RELATED LEARNING EXPERIENCE

MODULE 1

CARE OF CLIENTS WITH PROBLEMS IN

OXYGENATION, FLUIDS AND ELECTROLYTES,
INFECTIOUS, INFLAMMATORY & IMMUNOLOGIC
RESPONSE, CELLULAR ABERRATIONS, ACUTE AND
CHRONIC

NCM 112

APRIL JXEEL L. PALALAY, MAN, RN

JAINAH ROSE F. GUBAC, MAN, RN
LALYN N. CABAUATAN, MAN, RN
WENNA MAY S. RAMOJAL, RN
DINDO C. EREJE, RN
2021

UNIVERSITY OF SOUTHERN MINDANAO

 Kabacan, Cotabato

(Flyleaf)
Author’s Declaration

Ideas, concepts, diagrams and/or illustrations depicted in this learning

material are excerpts from established references and properly noted in the
list of literatures cited herein. The author in this learning material remains a
compiler and does not claim full and authentic ownership of all the contents of
this module, nor in any manner willfully infringe the copyright law and other
existing provisions appertaining thereto.

This learning material is printed for the sole use of classroom or

distance/remote learning of USM and is not intended for commercial
purposes. Any use or reproduction in part or in full, whether electronic or
mechanical, photocopying or recording in any information storage and
retrieval system, other than what it is intended for requires the consent of
authorized and competent authority of the University of Southern Mindanao.

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USM VISION

Quality and relevant education for its clientele to be globally

competitive, culture sensitive and morally responsive human resources for
sustainable development

USM MISSION

Help accelerate socio-economic development, promote harmony

among diverse communities and improve quality of life through instruction,
research, extension and resource generation in Southern Philippines.

UNIVERSITY QUALITY POLICY STATEMENT

The University of Southern Mindanao, as a premier university, is

committed to provide quality instruction, research development and extension
services and resource generation that exceed stakeholders’ expectations
through the management of continual improvement efforts on the following
initiatives.
1. Establish Key Result Areas and performance indicators across all
mandated functions;
2. Implement quality educational programs;
3. Guarantee competent educational service providers;
4. Spearhead need-based research outputs for commercialization,
publication, patenting, and develop technologies for food security,
climate change mitigation and improvement in the quality of life;
5. Facilitate transfer of technologies generated from research to the
community for sustainable development;
6. Strengthen relationship with stakeholders;
7. Sustain good governance and culture sensitivity; and
8. Comply to customer, regulatory and statutory requirements.

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 TABLE OF CONTENTS

Page
Chapter 3 Preparing a Sterile Field
Establishing a Sterile Field 2
Preparing Sterile Field and Opening a Sterile Pack 3
Surgical Instrumentation 8
Adding Items to Sterile Field and Adding Liquids to 25
Sterile Field
Placing Needle to Needle 30
Placing and Removing Blade to Blade Holder 32
Reporting of Instruments Prior to Closure of Surgical Site 39

COURSE GUIDE

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Course Information
Course Title Care of Clients with Problems in Oxygenation,
Fluids and Electrolytes, Infectious, Inflammatory
and Immunologic Response, Cellular Aberrations,
Acute and Chronic
Course Code NCM 112
Pre-requisite/Co-r NCM 109
equisite

Course Description

This course deals with concepts, principles, theories and techniques in the
nursing care management of clients with maladaptive patterns of behavior of
individuals, families, population groups and communities, across the lifespan,
in any health care setting. The learners are expected to provide safe,
appropriate, evidence-based, holistic and individualized care to meet the full
range of needs of the client person/s experiencing psychiatric emergencies
and/or those with mental health alteration/s through the principles and
cultural/ethnic sensitivities.

Course Objectives/Outcomes

Upon passing the course, you must be able to:

1. Apply knowledge of physical, social, natural and health sciences, and
humanities in the practice of nursing.
2. Provide safe, appropriate, and holistic care to individuals, families,
population group, and community utilizing nursing process.
3. Apply guidelines and principles of evidenced-based practice in the
delivery of care.
4. Practice nursing in accordance with existing laws, legal, ethical, and
moral principles and standards.
5. Communicate effectively in speaking, writing, and presenting using
culturally appropriate language.
6. Document to include reporting up-to-date client care accurately and
comprehensively.
7. Work effectively in collaboration with inter -, intra -, and
multi-disciplinary and multi-cultural teams.

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Course Requirements/Assessment and Evaluation

Scheme/Grading System

RLE Breakdown of Grades:

1. Attendance = 10%
2. Short Quiz = 15%
3. Term Exam = 35%
4. Term Requirement = 40%

House Rules/Class Policies

1. All rules pertaining to student discipline under the USM Revised

Student Handbook shall be strictly implemented.
2. Written outputs should be well- written and must follow given
specifications. Honesty and integrity in ideas and contents should be
exercised; there will be no consideration for plagiarism.
3. Participation in class activities and discussion is expected from each
student during on-site meetings.
4. Students are encouraged to consult with the teacher. Professor will be
available for consultation and advisement during RLE hours only from
Monday to Friday either through e-mail, chat, mobile text, or phone call.
5. Exercises on modules shall be submitted on the date announced by
the professor.
6. The professor reserves the right to amend, modify, or reverse any of
the rules afore stated as the circumstances warrant.

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 CHAPTER 3

PREPARING A STERILE FIELD

STERILE FIELD

GENERAL CONSIDERATIONS

1. Only sterile items are used within the sterile field.

a. Prior to items being dispensed to the sterile field check the external and internal

chemical indicators on and in the package, check for package integrity, and package

expiration (if appropriate).

