patient’s skin through
shaving, mechanical washing and chemical washing.
● Purpose: to reduce the number of microorganisms in the field of operation
thereby preventing infection.
Special Considerations:
● To determine the area to be shaved and its extent, know the operation to be
done, the organ involved and its location and the proposed incision.
● Practice modesty and provide privacy
● Ask the patient’s permission in cutting the eyelashes and hair
● Examine the area to be shaved for any signs of irritation or any abnormal
conditions. Report this to the nurse on duty.
 ● Do not cut the patient’s skin
● In abdominal operations, pay particular attention to the umbilicus.
● Shave the operative site the day or the night before the operation (this is done
at the ward)
● In shaving, follow the direction of the growth of the hair while the free hand
exerts an opposite force by pulling the skin to the opposite direction.
○ To make shaving less painful.
○ To shave off the hair thoroughly from the skin
● If a wound is present on the area to be shaved, start from the clean area to the
dirty area.
● Expose the area to be shaved 6-8 inches from the probable line of incision
● Use sponges saturated with liquid soap to soften the hair and adhering dirt,
concentrate on the clean area first before going to the dirty area.

Types of Operation Areas to Prepare

Eye operation ● Cut the eyelashes of the affected eye. This is done in operating room. Use a
small straight eye scissors (Steven’s) clean with alcohol and apply Vaseline.
● No shaving is done unless the patient has moustache. With hairy face or hairy
nose.

Nasal and Sinus operation ● Shave 2 ½ inches around the ear

Ear operation ● Anteriorly shave from the chin down to the nipple line. Laterally shave from the
Neck operation patient’s hairline to the sides of the neck including the shoulders and axilla.
● Posteriorly, shave from the hairline down to the level of the clavicle.

Chest operation ● Shave from the base of the down to the waistline including the axilla and inner
aspect of the arm. Posteriorly, shave from the shoulder line down to the waist
attending 2 ½ beyond the spinal column.

Abdominal and Pelvic ● Shave from the nipple line down to the symphysis, pubis, vulva, perineum and
operation the thighs 2 inches from the groin. Include the sides or flanks of the patient.

Kidney operation ● Anteriorly shave from the nipple line down to the perineum from side to side
and posteriorly on the affected side, shave from the subcapular area down to
the buttocks and 2 inches beyond the spinal column.

Vaginal, Scrotal and Rectal ● Shave the waistline to the perineum. Include the anterior and inner aspects of
operations the thighs 6 inches from the groin. Posteriorly, shave the entire buttocks. Pay
particular attention to the hair between the folds of the buttocks and anus

Lower extremity ● If the operations are at the distal portion, clean from 2 inches above the knee,
all around the extremity to the toes. If the operations is at the knee or little bit
above or below it, clean the entire extremity from the groin to the toes. Pay
particular attention to the interdigital spaces

Upper extremity ● If the operation is at the distal portion of the arm, clean from 2 inches above
the elbow to the fingers all around. If the operation is at the elbow or a little
above or below it, shave from the axilla to the fingers and all around the
extremity.

OPERATING ROOM TEAM

Members Sterile:
● Surgeon
● Assistant to the surgeon
● Scrub Nurse

Unsterile
● Anesthesiologist
● Circulating Nurse
Behavioral Objective ● Identify the operating room team members
● Enumerate each team member's responsibility
● To define the roles of the team members in giving total care to the patient who
is undergoing a surgical procedure.

