Perioperative Nursing

- refers to the nursing care provided in the total

surgical experience of the patient

- nursing care delivered to a patient before (pre),

during (intra) and after (post) surgery.
PHASES OF PERIOPERATIVE NURSING CARE

– Preoperative Nursing Care

– Intraoperative Nursing Care
– Postoperative Nursing Care
PRE-OPERATIVE PHASE
• From the time the decision is made for
surgical intervention until the transfer of the
patient to the operating table

INTRA-OPERATIVE PHASE
• From the time the patient is received in the
OR until admitted to the post anesthesia unit

POST-OPERATIVE PHASE
• Begins from the time of admission to the
PACU and ends when healing is complete
The over-all goal of nursing care
during the PRE-OPERATIVE phase
is to prepare the patient mentally
and physically.
The over-all goal of nursing care
during the INTRA-OPERATIVE phase
is to maintain client safety.
The over-all goals of nursing care
during the POST-OPERATIVE phase
are to promote healing and comfort,
restore the highest possible
wellness and prevent associated
risk.
 PREOPERATIVE NURSING CARE
OBTAINING INFORMED CONSENT
• The surgeon is responsible for obtaining the consent for
surgery.
• No sedation should be administered to the client before
the client signs the consent.
• Minors may need a parent or legal guardian to sign the
consent form.
• Older clients may need a legal guardian to sign the
consent form.
• The nurse may witness the client’s signing of the consent
form, but the nurse must be sure that the client has
understood the surgeon’s explanation of the surgery.
• The nurse needs to document the witnessing of the
signing of the consent form, after the client acknowledges
understanding the procedure.
 Arellano Medical Center
Legarda, Manila

Consent for Surgery

I hereby authorize Dr. ________________ and the staff of the hospital to perform
_____________, and as such additional operation(s) or procedure(s) as are considered
necessary on the basis of their being a threat to life found during the course of the said
operation.

The nature and purpose of the operation, the risk involved, and the possibility of
complication have been explained to me, in my dialect or in a language which I
understand. I acknowledge that no guarantee has been made as to the results that may
be obtained.

_________________ __________________
Signature of Patient Signature of Witness

_________________
Date and time
 (Continuation of the CONSENT form…)

This authorization must be signed by the next of kin of the patient in case the patient is a minor or
physically or mentally incompetent.

Patient is a minor. _____ years

Patient is unable to sign because ___________________________________________
_______________________________________________________________________.
------------------------------------------------------------------------------------------------------------------

I, _________________________ being the next of kin of ________________________

(Name in Print and Signature) (Name of Patient)

hereby authorize Dr. _____________________ and the staff of the said hospital to perform the
said surgery.

_______________________ _____________________________
Signature of Witness Signature of Next of Kin

_______________________ _____________________________
Date and Time Relationship to Patient
NUTRITION

• Review the physician’s orders regarding the NPO

status before surgery
• Solid foods and liquids usually are withheld for 6
to 8 hours before general anesthesia and for 3
hours before surgery with local anesthesia to
avoid aspiration
• Prepare to initiate an IV line and administer IV
fluids as prescribed
• Prepare to administer total parenteral nutrition to
clients who are malnourished, have protein or
metabolic deficiencies or cannot ingest foods
ELIMINATION

• If the client is to have intestinal or abdominal

surgery, an enema or laxative or both may be
prescribed the night before surgery.
• The client should void immediately before surgery.
• Prepare to insert a Foley catheter if ordered.
• If Foley catheter is in place, it should be emptied
immediately before surgery, and the nurse should
document the amount and characteristics of the
urine.
SURGICAL SITE

• Prepare to clean the surgical site with a mild anti-

septic soap the night before surgery as prescribed.
• Prepare to shave the operative site as prescribed.
• Hair should be shaved only if it will interfere with
the surgical procedure and only if prescribed.
PREOPERATIVE CLIENT TEACHING
• Inform the client about what to expect post-operatively.
• Inform the client to notify the nurse if the client experiences
any pain post-operatively and that pain medication will be
prescribed to be given as the client requests.
• Inform the client that requesting a narcotic after surgery will
not make the client a drug addict.
• Demonstrate the use of a patient-controlled analgesia* pump
if its use is prescribed.
• Instruct the client to use non-invasive pain relief techniques
such as relaxation, distraction techniques, and guided
imagery before the pain occurs and as soon as the pain is
noticed.
• The nurse should instruct the client not to smoke for at least
24 hours before surgery.
• Instruct the client in deep breathing and coughing techniques,
use of incentive spirometry, and the importance of performing
the techniques post-operatively to prevent the development of
pneumonia and atelectasis.
 Deep Breathing and Coughing Exercises

– Instruct the client that a sitting position gives

the best lung expansion.
– Instruct the client to breathe deeply 3 times,
inhaling through the nostrils and exhaling slowly
through pursed lips.
– Instruct the client that the third breath should be
held for 3 seconds; then the client should
cough deeply 3 times.
– The client should perform this exercise every 2
hours .
Administering Incentive Spirometry

– Instruct the client to assume a sitting or upright

position.
– Instruct the client to place the mouth tightly
around the mouthpiece.
– Instruct the client to inhale slowly to raise and
maintain the flow rate indicator between the
600 and 900 marks.
– Instruct the client to hold the breath for 5
seconds, and then to exhale through pursed
lips.
– Instruct the client to repeat this process 10
times every hour.
Incentive Spirometer
Instruct the client in leg and foot exercises to prevent
venous stasis of blood and to facilitate venous blood
return
Leg and Foot Exercises
Splinting of the Incision

– If the surgical incision is abdominal or

thoracic, instruct the client to place a pillow, or
one hand with the other hand on top, over the
incisional area.
– During deep breathing and coughing, the
client presses gently against the incisional
area to splint or support it.
• Inform the client of any invasive devices that may
be needed after surgery, such as nasogastric tube,
drain, Foley catheter, epidural catheter, or
intravenous or subclavian lines.

• Instruct the client not to pull any of the intravenous

devices, for they will be removed as soon as
possible.
PSYCHOSOCIAL PREPARATION

• Be alert to the client’s level of anxiety.