2. Items which display a manufacturer’s expiry date are considered unsafe for use after that

date. (Rationale: Expiry dates do not guarantee either sterility or lack of sterility

1. Frequently expiry dates refer to the degradation of the product or a component of

the product after the specified date.)

3. If in doubt about the sterility of the packaged item, it is not considered sterile. This

includes:

a. items found in unmonitored areas,

b. any indication of the package being wet (e.g., water stains, dampness or

condensation in package),

c. any package without chemical indicator (CI) showing a “pass” result,

d. any package that has been dropped or, e. any package that shows evidence of

crushing, perforations or holes.

4. Whenever a sterile item has been compromised, the package contents, gown or the

sterile field involved are considered contaminated. This may happen when:

a. non sterile items contact sterile items;

b. liquids or moisture soak through a drape, gown, or package (strikethrough).

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5. Single-use medical devices are used on an individual client for a single procedure and

then are discarded.

6. Reusable medical devices are reprocessed according to the manufacturer’s directions for

use and in accordance with current Alberta Health Standards.

7. Refer to IPC recommendations on Storage of Clean and Sterile Supplies in Clinical Areas

for details on storage and handling sterile supplies such as temperature and humidity

requirements.

ESTABLISHING A STERILE FIELD

1. Use sterile drapes to cover surfaces or operative fields and provide a barrier against

micro-organisms, liquids, and particulate matter.

2. Surgical drapes are only sterile at table level.

a. The drape below the working surface is not under direct vision of the surgical team

and is not considered sterile. The edges of the table top serve as a demarcation line

between sterile and non-sterile.

b. Any item that falls below the table level is considered unsterile. This applies to the

edges of the drape and portion of suction and irrigation tubing that is handed off the

sterile field.

3. If the drape does not cover the entire surface, a 1-inch margin around the edge of the

drape is considered unsterile.

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 4. The edges of packages are considered unsterile. When opening packages for a

sterile procedure prevent the wrapper from touching the sterile field or package

contents.

a. Control all flaps of non-woven wrap to prevent them from touching the sterile field.

(Figure 26).

b.The sterile boundary of a peel-open package is the inner edge. Peel pouches are

peeled back not ripped or torn when opening. Do not push devices through the peel

pouch. The inner edge of the seal is the demarcation for sterile and non-sterile.

(Figure 27)

c. Do not flip or drop items onto the sterile field. (Figure 28)

5. Clean and dry flat surfaces before placing a sterile bundle or drape on them.

(Rationale: moisture may cause strike-through and contaminate the sterile field. Dust

may become airborne and land on the sterile field.)

PREPARING STERILE FIELD AND OPENING A STERILE PACK

The sterile field consists of the area surrounding the site of the incision or perforation into

tissue, or the site of introduction of an instrument into a body orifice that has been prepared

for a surgical or other invasive procedure.3 The sterile field also includes all work areas,

furniture, and equipment covered with sterile drapes and drape accessories, and all

3
personnel who are wearing sterile attire. Perioperative personnel are key to creating,

maintaining, and monitoring the sterile field. Before preparing a sterile field, they should

perform a surgical hand scrub and don a sterile gown and gloves. This helps minimize

contamination by microbes present on the skin and clothing.

Placement and Timing of Sterile Field Preparation

The sterile field should be prepared where it will be used.3 Moving the sterile field after it is

created increases the risk of contamination, because air currents created by movement can

lead to microbial and particle contamination. For the same reason, movement of personnel

around the sterile field should be kept to a minimum.

In addition, the sterile field should be prepared as near as possible to the start time of the

surgical or other invasive procedure. This helps minimize the amount of dust and other

airborne particles that settle on the field, which is important because these particles can

increase contamination by bacteria and other microbes. AORN recommendations note that

the potential for contamination is event-related, and that there is no specified time for

preparing a sterile field relative to the time of the procedure.3 To prevent a variety of hazards

and the risk of microbial transmission between patients, only one patient at a time should be

in the OR or other procedure room. To further decrease the risk of cross-contamination of

the sterile field, sterile supplies should be opened for only one patient at a time in the OR or

other procedure room

Inspection Before Opening

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Before introducing any object to a sterile field, the item should be inspected to verify that it

has been correctly processed and packaged and that the packaging is intact. These

practices help reduce the chance of inadvertent microbial contamination. The following are

general steps that should be followed before introducing any item to a sterile field:

• Check for an expiration date before opening the item. If this date has passed, do

not use the item.

• Check the wrappers of instrument trays for moisture and to be sure they have not

torn.

• Check the chemical sterilization indicator in the package to make sure the color has

changed as expected, which signifies appropriate sterilization.

Opening and Delivery Technique for Wrapped Items

Assisting team members should hand sterile items directly to a scrubbed team member or

place them securely on the sterile field, so they do not slide off or push other items off the

field. Items should not be tossed. Tossing an item could compromise the sterile drape or

cause other items to shift. To avoid tearing or puncturing the surgical drape, heavy or sharp

items should either be handed directly to a scrubbed team member or opened on a

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separate, clean, dry surface. Whenever opening wrapped sterile supplies, the perioperative

team member should:

• First open the wrapper flap that is farthest away from his or her body.

• Then open each side flap.

• Last, open the near (or closest) flap.

This helps prevent movement of an unsterile arm over the sterile contents of the package,

which could contaminate it. The edges of the wrapper are considered contaminated. They

should be secured and not allowed to touch sterile areas or items

Republic of the Philippines

University of Southern Mindanao
College of Health Sciences
Department of Nursing
Kabacan, Cotabato

PERFORMANCE CHECKLIST

Preparing a Sterile Field and Opening a Sterile Pack for Major Operation

Name of Student:______________________________________ Date: _______________

Clinical Instructor:__________________________________ Year and Section: _________

PREPARATION  PERFORMED MASTERED COMMENTS

     

YES  NO

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 1. Prepare sterile field just before
planned  procedure.