SUBDIVISIONS OF A. The Scrubbed Sterile Team

OPERATING TEAM ROOM ● The members of this team scrub their hands and arms. They don sterile gowns
ACCORDING TO THE and gloves and enter to the sterile field and handle only sterile items.
FUNCTION OF ITS ● Composed of the following:
MEMBERS ○ Operating Surgeon
○ Assistant/s to the surgeon
○ Scrub Nurse
B. The Unscrubbed Unsterile Team
● The members of this team do not enter the sterile field(A sterile field is an area
created by placing sterile surgical drapes around the patient's surgical site and
on the stand that will hold sterile instruments and other items needed during
surgery.).
● They function outside and around it. They must assume responsibility for
maintaining sterile technique during the operation, but they handle supplies
and equipment not considered sterile. Using the principles of aseptic
technique, they keep the sterile team supplied direct patient care and handle
other requirements that may come up during the operation.
● Composed of the following:
○ Anesthesiologist
○ Circulating Nurse

DUTIES AND RESPONSIBILITIES OF EACH TEAM

A. The Scrubbed 1. Surgeon

Sterile Team ● He serves as the leader of the team.
● He must be certain that all team members are aware of what is needed during
the procedure and that all necessary equipments and instruments are
available.
● He performs the surgery

2. Assistant to the surgeon

● He may be a surgeon, a resident, an intern or a clerk.
● He assists the surgeon during the surgery in any way the surgeon requests.
● He holds retractors in the wound to expose the operative site.
● He places clamps on blood vessels.
● He assists in suturing and ligating bleeders.

3. Scrub Nurse
● Sets up sterile supplies and instruments
● Assists the surgeon as needed throughout the surgery.
● Assists in gowning and gloving the surgical team
● Assists in draping the patient and the field
● Keeps accurate needle/instrument count( which is very important)
● Supplies sterile dressing materials
● Discard soiled linen into hamper after checking it for instruments.
● Cares for all instruments and supplies left after case.

B. The Unscrubbed 1. Anesthesiologist

Unsterile ● a physician who specializes in anesthesiology.
● Gives and controls the anesthetic for the patient
● Must see to it that all the equipment and supplies necessary for the induction of
anesthesia are available.
● Determines when the surgeon or circulating nurse may proceed with
positioning and preparing the operative site.
● Monitors the patient's vital signs during the operation.
● Keeps the surgeon aware of the patient's condition.
 ● Determines when the patient may be moved to the post-anesthesia recovery
stretcher after the operation has been completed.

2. Circulating Nurse
● Functions as the overseer of the room during the procedure to maintain
sterility.
● Assists the entire team and the patient.
● Sends for patient at appropriate time.
● Receives, greets, identifies patient.
● Checks chart for completeness.
● Assists patient in moving safely to operating room table.
● Assists Anesthesiologist when requested; stays with the patient during
induction.
● Ties scrubbed members' gowns.
● Checks operating room lights on at appropriate time and adjusts when needed.
● Prepares operative site.
● Connects catheter to drainage bottle, or catheterize if desired by the surgeon.
● Connects suction tubings to suction machine, connects cautery cord to cautery
machine.
● Position the patient as ordered by the Anesthesiologist after the induction of
anesthesia.
● Supplies foot stools if needed by the surgical team.
● Watches foreheads of the sterile team for perspiration.
● Fills out required operative records completely and legibly.
● Remains in the room as much as possible to be constantly available.
● Watches progress of surgery, anticipates needs, and reacts quickly to
emergency.
● Sees that the surgical team is supplied with every. Necessary item to perform
the operation efficiently.
● Uses equipment and supplies economically and conservatively.
● Directs cleaning of the room and preparations for the next operation

DUTIES AND 1. Before the SURGEON arrives

RESPONSIBILITIES OF ● Do a complete scrub according to accepted practice.
SCRUB NURSE ● Gown and glove, wipe powder off gloves before handling sterile items.
● Drape tables as necessary according to standard procedure.
● Move remaining contents of drape pack to the corner of instrument table if they
are not preset on table drape in a convenient place.
● Drape the Mayo stand (both the frame and the tray)
● Leave large solution basin in ring stand and tray remainder of the basins to the
instrument table.
● Count sponges, surgical needles and other sharp instruments with circulating
nurse according to established policy.
● Put blades on knife handles
● Prepare sutures in sequence in which the surgeon will use them, secure
surgical needles and sharps after completing count with the CN.