• Answer any questions or concerns the client may
have regarding surgery.
• Allow time for privacy for the client to prepare for
surgery psychologically.
• Provide support and assistance as needed.
PREOPERATIVE CHECKLIST
• Ensure that the client is wearing an identification bracelet.
• Assess for allergies.
• Review the preoperative checklist to be sure that each item
is addressed before the client is transported to surgery.
• Ensure that informed consent forms were signed for the
operative procedure, for any blood transfusions, for
disposal of a limb, or for surgical sterilization procedures.
• Ensure that a history and physical examination were
completed and documented in the client’s record.
• Ensure that consultation requests were completed and
documented in the client’s record.
• Ensure that prescribed laboratory results are documented
in the client’s record.
• Ensure that the electrocardiogram and chest
radiography reports are documented in the client’s
record.
• Ensure that a blood type, screen, type and
crossmatch is performed and documented in the
client’s record.
• Remove jewelry, makeup, dentures, hairpins, nail
polish, glasses and prostheses.
• Document that valuables were given to the client’s
family members or locked in the hospital safe.
• Document the last time that the client ate or drank.
• Document that the client voided before surgery.
• Document that the prescribed preoperative
medication was given .
• Monitor and document the client’s vital signs.
 Arellano Medical Center
Legarda, Manila

Preoperative Checklist

1. Was the consent for surgery signed properly? ________

2. Was the preoperative site well prepared? ________
3. Is the patient in proper OR attire? ________
4. Were dentures, jewelry and nail polish removed? ________
5. Are her/ his medicines/ OR supplies available and complete? ________
6. Were the pre-meds administered as ordered? ________
7. Has the patient voided before the pre-meds were given? ________
8. Vital signs before giving pre-meds:BP _____ Temp. ___ PR ___ RR ___
9. Vital signs after giving pre-meds: BP _____ Temp. ___ PR ___ RR ___
10. Date and time of operation _____________

Name of patient: _________________________

Sex: ___________ Age: __________

Checked/ Carried out by:

_______________________
NOD/ HN Sgnature
Clinical Area ___________
PREOPERATIVE MEDICATIONS

• Prepare to administer preoperative medications as

prescribed or on call to the operating room
immediately before surgery.
• Instruct the client about the desired effects of the
preoperative medication.
• After administering the preoperative medications,
keep the client in bed with the side rails up.
• Place the call bell next to the client; instruct the
client not to get out of bed and to call for
assistance if needed.
ARRIVAL IN THE OPERATING ROOM
• When the client arrives in the operating room, the
operating room nurse will verify the identification
bracelet with the client’s verbal response and will
review the client’s chart.
• The operating room nurse will confirm the
operative procedure and the operative site.
• The client’s chart will be checked for
completeness, reviewed for informed consent
forms, history and physical examination, and
allergic reaction information.
• Physician’s orders will be verified and
implemented.
• The intravenous line may be initiated at this time, if
prescribed.
• The anesthesia team will administer the prescribed
anesthesia.
- Done after patient has been anesthesized and
positioned on the operating table; skin of the
operating site and extensive area surrounding it is
mechanically cleansed again with an antiseptic
agent immediately prior to draping
SKIN PREPARATION

• Assess the client for sensitivity or allergies to scrub solution,

skin integrity, level of mobility and existing appliances,
catheters or other instrumentation.
• Review the chart for the surgery t be performed and review
the exact area to be prepped.
• Assess the client’s level of consciousness and mobility.
• Explain procedure to client and assess level of
understanding.
• Be sure that hairpins, jewelry, nail polish, contact lenses,
prostheses and dentures were removed.
• Assist client with the transfer from the wheelchair or bed to
the surgical table.
• Position the client for optimal access to the surgical site
according to institutional protocol.
• Cover with a blanket; used warmed covers, cover the hair if
required.
• Assemble the equipment needed.
• Remove rings and watch and wash hands and apply clean
gloves.
 The surgical prep sites follow, depending on the type of
surgery to be performed.

– HEAD AND NECK- The site extends from above the

eyebrows, over the top of the head, and includes the ears and
both anterior and posterior areas of the neck. The face and
eyebrows are not shaved.
– LATERAL NECK- Clean the external auditory canal with a
cotton swab. Anteriorly, prepare the side of the face, from
above the ear to the upper thorax to just below the clavicle.
Posteriorly, prepare from the neck to the supine including the
area above the scapula.
– CHEST SURGERY- The site extends from the neck to the
bottom of the rib cage and to the lateral midline. The shoulder
and arm of the operative side should be included.
– ABDOMINAL SURGERY- The preparation site extends from
the axilla to the pubis, extending bilaterally to the lateral
midline. All visible pubic hair should be shaved.
– PERINEAL SURGERY- Shave all pubic hair and the inner
thighs to the midthigh. The area starts above the pubic bone
anteriorly and extends beyond the anus posteriorly.
– CERVICAL SPINE SURGERY- Posteriorly from the top of the ears
to the waist. The area extends on each side to the midaxillary line.
– LUMBAR SPINE SURGERY- Posteriorly from the axilla down to
the midgluteal level of the buttocks. The area extends on each
side to the midaxillary line.
– RECTAL SURGERY- Shave the buttocks from the iliac crest down
to the upper third of the thighs, including the anal region. The area
extends to the midline on each side.
– FLANK SURGERY- Extends anteriorly from the axilla, down to the
upper thigh, including the external genital area. Posteriorly the
area extends from the midscapular to the midgluteal regions.
– HAND AND FOREARM SURGERY- The area includes the full
circumference of the affected arm, from the axilla to the fingertips.
– LOWER EXTREMITY SURGERY- The area includes the entire leg,
toes, and foot of the affected leg from the umbilicus anteriorly and
the top of the buttocks posteriorly.
– LOWER LEG SURGERY- The area to be prepared includes the
circumference of the entire region from midthigh to the distal toes
of the affected leg.
• Arrange for adequate light on the area to be
prepared.
• Using warm water, hold the skin taut and hold
the razor at a 45-degree angle. Shave the area
carefully by stroking in the direction of hair
growth. Rinse the razor carefully to remove
accumulated hair from the blade.
• Dry the client’s skin with a sterile towel.
• Clear the shaving supplies from the preparation
area.
• Apply sterile gloves and gown.
• Scrub the surgical site with an antibacterial cleaner.
Using a rotary movement to clean the skin, begin in
the center and gradually enlarge the area with each
rotation.
• Continue this process for 3-10 minutes as prescribed
by institutional policy,
• Clean any hidden areas in the surgical site ( the ear
canals, under the fingernails, the umbilicus) using
cotton swabs,
• Rinse the area with sterile water. Wait for the site to
dry or pat dry with a sterile towel.
• Cover the area with sterile drapes, leaving the
surgical site exposed.
• Evaluate and document.
PREPARATION OF THE HEAD FOR CRANIOTOMY
PREPARATION OF THE NECK FOR
OTOLOGICAL SURGERY
PREPARATION OF THE NECK & THORAX
FOR THYROIDECTOMY
 SURGICAL PREPARATION OF
UPPER EXTREMITIES AND TRUNK
FOR SURGERY
 Preoperative Preparation