2. Select clean work surface above

waist  level.

3. Assemble necessary equipment.

4. Check dates or labels on

supplies for  sterility of
equipment.

5. Wash hands thoroughly.

6. Place pack containing sterile

drape on  work surface and open
it.

7. With fingertips of one hand, pick up

folded  top edge of sterile drape.

8. Gently lift drape up from its outer

cover  and let it unfold by itself
without touching  any object.

9. Allow top half of the drape to be

placed  over work surface last.

10. Grasp 1-inch border around

edge to  position as needed.

11. Using sterile forcep, unfold the outer

flap  without touching any object.

12. Maintains body mechanics

throughout the  procedure.

13. Manifests neatness in the

performed  procedure.

14. Receptive to criticisms.

15. Observes courtesy.

16. Shows calmness while performing

the  procedure.

17. Uses correct English.

18. Shows mastery of the procedure.

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 SURGICAL INSTRUMENTATION

Surgical instruments are high quality tools that are designed for accomplishing a

specific desired effect during invasive procedures. Instruments are integral components of all

surgical procedures. Perioperative staff members must understand the use, handling, and

care of surgical instruments. Proper cleaning and handling minimize damage, increases

instrument life expectancy, and protects instruments, which are a major financial investment

for facilities. Careful planning, preparation, and use of instruments will contribute to an

efficient and effective surgical procedure within a safe environment

Surgical instruments perform basic functions such as holding or retracting tissue;

dissecting, cutting, or incising tissue; and assisting with suturing and or closure of the

surgical incision. Most surgical instruments are made of stainless steel or other metals. The

metal selected must be easily cleaned, disinfected, and maintained.

Surgical procedures are becoming more complicated and intricate and as a result

surgical instruments are becoming more complex, more precise in design, and more delicate

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in structure. With the development of new tools, instrument care and handling become more

challenging. There are currently hundreds of different types of surgical instruments and more

are being developed everyday as surgical procedures change and evolve.

BRIEF HISTORY

Surgical instruments go as far back as 10,000 BC. Archaeological discoveries have

unveiled cutting tools like a sharp flint used to sharpen animal teeth, grasping tools to extract

arrows, saws, forceps and other ancient surgical instruments. Rubble amidst the volcanic

ashes of the old Roman city of Pompeii unveiled an entire well-preserved arsenal of surgical

instruments. The find is known as the House of the Surgeon, because of the nature of the

collection found in the home.

Fig. 1. Hooks (Greek name: agkistron, Latin name: hamus, acutus): served the same

purpose as today, to dissect blood vessels, manipulation or retracting. Both blunt and sharp.

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Fig. 2. Scissors (Greek: psalis, Latin: forfex) were used in ancient Rome for cutting hair,

which was considered a medical procedure. Regular scissors where used. There are few

references for surgical use of scissors, except for a few references to tissue cutting.

Fig. 3. Forceps (Greek: tricholabis, Latin: vulsella) may not have been surgical instruments.

There is little indication that the forceps were used for medical purpose, but rather articles

mentioned them in cosmetic usage such hair removal and art.

Note* Images courtesy of Historical Collections & Services, Claude Moore Health Sciences

Library, University of Virginia.

MANUFACTURING PROCESSES

Surgical instruments are the surgeon’s tools. Each one is designed and carefully crafted

for an intended surgical purpose. They must be durable and not prone to rusting, chipping,

or denting with normal handling, which is why most are made with stainless steel, a

combination of carbon, chromium, iron, and a few other alloys (i.e., metals).

1. Stainless Steel

2. Titanium

3. Vitallium

4. Other Metals: steel alloys, brass, silver, or aluminum. Some cutting blades, tips, and

jaws are laminated with tungsten carbide.

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 Note* It is important for perioperative staff members to know what each instrument is

made of. The metal alloys used in surgical instruments must be resistant to corrosion,

which can result from exposure to blood, body fluids, cleaning solutions, sterilization, and

the atmosphere.

PERFORMANCE

Surgical instruments are designed to perform diagnostic, therapeutic, or investigative

operations having specific functions such as to cut or incise, retract, grasp, hold or occlude,

dilate or probe, suture or ligate. The majority of surgical instruments are made of stainless

steel or titanium (used where non-magnetic instruments are required). Stainless steel is an

alloy that contains a minimum 12% chromium for corrosion resistance. The instruments can

vary in quality and price and often represent a large portion of a surgical budget. Caring for

this investment is the responsibility of all who use them from technicians to surgeons.

Instrument Names

Surgical nomenclature lacks standardization, but will generally follow certain patterns. For

example, instruments may be named:

1. by the action that the instrument is designed to perform (e.g., scissors, knife),

2. to recognize the inventor (e.g., Debakey forceps), or

3. a combination of how the instrument is to perform in a particular type of surgery and

an inventor’s name (e.g., a Lambotte osteotome, a tool that is designed to cut bone,

invented by Lambotte).

*Names of instruments also vary by the region of the country in which they are used, the

surgeon’s preference for a name, and the facility’s commonly used name.

TYPES OF SURGICAL INSTRUMENTS

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 Many different kinds of surgical instruments and tools have been invented over the

years. Instruments may be designed for general surgical use or for use during a specific

procedure.

Generally, there is a natural progression of instrument use during a surgical procedure.