2. After SURGEON and ASSISTANT(s) scrub

● Gown and glove the surgeon and assistant(s) as soon after they enter the
room as possible.
● Assist in draping the patient, according to the routine procedure
● Bring Mayo stand into position over patient after draping is completed
● Lay a towel or magnetic pad for instruments below fenestration (opening) in the
drape.
● Attach suction tubing and electrical (surgical) cord, if either or both are to be
used, to drape with a non-performing clamp.

3. During the OPERATION

● Pass skin knife to the surgeon and hemostat to assistant.
● Hand up towels or hooks for fastening them to skin, if plastic drape has not
been applied as the first drape as soon as the subcutaneous bleeders have
 been ligated.
● Watch field and try to anticipate the surgeons need.
● Pass instruments in a decisive and positive manner.
● Keep two clean sponges or ta pes on the fields.
● Save and cure for all tissue specimens according to policy/procedure.
● Maintain sterile technique.

4. During CLOSURE
● Count sponges, sharps and instruments with CN before surgeon begins
closure of the wound, in accordance with established count procedures.
● Clear off Mayo stand, as time permits, leaving a knife handle with Made tissue
forceps scissors, four hemostats and two Allis.
● Have a damp sponge ready to wash blood from are surrounding the incision as
soon as closure of the skin have completed.
● Have dressings ready.

Precautions and Techniques for the Scrub Nurse

● The scrub nurse should know the various steps of the different operations so
that she may keep one step in advance of the surgeon at all times.
(ANTICIPATION)
● The scrub nurse may pass the instrument to the surgeon with her right hand, or
the one nearest the operative field.
● When passing the instrument, it should be held at the shank between the
cushions of the thumb and first two fingers, with the tip visible and the handle is
free for the surgeon's palm
● The curve of the instrument goes with the curves of the surgeon’s hands
● By a slight turn of the wrist, the rings of instruments' handle are gently rung
over the surgeon's finger
● Tissue and thumb forceps are held with the tip down
● Slightly soiled instrument should be wiped off with a wet sponge to remove all
free fatty substances and bloods, they should then be returned to proper
positioning
● Instruments tables should never be in a disorderly state during an operation so
that the scrub nurse can work smoothly and with speed
● Impaired instruments should never be passed to the surgeon.
● Any instruments and supplies that have come into contact with contaminated
areas must be discarded. They should be lifted from the field with transfer
forceps or received by the kidney basin and should never be touched with the
gloved hands.
● The scrub nurse should be familiar with surgeon's hand signal.

DUTIES AND ● The circulating role is a major one for perioperative nurses. He or she
RESPONSIBILITIES OF assesses the client preoperatively, planning for optimal care during the surgical
CIRCULATING NURSE intervention, coordinating all personnel within the operating room. The
circulator does not wear sterile clothing and can go in and out of the operating
room.

1. After the SCRUB PERSON scrubs

● Fasten back of scrub person’s gown.
● If tray of instruments is in the sterilizer in the sub sterile room, sterile lifting
handles must be used to bring tray from sterilizer to a sterile surface.
● Open packages of sterile supplies, such as syringes, suction tubing, sutures,
sponges and gloves
● Flip suture packets onto instrument table, or open over wraps for scrub person
to take packets
● Pour solution, (usually normal saline) into the round basin for sponges on
instrument table, and into the splash basin in ring stand will be needed
● Count sponges, sharps and instruments with the scrub nurse. (SOP)

2. After PATIENT arrives

 ● Greet and identify patient, introduce yourself if no pre assessment.
● Check nursing care plan and patient’s chart for pertinent information, including
consent.
● Be sure that patient’s hair is covered with cap to prevent dissemination of
microorganisms, to protect if from being soiled, and to prevent static spark near
the anesthesia machine.
● Assist patient in moving onto the operating table (good BM).
● Apply restraint straps over legs and secure arms (put blanket).
● Help anesthesiologist to PRN apply to apply and connect monitoring devices,
headsets for music, etc.
● Assist anesthesiologist, surgeon or assistant PRN when IV will be started.