Objectives:

1. Enumerate the principle of sterile technique.

2. Observe correct sterile aseptic technique in the operating room.
3. Discuss the different positions of the patient for surgery.
4. Discuss the principles of surgical asepsis.
5. Apply principles of asepsis in handling sterile technique.
6. Describe the operating room attire.
7. Explain the purpose of wearing operating room attire.
8. Define surgical scrub.
9. Enumerate step by step the correct procedures of surgical scrubbing.
10. State the purpose of gowning and gloving.
11. Differentiate between an open glove technique and closed glove
technique.
12. Observe and describe how an OR nurse does surgical scrub, gowning
and gloving.
13. Put on and remove sterile gown and gloves following accepted
principles.
 Activities

• Orient students to the physical set-up of

operating room, personnel, and policies.
• Practice surgical scrubbing in the skills
laboratory.
• Position patient in the OR table according to
surgeon’s preference.
• Perform surgical scrub, gowning and gloving
while observing the principles of surgical
asepsis.
 Operating Room Attire
Purpose: To provide effective barriers that prevent
the dissemination of microorganisms to the patient
and to protect personnel from infected patients
• Scrub dress/ suit
• Head cover
• Mask
• Sterile gown
• Sterile gloves
• Shoes
• Surgical glasses/ Visor
Scrub Suit
 Head Cover/
Surgical Caps & Hoods
Mask
Ways to Wear Masks
Wrong ways to wear a mask
Surgical Gowns
Sterile Gloves
Surgical Shoe Covers
Surgical Glasses/ Visor
Positions for Surgery
 Positions for Surgery
• Supine/ Dorsal – usual position for induction of
general anesthesia and for entering the major body
cavities
• Modified Trendelenburg – used for lower abdominal
surgery and some lower extremity surgery
• Reverse Modified Trendelenburg – used for upper
abdominal, neck and face surgery
• Lithotomy – used in operation requiring perineal
approach
• Prone – used in surgery on the posterior part of the
body
• Lateral – used for operation on the kidneys, lungs or
hips
• Modified Fowler’s – sitting position; used mostly in
neurosurgery
• Modified jacknife – for rectal surgery
Principles of Sterile Technique
Principles of Sterile Technique
Sterile field
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 one’s 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 following:
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 the
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
• The sterile technique is the basis of modern
surgery.

A. Sterile persons have scrubbed and are

gowned and gloved; Unsterile persons have
not. Persons who are sterile touch only sterile
articles. Persons who are not sterile touch
only unsterile articles.

All supplies for the sterile team members reach

them by means of the circulating nurse, through
the medium of sterile forceps or wrappers on
sterile packages.
B. Only sterile items are used within the sterile field.

Some items such as linen, sponges, or basins may be

obtained from the stock supply of sterile packages.
Others, such as instruments, may be sterilized
immediately preceding the operation and removed
directly from the sterilizer to the sterile table.

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. Known or potentially
contaminated items must not be transferred to the sterile
field, for example:

1. If sterile package is found in the nonsterile workroom

2. If uncertain about actual timing or operation of
sterilizer: Items processed in a suspect load are
considered unsterile.
3. If unsterile person comes into close contact with a
sterile table and vice-versa
4. If sterile table or unwrapped sterile items are not
under constant observation; if a sterile table or sterile
articles are left unguarded and uncovered for
more
than 30 minutes
5. If sterile package falls to the floor, it must then be
discarded.
C. 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 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. eg, when picking
up a gown, if the top of the gown drops below
waist level, it is discarded.
D. Tables are sterile only at table level.

1. Only the top of a sterile draped table is considered

sterile. Edges and sides of drape extending below the
table level are considered unsterile.
2. Anything falling over or extending over table edge,
such as sutures are considered unsterile and are
discarded. 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.
E. 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.
F. Unsterile persons avoid reaching over a sterile
field. Sterile persons avoid leaning over an
unsterile area.

1. The scrub nurse sets basin or glasses to be filled at

the edge of the sterile table. The circulating nurse
stands near the edge of the table to fill them.
2. The circulating nurse stands at a distance from the
sterile field to adjust the light over it.
3. The surgeon turns away from the sterile field to have
perspiration mopped from his brow.
4. The sterile nurse drapes a nonsterile table toward
self first to protect gown.
5. The circulating nurse, using sterile forceps, drapes a
table away from her first.
G. Edges of anything that encloses sterile
contents are considered unsterile. ex: the
edges of wrappers on sterile packages, caps
on solution bottles and test tube covers

1. Sterile persons lift contents from packages by

reaching down and lifting them straight up, holding
elbows high.
2. Steam reaches only the area within the gasket of
a sterilizer. Instrument trays should not touch the
edge of the sterilizer outside the gasket.
3. The circulating nurse peels the cover of a solution
bottle or test tube, the edge of the cover never
touches the lip.
4. If the instruments are boiled, the tray must not
touch the edge of the sterilizer when lifting it out.
H. 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.

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.
I. Sterile areas are continuously kept in view.
Inadvertent contamination of sterile areas must be
readily visible.

1. Sterile persons face sterile areas.

2. When sterile packs are opened in a room, or a
sterile field is set up, someone must remain in the
room.
J. Sterile persons keep 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 the
room.
7. Movement within and around a sterile area is kept
to a minimum to avoid contamination of sterile
items or persons.
K. Sterile persons keep contact with sterile areas to
a minimum.

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.
L. Unsterile persons avoid sterile areas.
A wide margin of safety must be maintained when
passing sterile areas.