Paying close attention to what is happening on the surgical field and knowing this

progression will help the scrub person to anticipate which instrument will be needed:

● An incision is made using a cutting instrument, such as a knife or scissors. Clamps or

forceps may be used to control superficial bleeding at this point. Electrosurgical

energy delivered through an active electrode may be used to create hemostasis or to

extend the excision.

● Cutting of internal tissue layers is accomplished with scissors.

● Exposure of the surgical field is made possible by retractors.

● Suction evacuation is used to eliminate the surgical smoke plume created by the

electrosurgical unit and to suction fluid or blood from the surgical field.

It is easy to see that surgical instruments can be classified into four main categories:

1. cutting and dissecting,

2. clamping,

3. grasping or holding, and

4. exposing and retracting.

Cutting and Dissecting Instruments

Basic cutting and dissecting instruments, sometimes referred to as “sharps,” do

exactly what their name implies; they cut and dissect tissue or other materials. The useable

part of the instrument has a sharp or cutting edge. Cutting instruments include knives,

scalpels, and scissors of all types and shapes.

Knives and scalpels

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 The words knife and scalpel are used interchangeably, but generally, a scalpel has a

detachable, disposable blade and non-disposable handle, while the term knife refers to

single unit cutting device such as an amputation knife. The handle size and configuration of

scalpel handles varies to accommodate the area of use. Knife blades may have curved

edges or sharp, stabbing points. When using a knife, care must be taken to avoid injury to

self or others.

Fig. 4. Illustration of scalpel and knife

Scissors

Scissors are designed in short, medium, long, and heavy lengths and may be blunt or

sharp with straight or curved tips on their cutting edges. Scissors consist of a pair of metal

blades connected in such a way that the edges of the blades cut materials placed between

them when the handles are brought together. A conventional scissors requires one

movement to open the jaws and another to close them. Some scissors, particularly those

used in delicate plastic and eye surgery, have a spring that holds the jaws open. Squeezing

the handle together closes the blades and relaxing of the grip opens them.

The smaller sized blades are used at the surface for small incisions and the longer blades go

deeper into cavities. Curved blades provide a better visual of the working area and straight

blades can be used for any type of incision.

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 Fig. 5. Illustration of scissors

Standard Scissor Tips

Standard scissors are available in a variety of lengths and patterns with straight, curved or
angled blades. Heavy duty patterns are for blunt dissection. Fine, thin blades are used for
delicate cutting.
1. Curved/straight blades
2. Blunt/blunt blades
3. Sharp/sharp blades
4. Sharp/blunt blades

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 Fig. 6. Sample illustration of scissor tips.

Tissue Scissors

Tissue scissors are used for tissue dissection. Most tissue scissors have curved

tapered points. Metzenbaum scissors are used to cut medium to delicate tissue while the

sturdier Mayo scissors are used to cut heavy or thicker tissue or structures such as fascia. A

Metzenbaum scissors can be distinguished from the Mayo scissors by its narrow shaft and

tips. The curvature on the Metzenbaum and other tissue scissors is desirable to surgeons

because it facilitates the ability to see the tips of the scissors during dissection and because

they can reach around other structures. Small, fine scissors with sharp tips (e.g., iris

scissors, Castroviejo scissors), are used for delicate ophthalmic or reconstructive surgery.

Suture Scissors

Suture scissors usually have straight blades and blunt points. Straight Mayo scissors

are used primarily to cut suture. Angled bandage scissors can be used to cut bandages and

dressings. Wire scissors should be used to cut wire and very heavy sutures.

Other Cutting and Dissecting Instruments

⮚ include chisels, curettes, osteotomes, rasps, rongeurs, saws, trephines, and

Powered Cutting Instruments

1. Chisels are used to sculpt bone and have one beveled edge. A mallet is used in

conjunction with a chisel.

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2. Curettes are used to scrape soft tissue or bone. They are manufactured with

different size cupped ends and several angles and lengths. Uterine curettes are used

to scrape the endometrial lining of the uterus.

3. Osteotomes are bone-cutting instruments used for shaping or marking bone. They

have a double, beveled edge and come in several widths and are both curved and

straight in design. They may be used to remove periosteum from bone. A mallet is

used in conjunction with an osteotome.

4. Rasps can be used to smooth rough bone surfaces or to evacuate the medullary

canal in preparation for insertion of an orthopedic prosthesis. They may be single- or

double-ended, with curved or tapered blades. Rasps may be forward- or backward-

cutting, with fine or coarse teeth.

5. Rongeurs are biting instruments used for cutting tough tissue or bone. The biting

cup comes in various sizes and angles. When the surgeon squeezes the handles

together, the two sharp, cup-like ends come together to bite into the tissue and

remove a small section. Rongeurs are most commonly used on bones or heavy

ligaments. They may be double- or single action.

6. Saws include any notched blade used for cutting bone.

7. Trephines are used to cut bone from the skull. A trephine has a circular, sharpened

edge.

8. Powered Cutting Instruments >precision devices designed to make working with

bone and cartilage easier and quicker than working by hand. They are used most

often for precision drilling, cutting, shaping, and beveling bone. There are many

interchangeable attachments available for powered surgical hand pieces, and they

are used in a wide variety of procedures. Some uses include:

a) Drilling holes for placement of a metal plate to hold a fracture together.

This requires drill points, screws, and a screwdriver.

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 b) Removing, reshaping, and reaming of bone at the knee or hip joint for

placement of a total joint prosthesis. This requires saw blades and drill

bits of various sizes and shapes. Both forward and reverse speeds are

necessary for some of these activities.