3. During induction of GENERAL ANESTHESIA

● Stay in room and near patient to comfort him or her and assist anesthesiologist
in the event that excitement or any other contingency occurs.
● Be as quiet as possible.

4. After patient is ANESTHESIZED

● Re-position patient only after anesthesiologist says the patient is anesthetized
to extent that he/she will not be disturbed by being moved or touched.
● Attaché anesthesia screen and other table attachments as needed
● Note patient’s position to be certain all measures for his or her safety is
observed
● Place inactive electrode pad or plate in contact with patient’s skin, if electrical
unit is to be used to ground the patient properly.
● Expose appropriate are for skin preparation.
● Turn on overhead spotlight over site of incision.

5. After SURGEON and ASSISTANT(s) scrub

● Assist with gowning
● Observe for any break in technique during draping
● Assist scrub nurse in moving Mayo stand and instrument table into position,
being careful not to touch drapes
● Focus overhead operating light on site on incision, unless sterile handles will
be used
● Set platforms for team members who need them or place stools in position for
surgeons who prefer to operate seated
● Position kick buckets on sides of operating table and splash basin, if used near
surgeon
● Connect suction if necessary
● Connect electro-surgical electrode cord or any other electrical equipments to
be used

6. During OPERATION
● Be alert to anticipate needs of the sterile team.
● Stay in room.
● Keep discarded sponges carefully collected, separated by sizes and counted.
● Assist in monitoring blood loss.
● Obtain blood products for transfusion if necessary from refrigerator.
● Know condition of patient at all times.
● Prepare and label specimens for transportation to the laboratory.
● Pathologic specimens should not be allowed to dry out.
● Complete patient’s chart, permanent operating records and requisitions of
laboratory tests or chargeable items as required.
● Be alert to any breaks in sterile technique.

7. During CLOSURE
● Count sponges, sharps and instruments with scrub nurse.
● If another patient is scheduled to follow, ask phone station 45 minutes before
scheduled time of operation for pre-op meds to be given, transport patient in
holding area.
 ● Prepare for room clean up so minimal time will be expended between
operations.
● Send for PACU stretcher or bed.
● Secure IV solutions bag on a standard to avoid fall or break.
● Be sure chart and other records including NCP accompany patient.
● Have ICU nursing assistant help transport patient to the unit.

BASIC INSTRUMENTS

Parts of an Instrument ● Tip

● Serrated Jaw
● Box lock
● Shank
● Ring handle

Classifications of Instruments and their Uses

1. Cutting or Dissecting a. Scalpel / Skin knife

● are designed for incising the skin and for sharp dissection
● Sizes:
1. Blade holder #3
○ this is fitted for blade# 10, 11(stab knife), 12(hook
knife), 14, 15 and above up to below size #20
2. Blade holder #4
○ this is fitted for blade nos. 20 and above

b. Scissors
● The blade of scissors may be straight, angled, or curved, as
well as either pointed or blunt at the tips . The handle may
be long or short. Some scissors are used only to cut or
dissect tissues.
● To maintain sharpness of the cutting edges and proper
alignment of the blades, scissors should be used only for
their intended purpose.
● Curved / angled blades are needed to reach under/around
structures.
● Long handles are used to reach deep into body cavities.
1. Mayo straight
○ Known as suture scissor. Used to cut suture
2. Mayo curve
○ Known as tissue scissor. Used to cut tough tissues
3. Metzenbaum small (curved or straight)
● used to cut delicate tissue

Blades
● # 10
○ Is used most often. It has a rounded cutting edge
along one side and fits on # 3, 7, & 9 handles.
● #11
○ Has a straight edge that comes to a sharp. Fits on #
3, 7, & 9 handles.
● #12
○ Is shaped like a hook, with the cutting edge on the
 inside curvature. It fit on # 3, 7, & 9 handles.
● #15
○ Has a smaller and shorter curved cutting than # 10.
Fit on # 3, 7, & 9 handles. This # 15 blade has the
same shape but is smaller for tiny incisions such as
those some pediatric procedures.
● #20, 21, & 22
○ Have the same shape of that # 10 but are larger,
they fit on # 4 handle
● #23
○ Has curved cutting edge that comes to more of a
point than
● # 20, 21, & 22 blades.
○ Fits on # 4 handle.
● Wire scissors
● Bone cutters
● Bone roungers
● Chisels
● Osteotomes
● Dermatomes
● Bone saws
● Rasps
● Files