1. Unsterile persons maintain at least one foot

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, eg, between sterile instrument tables.
4. Circulating nurse restricts to a minimum activity
near sterile field.
M. Destruction of the integrity of microbial barriers
results in contamination.
The integrity of a sterile package or sterile drape is
destroyed by perforation, puncture or strike-through
(soaking of moisture through unsterile layers to
sterile layers or vice versa- may transport bacteria
to sterile area). To ensure sterility:

1. Sterile packages are laid on dry surfaces.

2. If sterile packages become damp or wet, it is re-
sterilized or discarded. A package is considered
nonsterile if any 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 paper are permitted
to cool after removal from the sterilizer to avoid
steam condensation and resultant contamination.
6. Sterile areas are stored in clean dry areas.
7. Sterile packages are handled with clean dry hands.
8. Undue pressure on sterile pack is avoided to prevent
forcing sterile air out and pulling unsterile air into the
pack.
N. Microorganisms must be kept to an irreducible
minimum.
Perfect asepsis in the operative field is the ideal.
Although all the microorganisms cannot be
eliminated, this does not obviate the necessity for
sterile technique. It is generally agreed that:

1. Skin cannot be sterilized.

Skin is a potential source of contamination in every
operation.
 All possible means are used to prevent entrance of
microorganisms into wound.
Preventive measures include:
a. Transient and resident flora are removed from skin
around operative site of patient and the hands and
arms of sterile team members by mechanical
washing and chemical antiseptics. (shaved and
scrubbed)
b. Gowning and gloving of operating team is
accomplished without contamination of sterile
exterior of gowns and gloves. (without touching with
their bare hands)
c. Sterile gloved hands do not directly touch skin and
then deeper tissues.
d. If glove is pricked or punctured by a needle or
instrument, glove is changed immediately. Needle
or instrument is discarded from sterile field.
e. In draping, all the skin area is covered except the
site of incision.
f. All operators scrub their hands and arms.
g. Operators scrub between cases to remove
bacteria that may have emerged from the pores
with perspiration under the gloves.
h. The knife used for the skin incision is placed in a
specimen basin which thereafter is considered
contaminated.
2. Some areas cannot be scrubbed.
When the operative field includes the mouth,
nose, throat or anus, the number of
microorganisms is great. Various parts of the
body, such as the GIT and the vagina, usually are
resistant to infection from flora that normally
inhabit these parts.
The following steps may be taken to reduce the
number of microorganisms present in these areas
and to prevent scattering them:
a. Surgeon makes an effort to use a sponge only
once, then discards it.
b. The GIT , especially the colon, is contaminated.
Measures are taken to prevent spreading this
contamination.
- gastric route when possible
- cautery when cutting across a lumen
- colostomy is walled off from the operative site
when possible
- antibiotics given preoperatively
- septic routine clean-up after procedure on the
colon
3. Infected areas are grossly contaminated.
The team avoids spreading the contamination.

4. Air is contaminated by dust and droplets.

Examples of control measures:
- Masks are worn over the nose and mouth.(fit snugly)
- Talking is kept to minimum.
- Sneezing and coughing are avoided.
- Doors from corridors into the OR are kept closed.
- Floors are wet-mopped, not dry-swept as dust may
float in the air for a long time.
- OR attire is not worn outside the surgery suite.
- Wash hands before and after the care of each client.
 SUMMARY
Principles of Sterile Techniques

1. Sterile surface touching sterile surface means sterile.

2. Sterile surface touching un-sterile surface becomes

contaminated.

3. When there is doubt about the sterility of any item, it

must be considered not sterile.

4. Reaching across or above sterile with bare hands or

arms or other non-sterile item must be avoided.
5. Sterile materials must kept dry; moisture transmits
microorganism and contaminated.

6. Coughing, sneezing or unnecessary talking near or

over a sterile field must be avoided.

7. When wearing sterile gloves, hands must be kept

in sight, away from un-sterile objects and above
waist level.

8. The wrapper of a sterile pack must be opened,

away from the body, the distal flap first, the lateral
flaps next, and the proximal flap toward the body
last, thus it unnecessary to reach over the sterile
field.
9. The sterile zone is confined to the tabletop or to above
waist level. Anything that hangs, falls, or touches
below these levels is considered contaminated.

10.Any area of 1 inch or so surrounding the outer edge

of the sterile field must be considered un-sterile.

11.The sterile field must be kept in sight at all times. Do

not turn your back on it or leave. If you do, you cannot
be sure that it is still sterile.

12.The floor must be recognized as the most grossly

contaminated area. Clean or sterile items that fall on
the floor should be discarded or decontaminated.
 Parts of the Surgical Instrument

JAWS

RATCHET
TIP

BOXLOCK

FINGER RINGS
SHANK
 Functions of the Instrument Parts
• Finger Ringers: Provide place for the user to place
his fingers and grip the instrument securely
• Ratchet: Allows the instrument to be locked in place
• Shank: Connects the boxlock to the finger rings
• Boxlock: Hinge joint; controls the jaws of the
instrument
• Jaws: Along with the tip is the working part of the
instrument; may be smooth or serrated or cross-
hatched for grasping tissue or suture; can be
straight or curved
• Tips: Can be pointed or round; have teeth or no
teeth
Important Tips:
To identify and differentiate instruments:
- Look at the tip.
- Does it have teeth and what do the teeth look like?
- Is the jaw smooth or serrated?
- If the jaw is serrated, do the serrations run
horizontally or longitudinally?
- Do the serrations run the entire length or halfway
through the jaw?
 Blades

#10 #11 #12 #15

Use: For cutting the skin; for small puncture

incisions; for cutting tissue and blood vessels
 Scalpel handle
aka knife handle/ blade handle

Use: holding scalpel blade

 Needles

Use: For suturing; may be cutting or curved

 Needle Holder

*Jaw may have a groove

Use: For holding needle
 Towel Clip
aka towel clamp

Use: For securing towels and drapes; grasping

tissue; holding or reducing small bone fractures
Thumb forceps

Use: grasping tissue

 Tissue forceps
aka pick-ups; rat-tooth forceps

Use: For grasping tissue; closing wound

 Adson forceps
(plain) aka Adson dressing forceps

Use: grasping tissue

 Adson Tissue Forceps
(with teeth)

Use: grasping skin layer during wound closure

DeBakey Tissue Forceps

Use: grasping fine tissue

 Russian Forceps

Use: grasping tissue; aortic aneurysm plaque

 Sponge Forceps

Use: For holding sponges or grasping tissue

 Babcock

Use: grasping delicate tissue

(eg, fallopian tube, bowel, vas deferens)
 Allis

Use: grasping organ or tissue that is being removed

 Kocher
aka Ochsner

Use: grasping heavy tissue, eg, fascia

 Mixter
aka right angle

Use: clamping tissue; grasping a ligature around a

curve blood vessel for hemostatic purposes
 Mosquito Forceps
aka Halstead Hemostatic Clamp; stat

*can be straight or
curved; 5” long
Use: used for more
delicate tissues;
fine and small
hemostats used to
control the bleeding
of finer vessels
 Kelly Hemostatic Clamp