Clamping and Occluding Instruments/ Hemostats

Surgical clamps can be used to either compress or grasp a structure. They can be

either occluding or non-occluding (also referred to as crushing or non-crushing). The types of

clamps needed for a particular procedure will depend on the kind of tissue to be held (i.e.,

delicate or tough) and the depth of the surgical procedure (i.e., near the surface or deep).

Fig. 7. Sample illustration of a clamp

The two parts of a clamp fit together at a box lock which, when closed or clamped together,

remains locked until the ratchets are released. The easily identifiable parts of a clamp are:

● The point of the tip which, when closed, should fit tightly together unless it is

designed to only partially compress tissue.

● The jaws of the instrument are either smooth or are serrated to hold tissue securely.

17
 ● The box lock is the hinge point of the instrument tip and handle.

● The shank is the area between the box lock and the finger rings.

● The ratchet is part of the finger ring handle and interlocks to keep the clamp shut

when the instrument is closed

Ring forceps (also called hemostatic forceps) are hinged and look like ring scissors.

Frequently, hemostatic forceps have a locking mechanism called a ratchet, which is used for

clamping. The jaws of the locking forceps gradually come together as each increment of the

ratchet is employed. Ring forceps are used for grasping, holding firmly or exerting traction

upon objects. For especially delicate operations, generally ring handles with a locking ratchet

are preferred over thumb forceps. Locking hemostatic forceps may be called clamps and are

used to securely hold tissue. When they are used to control blood flow, they are called

hemostats. Hemostats are typically used to compress blood vessels or other tubular

structures to obstruct the flow of blood or fluids.

Hemostats

Hemostats are the most common of all clamping instruments. They are used to grasp

bleeding vessels and prevent blood loss with minimal tissue damage. Hemostats range in

size from short to long and from delicate to heavier in design. They can be straight or

curved. Examples of hemostats are the mosquito, Kelly, and Crile.

1. Mosquito clamps are used to control surface bleeders and handle delicate tissue

(e.g., plastic surgery hand surgery);

2. Kelly clamps are used to control bleeders in muscle tissue, to pass drains, and to

hold Kitner or peanut sponges; and,

3. Crile clamps are used to control bleeders in subcutaneous tissue.

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Perhaps the most important design feature of a hemostat is the jaw portion between the box

lock and the tip. Some hemostats are very slender and tapered to a fine point; others are

thicker, with more blunt tips. The inside surfaces have deep grooves or serrations, which

may go from side to side or run longitudinally in the same direction as the jaws. These

serrations allow bleeding vessels to be compressed with sufficient force to stop bleeding.

The serrations must be cleanly cut and perfectly meshed to prevent the tissue from slipping

free from the ends of the clamp.

Fig. 8. Common jaw pattern of surgical clamps

Occluding clamps

Occluding clamps are used to occlude or constrict tissue and to clamp or grasp bowel, ducts,

and other structures with lumens. These instruments are used to apply pressure. They

typically have vertical serrations or special jaws with finely meshed, multiple rows of

longitudinally arranged teeth. They function to prevent leakage and minimize trauma to

19
vessels that are to be re-anastomosed. Examples of occluding clamps are Babcock, Allis,

and Kocher clamps.

● Babcock clamps have curved fenestrated tips without teeth. They are used to grip

or enclose delicate structure such as bowel, appendix, ureters, or fallopian tubes.

The smooth edges and bowed shape allow grasping without penetrating, crushing, or

traumatizing tissue.

● Allis clamps also allow grasping and holding without crushing. They have multiple,

tiny, fine teeth that curve slightly inward. Allis clamps will hold slightly heavier tissue

than Babcock clamps because they have serrations along their edges.

● Kocher clamps are easily identified by the transverse serrations and the large teeth

at the tips. This enables the surgeon to grasp and tightly hold heavy, tough, or

slippery tissue such as fascia, bone, and cartilage. The Kocher is also known as an

Ochsner clamp.

GRASPING AND HOLDING INSTRUMENTS

Grasping or holding instruments allow the surgeon to dissect and suture tissue without

causing injury. Forceps and some varieties of clamps are referred to as grasping instruments

because of how they perform.

Forceps, or pickups as they are sometimes called, are two-bladed, tweezer-like instruments

that are designed to pick up, grasp, and hold tissue to facilitate dissection or suturing. There

are many varieties of tips available on forceps. The selection of forceps depends on the

intended use.

1. Smooth forceps have simple serrations and smooth, tapered points for use on

delicate tissue. Examples of smooth forceps include Adson forceps and Cushing or

bayonet forceps.

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 2. Toothed forceps may be either single-toothed or have multiple teeth that interlock.

These are used on dense structures such as tough skin, fascia or cartilage when a

firm grip is needed. They will tear or puncture more delicate tissues.

3. Atraumatic forceps are used to grasp fine, delicate tissue with minimal trauma.

They have either straight or angled tips and come in various lengths and jaw widths.

Examples of atraumatic forceps are DeBakey vascular forceps and bulldog and

Cooley forceps.

Other Grasping Instruments

Grasping instruments also may be designed like clamps with ring handles. They may have

smooth or serrated tips for grasping tissue.

1. Sponge forceps have ring-shaped jaws and are used to hold gauze sponges which

are then used for retraction, blunt dissection, or to absorb blood from the surgical

field. Sponge forceps may be straight or curved. Examples of these are Fletcher

sponge forceps and sponge sticks.

2. Towel forceps are typically used to attach and secure draping material but also may

be used to hold cartilage or scar tissue or to apply traction. They are available in

perforating and non-perforating varieties.