2. Clamping and Occluding used to apply pressure and used to control the flow of fluid, usually
blood and for occluding blood vessels
a. Peritoneal Forceps
● also known as: straight clamp and halstead
b. Kelly forceps
● Also know as round nose.

a. Curved kelly
● Used to clamp off vessels or pieces of tissue such as aorta
or uterus and an all-purpose hemostat.
b. Straight kelly
● Used to clamp off superficial arteries, vessels on the
muscle layers and an all-purpose hemostat. Use also in
clamping umbilical cord immediately following delivery of
baby.

a. Babcock(short/long)
● use to grasp delicate tissue (intestine, fallopian tube, ovary)

b. Kocher/ochsner
c. Allis forceps(short/long)
● has a sharp teeth to hold tissue firmly but can cause
damage. So used only on tissue which will be excised.
● Use to grasp tissue.
● Judd-allis – holds intestinal tissue
● Heavy allis – holds breast tissue

d. Towel clips
● Use to keep towels which restrict the surgical field attached
to the patient. Used to hold towels and drapes in place.

e. Tenaculum

4. Exposing / Retracting
Soft tissues, muscles and other
structures should be pulled aside for
exposure of the surgical site
f. Bone Holders
g. Stone forceps – Randal forceps
h. Needle Holder
● Used to hold suture needles (positioning the needle on the
jaw part) firmly and push them through tissue. It is also
used to secure scalpel blades to handles.
i. Tissue Forceps
i. Thumb forcep
○ Used for precision holdings. Used to pick up delicate
tissues for suturing.
ii. Tissue Forceps
○ Used to grasp tough tissue (fascia, breast). Forceps
may either have many teeth or a single tooth. Single
tooth forceps are also called “rat forceps”.
iii. Russian Forceps
○ They have serration up the tips, allowing a better
grasp of tissue with minimum trauma. Used for
smaller holds.
iv. Adson Forceps with teeth
○ These are used for any heavy duty clasping such as
with the skin and suturing. Used to grasp the skin.
Known also as Dura forceps.
v. Adson w/o teeth
○ Used to grasp delicate tissue.
vi. DeBakey Forceps
○ Used to grasp delicate tissue, particularly in
cardiovascular surgery.
Types:
1. Handheld: are usually used in pairs and they are held by the 1st
and 2nd assistant.
E.g. Deaver, army navy / skin retractor, Richardson.
a. Malleable/Ribbon Retractor
● Used to retract deep wounds. Maybe bent to various shape.
b. Deaver retractor
● Is used to retract deep abdominal or chest incisions.
Available in various widths.
c.Richardson Double-Ended Retractor
● It is used to pull layers of tissues aside in deep abdominal
or chest incisions to better visualize the surgery site.
d.Army Navy/Skin retractor
● It is held at one to retract shallow or superficial incisions.
e. Rake retractor
2. Self-Retaining: holding devices with 2 or more blades can be
inserted to spread the sedges of an incision and hold them apart.
a. Gelpi retractor (self-retaining)
● Used to retract shallow incisions.
b. Balfour with 3rd blade (self retaining)
● Used to retract wound edges during deep abdominal
procedures.
c. Weitlaner retractor (self retaining)
● Used to retract shallow incision. It is used when soft tissue
must be held opened, it can also be used when soft tissue
is to be held separate and with a space between the soft
tissue and bone
 d.Rib spreader

SUTURING a. Needles
b. Needle holder
● Used to grasp and hold curved surgical needles. It
resembles hemostatic forceps.
● It has short, sturdy jaws for grasping a needle without
damaging it or the suture material.
● The handles may be long to facilitate needle placement in
surgical site such as the chest or pelvis.
c. Stapling devices
● These are short bands of malleable with points that pierce
the skin. They are easy to sterilize, good in infected wound.
They are very quick to apply and good for use in skin