*5.5’’ – 7” long
*Heavy blades
*May be straight or curved
*looks like Pean clamp but is serrated only halfway
Use: clamping large blood vessels or tissues
 Pean
aka Mayo-Pean clamp

*5.5” – 9” long
* Can be straight or curved
* Looks like Kelly but jaws are fully serrated
 Crile Hemostatic Clamp
aka Hemostat

*5.5” , 6.5”, 7.5” long

* Can be straight or curved
Use: clamping large blood vessels or tissues
 Mayo Scissors
curved - dissecting scissors
straight – cutting scissors

*Heavy blades
Use: staight Mayo – cutting sutures, dressings and drains
curved Mayo – cutting or dissecting heavy tissue or muscle
 Metzenbaum Scissors
aka Metz

Use: cutting or dissecting delicate tissue

NOT used for cutting sutures, drains, heavy tissue
MAYO METZ
 Bandage Scissors

Use: cutting dressings and bandages

 Iris Scissors

Use: cutting and dissecting fine tissue

Army – Navy Retractor

*double-ended
*usually used in pairs
Use: exposing superficial wound
Richardson Retractor

Use: exposing wound

Richardson-Eastman Retractor

Use: exposing wound

Deaver Retractor

Use: deep retraction

Malleable Retractor
aka Ribbon

Use: exposing wound

Harrington Retractor
aka sweetheart; valentine

Use: exposing deep wound

 Balfour Retractor
aka self-retaining retractor; abdominal self-retracting

Use: deep abdominal retraction

Bladder Blade for Balfour Retractor
*double-ended
*usually used in pairs
Use: retracting superficial tissue
 Senn Retractor

double-ended
*usually used in pairs
Use: retracting superficial tissue
Hysterometer

Use:
 Tenaculum

Use: Grasping cervix

 Thomas Curette
aka Dull Curette

Use: scraping
endocervical and
endometrial linings
 Sims Curette
aka Sharp Curette

Use: scraping endocervical

and endometrial linings
Simpson Obstetrical Forceps

Use: delivering baby

Simpson-Luikart Obstetrical Forceps

Use: delivering baby

Naegele Obstetrical Forceps

Use: delivering baby

OTHERS
• Vaginal Speculum
• Bladder Retractor
• Dilator
• Sponge Forceps
• Russian Forceps
• Kocher/ Ochsner
• Babcock
• Allis
• Scissors
MINOR Set
MAJOR Set
 Surgical scrub
• used to remove debris from nails, hands, and
forearms
• reduce the numbers of transient and colonizing
microorganisms on the skin and
• inhibit rapid rebound growth of microorganisms
• decrease the client's risk for an infection should a
sterile glove tear or break

The skin on the nurse's hands and arms should be

intact (free of lesions) and the nails should be kept
short, clean, and healthy.
Surgical Scrub Procedure
A. Time Method
B. Counted Brush Stroke Method

*depends on the institution

 Time Method
Fingers, hands and arms are scrubbed by alloting a
prescribed amount of time to each anatomical area
and each step of the procedure.
A. Complete Scrub: 5-7 minutes; done
a. in the morning before the first gowning and
gloving
b. following a clean case, if gloves have been
removed inadvertently, before the gown
c. following a clean case, if gloves have had a hole
between them
d. following a clean case, if hands have been
contaminated in any other way
d. before an emergency case at anytime
B. Short Scrub – 3 minutes
• done following a clean case, if the hands and arms
have not been contaminated
• done to remove the bacteria that have emerged
from the pores and multiplied while the gloves were
on
 Brush Stroke Method
(for return demo)*

• A prescribed number of brush strokes, applied

lengthwise of the brush or sponge, is used for each
surface of the fingers, hands and arms. Scrub the
nails of one hand 30 strokes, all sides of each finger
20 strokes, the arms 20 strokes for each third of the
arm up to 2 inches above the elbow.
• Before each operation, all members of the surgical
team – that is, those who will touch the sterile
surgical field, surgical instruments or the wound –
should scrub their hands and arms to the elbows.
• Scrubbing cannot completely sterilize the skin, but
will decrease the bacterial load and risk of wound
contamination from the hands.
Surgical scrub items
 When scrubbing

• Remove all jewelry and trim the nails.

• Use soap, a brush (on the nails and finger tips) and
running water to clean thoroughly around and
underneath the nails.
• Scrub your hands and arms up to the elbows.
• After scrubbing, hold up your arms to allow water to
drip off your elbows.
• Clean clothing must be worn.
• Hair must be completely covered.
• Mask should be in place.
• Jewelry and earrings should be removed.
 Always ensure

• The water temperature is comfortable.

• The flow of water is gentle to avoid excessive
splashing.
• Hands are always held higher than the elbow.
Wear your cap and mask.
Turn on faucet with knee or foot control.
Get antiseptic soap/ solution.
Prewash hands and forearms.
Apply a liberal amount of soap/antiseptic onto hands
and rub hands and arms up to 2 inches above the
elbows.
• Rub palms against each other.
• Rub one palm of one hand to the back of the other
hand. Do the same to the other hand’s back.
• Forearms are done by stroking wrist in a circular
motion going upwards up to 2 inches beyond the
elbow.
• Do not return to the area you have already soaped.
• Rinse hands and arms so the water flows off at the
elbows.
Open prepackaged scrub brush if available.
Clean fingernails under running water.
Drop file into sink/ proper container when finished.
With brush in your dominant hand using a circular
motion, scrub nails and all skin areas of nondominant
and then dominant hand and arm using time or
counted brush stroke method (depending on hospital
policy).
Wet sponge of scrub brush to release antimicrobial soap
(Apply soap, if needed).
 Counted Brush Stroke Method
With brush in your dominant hand using a circular
motion, scrub nails and all skin areas of nondominant
hand and arm.
• nails – 30 strokes
• sides (4) of fingers (include web spaces) – 20 strokes
• back of hand – 20 strokes
• palm of hand – 20 strokes
• distal 3rd of the forearm – 20 strokes
• middle 3rd of the forearm – 20 strokes
• proximal 3rd of the forearm – 20 strokes
to 2 inches above the elbow

Rinse brush thoroughly, reapply soap.