3. Tenacula have sharp points that are used to penetrate and grasp tissue firmly. An

example is a uterine tenaculum that is used to manipulate the cervix of the uterus. 1

Tenacula may be single- or multitoothed.

EXPOSING AND RETRACTING INSTRUMENTS

These instruments are used for two major purposes:

1. to hold open the incision to provide exposure of the surgical site, and

21
 2. for holding back surrounding organs and tissue to facilitate the surgeon’s ability to

see during the procedure.

Retractors come in many different sizes and shapes. Retractors are referred to as either

hand-held or self-retaining. Smaller types can be held by the fingers or hands to retract skin

and subcutaneous tissue in shallow surgical areas while larger, heavier types may be

self-retaining and are used to retract muscle tissue and organs in deeper surgical sites.

Hand-held retractor

Hand-held retractors consist of a shaft with a curved, hooked, straight, or angled blade on

one or both ends. They usually come in pairs. Some examples of hand held retractors are:

1. Army-Navy retractors or USA retractors are used in shallow incisions. These

double-ended retractors are 10 eight inches long and have a different-sized blade at

each end.

2. Senn retractors – used to maintain exposure in small areas, such as in carpal tunnel

surgery. These retractors are double-ended and have both sharp and blunt prongs.

3. Malleable ribbon retractors – flat metal ribbons that can be shaped or bent by the

surgeon into the needed shape to adequately retract tissue. They can be used to

protect soft tissue during dissection or to provide retraction of bowel and soft tissue.

Many sizes and lengths are available.

4. Richardson retractors – frequently used in abdominal surgery to retract

subcutaneous tissue. They come in many sizes and can be used singly or in pairs.

5. Volkmann retractors – hand-held rake retractors that come with two to six sharp or

dull prongs. They must be handled very carefully to prevent injury. They are used to

retract superficial tissue.

Self-retaining retractors

22
 Self-retaining retractors have holding devices, locks, and catches which keep the

retractor in a preset position after it is inserted and adjusted. Some may be clamped in situ

or suspended at the end of a robotic arm or attached to the operating room bed and kept in

place by clamps. All pieces of self-retaining retractors with multiple detachable parts should

be checked and accounted for before and after the surgical procedure to reduce the risk of

retained surgical items. Examples of self-retaining retractors include the following.

1. Jansen retractors – frequently used in biopsies, they have two blunt blades held

apart by a ratchet with either 3 or 4 prongs on each side.

2. Weitlaner retractors – used to maintain wound exposure during procedures such as

inguinal hernia repairs and are similar to a Jansen. Weitlaners may have sharp or

blunt jaws and either an arrangement of teeth that is 2 x 3 or 3 x 4.

3. Balfour retractor – used to retract the abdominal wall during abdominalsurgery. The

blade on a Balfour is a separate piece of this retractor and is attached and adjusted

on the spreader with a wing nut. The spreader can have shallow or deep blades.

4. O’Conner-O’Sullivan retractors – also used in abdominal surgery but more

specifically for hysterectomies. This retractor comes in various configurations with

both permanently attached and adjustable blades.

5. Bookwalter retractors – table mounted and most frequently used in hepatic and

thoraco-abdominal procedures.

SUTURING AND STAPLING INSTRUMENTS

Needle holders

Needle holders may look somewhat like clamps, but they are designed specifically to grasp

and firmly hold curved suture needles, not tissue. Although they resemble hemostats, they

usually have shorter, stubbier jaws. The jaws may be straight, curved, or angled. Most have

23
many small serrations on the insides of the jaws that hold the needle in place during

suturing.

Needle holders may have a ratchet similar to that of a hemostat, or they may use a locking

or non-locking spring action. Needle holders come in many shapes and sizes to fit different

needles as well as the procedures to be performed. Examples include the following:

1. Mayo-Hegar needle holders – long and narrow, used to hold medium to

heavy-gauge needles to apply heavy sutures in deep abdominal areas, such as

during cardiothoracic surgery. They are also widely used in general surgery

2. Collier needle holders – hold medium-gauge needles.

3. Brown needle holders – hold small-gauge needles to apply sutures in superficial

tissue (e.g., for plastic surgery).

Staplers and hemostatic clip appliers

Surgical stapling instruments are often used to suture tissue quickly. As surgeons

have gained experience in the use of stapling devices, many different types have been

developed to suture and resect tissue. They can come as a single-use device or a

stainless-steel instrument with disposable staple cartridges.

Staplers are widely used in a variety of procedures that require ligation and division,

anastomosis, resection, and skin and fascia closure. Skin staples have become one of the

most frequently chosen methods of skin closure.

Nonreactive metal staples will remain permanently in the tissue. If staples must be

removed, as with skin staples, an extractor is required.

Hemostatic clip appliers are small V-shaped staples that are used to occlude a

vessel. These staples are usually placed one at a time with the use of a stainless-steel

instrument. The staples are hand loaded and passed to the surgeon who places them

around the vessel and then closes the applier to close the staple.

24
Accessory Instruments

● there are accessory instruments that do not fit into any of these categories by nature

of their function.

1. Suction tips are used to remove blood and/or body fluids as they accumulate

to provide better ability to see the surgical site. Suction tips are available in

different sizes and designs and may be provided as non-disposable or

disposable.

2. Ruler, probes, and grooves are used to measure and to dilate and probe

vessel lumens.

3. Towel clips with sharp points are sometimes used with sterile cloth towels

during the draping process. Once towel clips have been placed, they cannot

be repositioned. Non-perforating towel clips are available that can be used to

secure drapes and tubing.

4. Mallets are hammer-like instruments used for striking objects like chisels or

osteotomes.