Orthopedic-surgery instruments a. Periostial elevator

● This is a screwdriver looking device which is used to lift the
periosteum from the bone during orthopedic procedures.
b. Mallet
● All purpose instruments often used to help with chiseling in
orthopedic procedures.
c. Chisel
● A straight chisel used with a mallet to help cut and shape
bones.
d. Rounger
● Heavy duty cutting plier-like instruments used to remove
bone. Used when you need to get to something deep to
bone, such as in a hemilaminectomy.
 SURGICAL HAND WASHING AND DRYING OF HANDS

● Is the removal of as many as bacteria as possible from the hands and arms by mechanical washing
and chemical disinfection before taking part in a surgical procedure.
● Purpose: Surgical scrubs help prevent the possibility of contamination and infection of the operative
wound by bacteria on the hands and arms.

Points to Remember In Surgical Scrub

● Rinse as often as possible using one direction only. Start from the fingertips going to the arm taking
care not to touch the faucet and the sink.
● A person with cut and burn should not scrub because of the high bacterial count.
● The hands and arms can never be rendered sterile no matter how long or how strong the antiseptics.
● Surgical scrub is most effective when firm motion is applied. Short horizontal or circular stroke could
be used.
● Use an ample supply of antiseptics.
● Since the hands are to be cleaner than any other area, after the initial hand wash, they are held
higher than the elbows during the rest of the procedure to prevent water from running back the
scrubbed hands.
Points to Remember in Drying the Hands( BEST technique how to don your gloves easily is to dry
your hands well)
● Reach down onto the sterile package and pick up the towel. Take care that water does not drip onto
the contents of the pack.
● Open the towel out full length. Be careful not to touch the towel to the non sterile scrub suit.
● Dry both hands, then one arm on one end of the towel; use the opposite end of the towel for the other
arm.
● To dry an arm, hold the towel in the opposite hand, and using an oscillating motion of the arm, draw
the towel up to the elbow.

PREPARATION

1. Attend to personal needs Some operations are long that’s why physiologic
needs should be taken care of before a procedure

2. Adjust cap and mask properly. Hair should be

confined in the cap and the mask should
cover mouth, nose and chin.

3. If your sleeves are long, roll them 3 inches

above the elbow.

4. Remove jewelry. Check hand for cuts and Cuts and burns can be breeding grounds for
burns and make sure that your nails are cut bacteria. Keeping nails short prevents puncturing or
short. tearing the gloves.

DO NOT FORGET TO OPEN YOUR BRUSH (do not unwrap yet)

I. Surgical scrubbing

1. Perform medical handwashing. Wash hands

thoroughly with soap and water about 2
inches above the elbow for 1 minute
a. Wet: elbow > forearm > hand > fingers
b. Use elbow to “pump” soap
c. Lather soap
d. W- palm to palm
 e. A- palm to palm with fingers interlaced
f. A- palm to dorsal of hand w/ fingers
interlaced
g. S- knuckles
h. H- thumb- rotating manner
i. T- fingertips to palm of hand
j. E- wrist to elbows

****HANDS SHOULD BE ABOVE THE ELBOWS

2. Rinse hand thoroughly from fingers to elbows

3. Unwrap and get the sterile brush and wet the

brush

4. Hold the brush with your left hand, use your

right elbow to “pump” soap 1-2x on the brush
and make sure that the brush will not come in
contact with anything unsterile.

5. Perform scrubbing
a. FINGERS AND NAILS: 20 strokes
b. PALMS: 15 strokes
c. DORSAL OF PALM: 15 strokes
d. INTERDIGITAL SPACES: 15 strokes

6. Divide the forearm in 3 in increment. Scrub all

4 sides with 15 circular strokes each starting
from the lateral part of the forearm to the
posterior side. then , scrub elbow for 20
strokes

7. Rinse the brush, transfer to another hand and

put soap again.