Repeat above procedure with dominant hand and arm.
Discard brush into proper container/ Drop brush
onto the sink (depending on hospital policy).
Rinse from fingertips to elbows and away from
the body, letting water drip from elbows.
Keep hands higher than elbows and away from the
body. Proceed to the operating room with your back
to the door.
Drying Hands after Surgical Scrub

1. Pick up the towel from the

gown pack and hold away
from you at all times.
2. Step backward and let towel
open.
3. Dry left hand to mid-lower
arm; then transfer dry end of
towel to other hand.
4. Dry right hand to mid-lower
arm. Do not return to an area
you have already dried.
5. Fold towel into thirds.
Dry elbow areas.
6. Discard towel in linen
hamper.
 Gowning
Purposes:
• To exclude skin as a possible contaminant and to
create a barrier between sterile and unsterile areas
• To permit the wearer to come within the sterile field
• To carry out sterile techniques during an operative
procedure

General Considerations
• The scrub nurse gowns and gloves self, then gowns
and gloves the surgeon and assistants.
• The sterile gown is folded inside out.
 Putting on a surgical gown

1.Grasp the sterile

gown at the neckline
with both hands. Step
back from the table.
2. Holding the folded
gown at the neckline
with the inside
toward you, keep
your hands on the
inside of the gown
as you let the gown
unfold in front of you
at arm’s length. Do
not allow it to touch
anything.
3. Hold the
unfolded gown
at shoulder level
and
simultaneously
push both
hands and arms
into the sleeves.
4. The circulating
nurse assists by
reaching inside
the gown to the
sleeve seams
and pulls the
gown over your
shoulders. Then
she secures the
ties at the
neckline and
waist (swinging
motion).
 Gowning another Person

• A team member in sterile gown and gloves

(scrub nurse/ scrub technician) may assist
another team member in gowning.
1. Give the towel to the surgeon, being careful not
to touch the hand.
2. Unfold the gown, holding it at the neckband.
3. Keep the hands on the outside part of the gown
under the protective cuff and shoulder area.
Offer the inside of the gown to the surgeon. The
surgeon slips into the sleeves.
 Gloving

The sterile gloves are put on immediately after

gowning.

Purposes:
• To exclude skin as a possible contaminant
• To create a barrier between sterile and unsterile
areas
• To permit the wearer to handle sterile supplies or
tissues of the operative wound
Three gloving techniques exist:
1. Closed – preferred when initially putting on
sterile gown and gloves
2. Open – used when sterile gloves are replaced
or a sterile gown is not required
3. Assisted – used when one team member
wearing sterile gown and gloves helps another
team member put on his sterile gloves
 A. Closed Glove Technique

1. Using the right

hand, and keeping it
within the cuff of the
sleeve, pick up the left
glove by grasping the
folded cuff. Place left
glove palm-side down
along the forearm of
left hand, (thumb to
thumb) with thumb
and fingers pointind
toward the elbow. The
glove cuff should be
over the gown cuff.
2. Securely hold the
glove cuff of the hand
being gloved. With the
other gown-protected
hand, stretch the
glove cuff over the
end of the gown
sleeve and hand.
3. Pull the glove on over
your extended fingers
until it completely
covers the gown cuff.
Adjust your hand and
fingers in the glove.
4. Using your gloved
hand, pick up the
second glove from the
sterile wrapper.
5. Repeat the above
procedure with the
other hand to put on
the second glove.
6. Pull the second glove
over your extended
fingers until it
completely covers the
gown cuff. Adjust your
hand and fingers in
the glove.
 B. Open Glove Technique

1. Lift the right glove

from the wrapper by
the edge of the
everted glove cuff,
using your left thumb
and finger.
2. Slide the glove over
your right hand,
holding the glove cuff.
Adjust your hands and
fingers inside the
glove.
3. Using your gloved
right hand, pick up the
second glove by
placing your gloved
fingers under the
everted glove cuff.
Slide your ungloved
hand into the glove.
4. Adjust your hand
and fingers in the
glove.
5. Adjust both gloves to
cover the sterile gown
cuff. To adjust the
gloves, place your
gloved fingers under
the everted glove cuff
and pull the glove
upward.
 C. Assisted-Gloving Technique
(Gloving another Person)
1. Wearing sterile gown
and gloves, pick up
the right glove with
fingers under the
everted cuff glove
cuff. Hold the glove so
its thumb and palm
are facing the person
you are gloving. Then
stretch the glove cuff
to allow hand access
and maintain sterility.
2. Apply resistance as
the person you’re
gloving pushes his
hand into the glove.
3. Release the glove cuff
when the glove is
securely in place.

4. Repeat the procedure

with the other hand.
Draping - is the procedure of covering the patient
and surrounding area with a sterile barrier to create
and maintain an adequate sterile field during
operation
Points to remember:
•Drapes serve as barrier to prevent the passage of
microorganism between sterile and non-sterile
areas.
•The sterile field includes the patient, furniture, and
other equipment that is covered with sterile drapes.
• Sterile drapes are positioned over patient in such a
way that only a minimum area of skin around the
incisions site is exposed.