5. Speculums are used to hold open and provide access to an orifice (e.g.,

vagina, eye, nose).

ENDOSCOPIC (MINIMALLY INVASIVE) INSTRUMENTS

With the development and increase in endoscopic and minimally invasive surgical

procedures, laparoscopic and other minimally invasive instruments have been developed

and are used routinely. Their functions within a sealed peritoneal cavity are similar to

traditional surgical instruments, but their care can be much different. Perioperative nurses

need to be familiar with the specific cleaning, disinfection, decontamination, and sterilization

25
methods used for these types of instruments. Endoscopes are inserted into a body orifice or

through a small incision to allow surgeons to examine and operate in the interior body

cavities, hollow organs, or other structures.

Endoscopic Electrosurgical Instruments Endoscopic electrosurgical instruments require

special care and attention. These instruments provide cutting and coagulating capabilities.

Endoscopic spatulas and hooks are routinely used with monopolar current, but virtually any

type of dissector, blunt grasper, or scissors can be manufactured with this option. The shafts

of such instruments are insulated to avoid injury. This insulation must be carefully checked

during processing and immediately before use to avoid patient injuries. As with standard

surgical instruments, it is important to be familiar with the anatomy of these specialized

instruments. The identifiable parts are the:

1. handle (can come in several different configurations, controls the movement of the

instrument),

2. locking mechanism (allows the instrument to be secured in position),

3. shaft (allows movement and rotation within the endoscopic surgical field), and

4. tip (consists of the working end of the instrument and may include a grasper,

scissors, retractor, or electrosurgical devices).

Endoscopes

Endoscopes may be rigid, semirigid, or flexible. Their lenses may allow various

viewing angles. Diagnostic endoscopes are designed for observation only and have no

operating channels. Operative endoscopes have a second channel for irrigation, suction,

and insertion and connection of other instrumentation. They come in various diameters and

lengths, depending on patient and procedural requirements. Endoscopic forceps and

grasping instruments enable the surgeon to manipulate tissues.

26
Trocars and cannulas

When no natural orifice exists for insertion of a diagnostic or operative endoscope,

such openings can be created using a trocar and cannula. The cannula is inserted into the

operative site using a sharp trocar as an obturator or by making a small surgical incision and

inserting the cannula with a blunt-tipped obturator. Once the port of entry has been made,

the trocar or obturator is removed and the hollow tube cannula is left in place.

ADDING ITEMS TO STERILE FIELD AND ADDING LIQUID TO STERILE FIELD

Safety considerations:

● Check physician orders and hospital policy regarding procedure.

● Instruct patient how to assist throughout the procedure (e.g., lying still, not talking
over the sterile field or touching sterile objects).

● If required, check dressing on wound to assess for required supplies needed for the
procedure.

● Offer analgesic and/or bathroom to ensure patient comfort throughout the procedure.

● Explain procedure to the patient and give an approximate time frame for completing
the procedure.

Supplies can be opened (following packaging directions), then gently dropped onto the
sterile field.

● Gently drop items onto the sterile field or use sterile forceps to place sterile items
onto the field.
● If using equipment wrapped in linen, ensure sterility by checking the tape for date
and to view chemical indicator (stripes on the tape ensure sterility has been
achieved).
● When using paper-wrapped items, they should be dry and free from tears. Confirm
expiry date.
● Do not flip or toss objects onto the sterile field.

27
 Add solution to the sterile tray by pouring the solution carefully into the receptacle:

● Verify solution and expiry date.

● Open cap and place face up on non-sterile surface.

● Hold bottle two inches above receptacle and pour the required amount slowly and
without splashing.

● If bottle is multi-use, recap and label it with the date and time of opening. Most sterile
solutions are good for 24 hours.
● Do not touch the edge of the solution receptacle. Place the receptacle near the edge
of the sterile field.

28
This ensures the sterility of the solution and the use of the correct solution. It also ensures
the bottle of solution does not come in contact with the sterile field. Lastly, it verifies the type
of solution required for the procedure. Be careful not to drip solution onto the sterile field,
causing contamination. (When liquid permeates a sterile field it is called strike through.)

Republic of the Philippines

University of Southern Mindanao
College of Health Sciences
Department of Nursing
Kabacan, Cotabato

29
 PERFORMANCE CHECKLIST

Adding Items to Sterile Field

Name of Student:______________________________________ Date: _______________

Clinical Instructor:__________________________________ Year and Section: _________

PERFORME
PREPARATION D MASTERED COMMENTS
YES NO
1. Wash hands thoroughly.

2. Open sterile item while holding outside

wrapper in non-dominant hand.

3. Carefully peel wrapper onto non-dominant

hand.

4. Being sure wrapper does not fall down on

sterile, item onto field at angle. Do not hold
arm over sterile.

5. Small items maybe dropped from 6-8

inches above the sterile field. Large items
should be put down carefully.

6. Perform procedure using sterile technique.

7. Maintains body mechanics throughout the

procedure.

8. Manifests neatness in the performed

procedure.

9. Receptive to criticisms.

10. Observes courtesy.

11. Shows calmness while performing the

procedure.

12. Uses correct English.

13. Shows mastery of the procedure.

30
 Republic of the Philippines
University of Southern Mindanao
College of Health Sciences
Department of Nursing
Kabacan, Cotabato

PERFORMANCE CHECKLIST

Adding Liquid to Sterile Field

Name of Student:______________________________________ Date: _______________

Clinical Instructor:__________________________________ Year and Section: _________

PERFORME
PREPARATION D MASTERED COMMENTS
YES NO
1. Wash hands thoroughly.