8. Repeat 5-7 to other arm.

9. Allow water to drip from elbows Hands should be above the elbow.

10. Rinse hands and arms thoroughly

Fingers > hands> forearm> elbow

OPEN OR DOOR USING BACK

II. Drying of hands

1. Bend slightly, pick up hand towel and STEP BACK Always remember to step back to prevent
contaminating the sterile area

2. Grasp the corner of the towel and open it

lengthwise and make sure that the towel does not
touch unsterile parts of the body.

3. Hold hands and arms above the elbow and keep

the arms away from the body. Make sure that the
towel do not touch your sleeves

4. Hold one end of the towel with one of the hands,

 wrap the towel around the hand and use your free
hand to dry your 1)fingers 2) hand 3) forearm 4)
elbows in a rotating motion

5. Flip towel by grasping the other end and dry the

other hand in the same manner

6. Discard the towel into a linen receptacle or let the

circulating nurse take it from the distal end

GOWNING AND GLOVING TECHNIQUE (Self)

Donning and Gowning Techniques

● Sterile gloves may be donned by the open method or the closed method. Gloves are worn during
many procedures to maintain sterility of equipment and to protect a client’s wound.

OPEN METHOD
Purposes
● To enable the nurse to handle or touch sterile objects freely without contaminating them.
● To prevent transmission of potentially infective organisms from the nurse’s hands to clients at high
risk for infection.

A. Gowning

1. Use one hand to pick-up the entire folded Only touch the inside top layer
gown from the table, grasping the gown
through all layers

2. Step back and from the table into a clear area Provide wide margin of safety while gowning

3. Hold the gown in the rear neck and allow it to Be careful not to touch either the body or other
unfold unsterile items/objects

4. Grasp the inside front of the gown, just below

the eckband, unfold the gown, and keep the
inside of the gown toward the body

5. Keep the hands at the shoulder level and put
hands inside the shoulders of the gown
The circulating nurse will reach inside the gown to
the sleeve seams and pull the sleeves over the
hands and wrists. The back of the gown is securely
closed at the neck and waist with ties or fasteners.
Touch the outside of the gown only at the line of ties
or fasteners at the back

B. Gloving

1. Open the sterile glove wrapper while the Place the package of gloves on a clean, dry surface
hands are still covered by the sleeves ● Any moisture on the surface could
contaminate the gloves.

2. Pick the right hand glove with the left hand

holding it at the edge of averted cuff and
steps back from the field
3. Insert the right hand into the gloves and Keep the thumb of the inserted hand against the
explore the finger holes before inserting the palm of the hand during insertion.
whole hand completely, leaving the averted ● If the thumb is kept against the palm, it is less
cuff as is. likely to contaminate the outside of the glove.

4. Slip gloved right hand under the fold of the

averted cuff. Insert the left hand by exploring
the finger holes completely. Leave the folded
cuff

5. Make a pleat at the left cuff of the gown and

secure i place with right thumb

6. Slip four fingers of the right hand under the

fold of the glove and pull it up over the
pleated cuff of the sleeves. Fix gloe firmly

7. Repeat the procedure for the right hand.
Pick up the other glove with the sterile gloved hand,
inserting the gloved fingers under the cuff and
holding the gloved thumb close to the gloved palm.
● This helps prevent accidental contamination
of the glove by the bare hand.

DRAPING AND ARRANGING INSTRUMENTS IN THE MAYO TABLE

A. Draping the Mayo Table

1. Pick up sterile Mayo tray cover and slip

hands one at a time into the everted cuff and
unfold the other end into the antecubital fossa
of the arm to prevent falling below waist level

2. Stabilize the mayo tray by placing one foot at

the base, while sliding the mayo tray cover

3. Arrange the instruments on the sterile mayo

table according to a standard procedure

B. Mounting the blades on the blade holder

1. Grasp the blade at its strongest and widest A clicking sound indicates that the blade is properly
part (top portion) using the needle holder. in place
Pont the blade downward while slipping the
groove into the blade holder.