• Frequently draped furniture includes instrument or

“back” tables, mayo stands, and the ring stands.
Techniques to Remember in Draping:
• Allow sufficient time to permit careful application.
• Allow sufficient space to observe sterile technique.
• Handle the drape as little as possible.
• If a drape becomes contaminated, do not handle it
further. Discard it without contaminating gloves or other
articles.
• If in doubt as to its sterility, consider it contaminated.
• If end of the sheet falls below waist level, discard it.
• Never reach across the operating table to drape the
opposite side; go around the table.
• Take the towels and towel clips to the side of the table
from which the surgeon is going to apply them before
handling them to him.
• Carry the folded drapes to the operating table; watch
the front of the sterile gown; it may bulge and touch the
non-sterile table or blanket of the patient. Stand back
from the non-sterile table.
• Hold drapes high enough to avoid touching them on
the blanket but avoid touching the light.
• Do not let your gloved hand touch the skin of the
patient.
• Hold the linen high until it is directly over the proper
area, then lay it down where it is to remain.
• If drape is incorrectly placed, the circulating nurse
discards it from the table without contaminating
other drapes or site .
• If unfolding the sheet on the operative site, toward
the foot or the end of the table, protect the gloved
hand by enclosing it in the turned back cuff of the
sheet.
• A towel clip that has been fastened through a drape
has its points contaminated- remove it only if
absolutely necessary, then discard it.
• Place the drapes on a dry area.
 Draping
• Place the first drape sheet from the foot to the
knees. The scrub will select the sheet and hand one
end to the surgeon across the operating table,
supporting the folds, keeping it high, and holding it
taut until it is opened, then drop it (open fingers and
release sheet).
• The second drape sheet is handled in the same
manner. This sheet is placed below the incision site
with the edge of the sheet just below the incision
site. This draping sheet provides extra thickness of
material under the area from the Mayo tray to the
incision where instruments and sponges are placed.
It also closes some of the opening in the
laparotomy sheet, if necessary.
• The third step in draping is placing the four sterile
towels around the line of incision.
• The scrub unfolds first towel, passes the towel
drape to the surgeon with the strip side facing the
scrub. The surgeon places the towel within the
scrubbed area on the near side of the line of
incision, leaving only enough exposed skin for the
incision.
• The second towel is placed in the same way,
except the towel is placed on the lower side
(toward feet) of the line of incision.
• The third towel is passed the same way, except
the towel is placed on the upper side (toward
head) the line of incision.
• The last towel is passed to the surgeon the facing
the surgeon and is placed on the far side of the
line of incision. The adhesive area holds the towel
drapes in place.
• The towels may be held in place by towel clips.
• The scrub will select the surgical drape (lap sheet).
This lap sheet has a fenestration (opening) in the
drape for the incision.
• The scrub nurse carries the folded laparotomy sheet
to the table. Standing back from the table, with one
hand, the scrub lays sheet on the client and places
the opening directly over the prepared skin area,
outlined by the drape towels.
• The lap sheet will have an arrow or some other
indication to identify the head or foot portion of the
drape.
• Drop the folds over the sides of the table, then open
it downward over the patient's feet and upward over
the anesthetist screen. The hands approaching the
unsterile area are protected in a cuff of the drape
and the sheet may be stabilized with other hands.
 Opening a Sterile Pack
• A sterile team member (scrub nurse or technician) should
open a sterile pack from near side to far side.

• An unsterile team member (circulating nurse) should

open a sterile pack from far side to near side. Remember,
an unsterile team member must never reach over a sterile
field.
A circulating nurse opening the cover of a pack of
sterile drapes. She keeps her fingers under the cover
to avoid contact with the sterile parts.
As this scrub nurse/ technician places the sterile drape
cover on an OR stand, he keeps his fingers under the
drape’s cuff to protect his sterile/ gloved hands and avoid
contamination.
Scrub duties
 Scrub duties
•Perform surgical hand scrub.
•Gown and glove using closed glove technique.
•Re-gown and glove when breaks in technique occur.
•Assist the 1st scrub in setting up case (back table,
mayo stand and O.R. basins).
•Arrange instruments and supplies (back table, mayo
stand and O.R.).
•Count needles, instruments and sponges.
•Check instruments for proper functions.
•Prepare irrigating solution.
•Draw medications properly.
•Gown and glove surgeon and assistant.
•Assist with draping.
 Scrub duties
• Prepare electric cautery, suction and light handles for
proper use.
• Prepare necessary sutures.
• Pass instruments to surgeon and assistant.
• Retract, sponge, and suction during case as
necessary.
• Proper identification and handling of specimen.
• Prepare instruments for decontamination at completion
of case.
• Dispose of sharps properly.
• Discard soiled drapes and trash properly.
• Transport soiled drapes and trash properly.
• Anticipate the surgeon and assistant needs.
• Anticipate the operative procedure needs.
• Help apply wound dressing.
Circulating Responsibilities
 Circulating Responsibilities

• Clean operating room prior to case.

• Gather all supplies, instruments and equipment
necessary for case.
• Arrange O.R. furniture properly.
• Open and flip sterile supplies for the surgical
procedure.
• Assist with IV therapy.
• Assist the anesthesiologist.
• Assist with the skin preparation.
• Tie gowns of the scrub nurse and surgeon.
 Circulating Responsibilities

• Provide scrub personnel with sitting stools and foot

stools as necessary.
• Turn and help adjust lights as necessary.
• Supply the scrub nurse with necessary supplies.
• Receive and label specimen properly.
• Log and deliver specimen to pathology properly.
• Help apply wound dressing.
• Pull case for following procedure.
 SPONGE AND INSTRUMENT COUNTS

It is essential to keep track of the materials being

used in the operating room and during any
complicated procedure in order to avoid inadvertent
disposal or the potentially disastrous loss of sponges
and instruments in the wound.

It is standard practice to count supplies (instruments,

needles, screws and sponges):
•Before beginning a case
•Before final closure
•On completing the procedure
• The aim is to ensure that materials are not left behind or
lost. Pay special attention to small items and sponges.

• Create and make copies of a standard list of equipment

for use as a checklist to check equipment as it is set up
for the case and then as counts are completed during
the case. Include space for suture material and other
consumables added during the case.

• When trays are created with the instruments for a

specific case, such as a Caesarean section, also make
a checklist of the instruments included in that tray for
future reference.
Cleaning a wound and applying a sterile dressing
a. Prepare the client and assemble the equipment.
b. Remove binders and tape.
c. Remove and dispose of soiled dressing appropriately.
d. Set up the sterile supplies.
e. Clean the wound if indicated.
f. Apply the ordered ointment/ cream, if any.
g. Apply dressing to the drain site and the incision.
 Irrigating a Wound
• Wound irrigation - the process of washing debris,
drainage, or exudate out of the wound to promote
healing.
• Fluid used to irrigate a wound - normal saline,
Betadine, hydrogen peroxide, acetic acid, and
specially prepared antibiotic solutions. If cytotoxic
solutions are used, then the area must be
flushed/irrigated afterwards with normal saline.
• Wounds that require irrigation vary -simple open
lacerations; tunneled pressure ulcers; or complex,
open abdominal wounds extending down to the
abdominal fascia.
• Wound irrigation is a sterile procedure because the
skin's integrity, the body's primary defense against
infection, has been breached.
• The nurse must take care not to contaminate the
wound, but must also take care not to become
contaminated with wound drainage.
 Irrigating a Wound
1. Confirm the health care provider's order for wound
irrigation and note the type and strength of the
ordered irrigation solution.
2. Assess the client's pain level and medicate if needed
with analgesic 30 minutes before procedure if the
medication is to be given PO or IM.
3. Explain the procedure to the client.
4. Place a waterproof pad on the bed. Assist the client
onto the pad. Then assist the client into a position
that will allow the irrigant to flow through the wound
and into the basin from the cleanest to dirtiest area
of the wound.
5. Wash hands and apply the disposable gloves;
remove and discard the old dressing.
6. Assess the wound's appearance and note quality,
quantity, color, and odor of drainage.
7. Remove and discard the disposable gloves and
wash hands.
8. Prepare the sterile irrigation tray and dressing
supplies. Pour the room-temperature irrigation
solution into the solution container.
9. Apply sterile gloves (and goggles if needed).
10.Position the sterile basin below the wound so the
irrigant will flow from the cleanest area to the
dirtiest area and into the basin.
11.Fill the piston or bulb syringe with irrigant and gently
flush the wound. Hold the syringe approximately 1
inch above the wound bed to irrigate. Refill the
syringe and continue to flush the wound until the
solution returns clear and no exudate is noted or until
the prescribed amount of fluid has been used.
12.Dry the edges of the wound with sterile gauze.
13.Assess the wound's appearance and drainage.
14.Apply a sterile dressing. Remove sterile gloves and
dispose of properly. Wash hands.
15.Document all assessment findings and actions
taken.
 Obtaining a Wound
Drainage Specimen for Culturing
• Bacterial wound contamination is one of the most
common causes of altered wound healing.
• A surgical wound can become infected with
microorganisms preoperatively, intraoperatively, or
postoperatively.
• Infection slows healing by prolonging the
inflammatory phase of healing, competing for
nutrients, and producing chemicals and enzymes
that are damaging to the tissues. Identifying when
a wound is contaminated and the infectious agent
is an important step in wound healing.
• During the preoperative period, the wound may
become exposed to pathogens because of the
manner in which the wound was infected, such as in
traumatic injuries. Nicks or abrasions created during
preoperative shaving may also be a source of
pathogens.
• The risk for intraoperative exposure to pathogens
increases when the respiratory, gastrointestinal,
genitourinary, and oropharyngeal tracts are opened.
• Nonsurgical wounds from trauma, pressure ulcers, or
disease can become infected as well. If the amount
of bacteria in the wound is sufficient or the client's
immune defenses are compromised, clinical infection
may result and become apparent 2 to 11 days
postoperatively.
 Obtaining a Wound
Drainage Specimen for Culturing
1. Wash hands, apply disposable gloves, and remove
old dressing. Place old dressing in moisture-proof
container and remove and discard gloves. Wash
hands again.
2. Open the dressing supplies using sterile technique
and apply gloves.
3. Assess the wound's appearance; note quality,
quantity, color, and odor of discharge.
4. Irrigate the wound with normal saline prior to
culturing the wound; do not irrigate with antiseptic.
5. Using a sterile gauze pad, absorb the excess saline,
then discard the pad.
6. Remove the culture tube from the packaging.
Remove the culture swab from the culture tube and
gently roll the swab over the granulation tissue.
Avoid eschar and wound edges.
7. Replace the swab into the culture tube, being
careful not to touch the swab to the outside of the
tube. Recap the tube. Crush the ampule of medium
located in the bottom or cap of the tube .
8. Remove gloves, wash hands, and apply sterile
gloves. Dress the wound with sterile dressing.
9. Label the specimen, place in biohazard transport
bag, and arrange to transport the specimen to the
laboratory according to institutional policy.
10.Remove gloves and wash hands.
11.Document all assessment findings and actions
taken. Document that a specimen was obtained.
Removing Skin Sutures and Staples

• Sutures and staples are a surgical means of closing

a wound by sewing, wiring, or stapling the edges of
the wound together.
• Most wounds are sutured in layers to maintain
alignment of the tissues and reduce scarring.
• Sutures are generally removed 7 to 10 days after
surgery, depending on where the wound is located
and how well it is healing. Suture removal requires
a health care provider's orders.
• Timing is important because sutures left in too long
can increase the risk of infection and irritation from
a foreign substance.
• Sutures placed deep within the tissue layers are
made of absorbable materials.
• Surface sutures are made of wire, nylon, or cotton.
• Continuous sutures are made with one thread, tied at
the beginning and end of the suture line. Interrupted
sutures are tied individually.
• Staples are used for large incision areas where the
risk of dehiscence is greater, such as in
sterneotomies, in clients with increased adipose
tissue, abdominal areas, and wounds that fail to heal
or adhere.
Removing Skin Sutures and Staples
1. Wash hands.
2. Assess the wound to determine whether the edges of
the wound are well-approximated and healing has
occurred.
3. Ascertain whether the client has had sutures removed
before. If not, explain the procedure.
4. Close the door and curtains around the client's bed.
5. Raise the bed to a comfortable level.
6. Position the client for comfort with easy access and
visibility of the suture line.
7. Drape the client so that only the suture area is
exposed.
8. Open the suture removal kit, and assemble any
supplies needed within easy access on a clean surface.
9. Apply clean gloves to remove the old dressing and
place it in a disposable bag.
10.Remove gloves and rewash hands.
11.If dressings are to be used, assemble equipment and
supplies on sterile field.
12.Measure the heart rate, rhythm, and volume; the
respiratory rate and rhythm; and the blood pressure
bilaterally.
• Apply sterile gloves according to institutional policy.
• Clean the incision with saline-soaked gauze pads,
antiseptic swabs, or per institutional policy.
13.When removing an interrupted suture, hold forceps in
your nondominant hand and grasp the suture near the
knot.
14. Place the curved edge of the scissors under the
suture or near the knot.
15. Cut the suture close to the skin where the suture
emerges from the skin (not in the middle). Pull the
long end and remove it in one piece.
16. If the client has a continuous suture, cut both the
first and second suture before removing them.
17. Some policies require the removal of every other
suture, with the remaining sutures removed at a
later time. Assess the suture line to ensure that the
edges remain approximated.
18. Discard the sutures onto the gauze squares as they
are removed and then place the gauze squares in
the disposable bag when all the sutures have been
removed.
19.Assess the suture line to ensure that the edges
remain approximated and that all sutures have been
removed.
20.Apply adhesive strips or butterfly tape adhesive
strips across the suture line to secure the edges.
The amount of reinforcement varies depending on
the adherence of the suture line and the length of the
suture line. Adhesive skin closures may be placed 1
inch apart or closer together.
• Tincture of benzoin may be used.
21.Dispose of the soiled equipment.
22.Remove gloves and wash hands.
23.Repeat Actions 2 to 12.
• Use a staple extractor to remove every other staple.
Place the lower tip of staple remover under the staple
and squeeze the handles together. The ends of the
staple will extract from the skin. Move the staple
away from the skin surface and release the staple
into a disposal container. Assess the wound for
adherence. Move on to the next staple if the skin has
adhered well.
• Repeat Actions 20 to 22.