C. Placing the needle in the needle holder

1. Select a needle holder with jaws appropriate

for the size of the needle to be used

2. Clamp the body of the needle at the tip of the

needle holder one fourth to one-half away
from the eye or swaged area to the point

3. Lock the needle holder on the first or second

ratchet
D. Passing instruments/sponges

1. Passing a knife
a. Hold the blade holder to its handle
with the sharp edge facing down and
the tip of the blade towards the wrist,
never point it towards the surgeon.
The handle towards the surgeon.\
b. Keep the hand pronated with the
thumb opposed against the tip of the
index finger. Flex the wrist.

2. Passing an instrument A soft snap should be heard as the instrument come

a. Hold the instrument by the hinge and into contact with the awaiting hand of the surgeon
avoid entangling fingers in the rings.
The tip is visible pointing up and the
ring handle is free. The handle is
placed firmly and directly into the
waiting hand of the surgeon

3. Passing a needle holder with suture

a. Pass the needle holder with the
needle point up and the rings directed
toward the surgeon;s thumb when
grasped so that it is ready for use
without readjustment
b. Hold the free end of the suture while
passing the needle holder to the
surgeon so that the suture strand is
free and not entangled with the needle
holder. Hold the free end of the suture
in one hand while passing the needle
with the other hand

4. Passing sponges
a. Keep two sponges on the field. Put up
clean one before removing soiled
ones on an exchange basis

ANOTHER PERSON

A. Gowning

1. Open the hand towel and lay it on the Do not touch the surgeon’s hand
surgeon’s hand

2. Unfold the gown carefully, holding it at the

neckband

3. Keep the hands on the outside of the gow

and use the neck and shoulder areas of the
 gown as protection over the gloved hands,
offer the inside of the surface of the gown to
the surgeon.

4. Release the gown The surgeon holds his/her hands outstretched while
the circulating nurse pulls the gown onto the
shoulders and adjusts the sleeves so that the cuffs
are properly places. In doing so, only the inside of
the gown is touched at the seams

B. Gloving

1. Pick up the right glove and grasp it firmly with

the fingers under the everted cuff. Hold the
glove with the palmar side facing the surgeon

2. Stretches the cuff sufficiently for the surgeon

to introduce his/her hands. Avoid touching the
surgeon’s hand by holding out or abducting
them and exerts upward pressure as the
surgeons hand plunges his hand into the
glove

3. Unfolds everted glove cuff over the cuff of the

surgeon’s gown

4. Repeat procedures on the left hand

REMOVAL (of soiled garments)

The key to removing both sterile and non-sterile gloves is "Dirty to Dirty - Clean to Clean". That is,
contaminated surfaces only touch other contaminated surfaces: your bare hand, which is clean, touches only
clean areas inside the other glove.

A. Gown

1. Grasp the front of the gown at the shoulders

below the neckline after the circulator unties
the neck and back ties

2. Pull the gown downward from the shoulders,

turning the sleeves inside-out as it is. Pull off
the arms

3. Roll down the gown and discard it to the linen

hamper

B. Gloves

1. Remove the first glove by grasping the This keeps the soiled parts of the used gloves from
palmar side of the gloves of the nondominant touching the skin of the wrist or hand.
hand with the gloved fingers of the dominant
hand and pull it of inside out
2. Pull off the first glove completely by inverting
or rolling the glove inside out

3. Hold continuously the inverted removed glove Touching the outside of the second soiled gloves with
by the fingers of the remaining gloved hand. the bare hand is avoided
Plac the first two fingers of the bare hand
inside the cuff of the second glove.

4. Pull the second glove off the fingers by The soiled part of the glove is folded to the inside to
turning it inside out. This pulls the first glove reduce the chance of transferring any
inside the second glove microorganisms by direct contact.

5. Using the bare hand, remove gloves which

are now inside out, and dispose them in the
infectious trash receptacle

6. Perform hand hygiene