2. Prepare the sterile solution.

3. Pour a small amount of a sterile solution (e.g.

Betadine) into waste receptacle before you pour
the contents into the sterile receptacles.

4. To pour liquid into a container on the sterile

field, pour it from 6-8 inches above the receiving
container.

5. Pour slowly to prevent splashing.

6. Keep your arm as far as possible from the

sterile field.

7. Maintains body mechanics throughout the

procedure.

8. Manifests neatness in the performed procedure.

9. Receptive to criticisms.

10. Observes courtesy.

11. Shows calmness while performing the

procedure.

12. Uses correct English.

31
13. Shows mastery of the procedure.

PLACING NEEDLE TO NEEDLE HOLDER

EQUIPMENTS:
1. Surgical Needle
2. Needle Holder

SURGICAL NEEDLE
Are necessary for the placement of sutures in tissues; therefore, they must be
designed to carry suture material through tissues with minimal damage to the tissues.

SURGICAL NEEDLES THEY MUST BE:

● Sharp enough to penetrate tissues with minimal resistance.
● Rigid enough to resist bending, yet flexible enough to bend before breaking.
● Sterile and corrosion-resistant to prevent introduction of microorganisms or
foreign bodies into the wound.

BASIC NEEDLE DESIGN

1. CHORD LENGTH—The straight line distance from the point of a curved
needle to the swage.
2. NEEDLE LENGTH—The distance measured along the needle itself from
point to end.
3. RADIUS—The distance from the center of the circle to the body of the needle
if the curvature of the needle were continued to make a full circle.
4. DIAMETER—The gauge or thickness of the needle wire.

ALL SURGICAL NEEDLES NEEDLES HAVE THREE BASIC COMPONENTS:

● Eye (or swage)
Swaged needles are eyeless needles permanently attached to the suture strand by
the manufacturer.
THE NEEDLE EYE The eye falls into 1 of 3 categories:
· Closed eye: The closed eye is similar to a household sewing needle

32
 · French (split or spring) eye: French eye needles have a slit from
inside the eye to the end of the needle with ridges that catch and
hold the suture in place
· Swaged (eyeless)

● Body
The body of the needle is the portion which is grasped by the needle holder during
the surgical procedure. The body of the needle should be as close as possible to the
diameter of the suture material to minimize bleeding and leakage. Point Sharpness
and needle point geometry are critically important characteristics
● Point. Point Body Eye Swaged needle suture

PRINCIPLES OF CHOOSING A SURGICAL NEEDLE

● Taper point needles are used to suture tissues that are easy to penetrate.
● Cutting or TAPERCUT needles are used in tough, hard to- penetrate tissues.
● When in doubt about whether to choose a taper point or cutting needle, choose the
taper point for everything except skin sutures.

NEEDLE PERFORMANCE CHARACTERISTICS

The performance of a surgical needle depends on 2 major features:
a. Strength • ability to penetrate tissues easily
b. Ductility

PROCEDURE
1. Select an approximate size for the given needle.
2. Hold the needle holder tightly by squeezing it until the first ratchet catches. The
needle is hold vertically and longitudinally perpendicular to the needle holder.
3. Hold the needle holder by placing the thumb and the fourth finger into the loops
and by placing the index finger on the fulcrum of the needle holder.
4. Open the suture with needle packet with one tear to reveal the needle.
5. Grasp the needle two-thirds the distance from its pointed end.
6. Avoid grasping the needle at its proximal or distal extremities since this will
prevent damage to suture.
7. Use the ratchet lock to secure the position of the needle.

33
 PLACING AND REMOVING BLADE TO BLADE HOLDER

EQUIPMENTS:
1. Surgical Blade
2. Blade Hoder

Cutting & Dissecting

● Cutting instruments have sharp edges.

● They are used to dissect, incise, separate, or excise tissue.

● Most instrument sets will include #3 and #7 knife handles & suture, curved mayo,
metz and tenotomy scissors.

Blade Handles

● Come in various widths & lengths

● Blades are attached by slipping the slit in the blade into the groove on the handle

Other Blade Holders

• Long handles are used inside deep incisions (e.g., open abdominal cases)

• Beaver knifes are used for small delicate cases

Surgical Blades

• Blades with numeric prefix of “1” (e.g., 10, 11, 12, 15) fit #3 or #7 handles

• Blades with the numeric prefix “2” (e.g., 20, 21, 22, 23, 24) fit #4 handles

• #10 are used for large skin incisions

34
 • #15 are used for short shallow incisions

• #11 are used for initial skin puncture of tiny deep incisions

How to Use a Scalpel

• Scalpel blades like all sharps are inherently dangerous and should be used only
when necessary.
• Do not use it to cut papers, tapes, plastic bags as there are other more
appropriate instruments for such use.
• Use blunt manual dissection or curved surgical scissors to when prosecting and
dissecting. Use a scalpel blade only when necessary.
• Only one person should be handling the scalpel blade at any one time.
• Always keep the scalpel blades in clear view on the tray / table, away from the
specimen, pools of blood, tissues and other instruments.
• Pass the blade to another person by placing the blade on the table for the other
person to take it from the table. Avoid passing the blade to one another directly.
• The scalpel blade is not a pointing device and should never be used to point to an
object of interest in a specimen or to gesticulate in general.
• Great caution should be used in the vicinity of the person holding the a blade.
Personnel assisting in holding a specimen should be keep watch of the position
of the blade at all times.
• Do not use a scalpel blade bare, use a scalpel blade handle. Do not fashion a
scalpel blade handle from the packing package or other materials.
• Cutting in haste with the scalpel blade increases the danger of handling the
instrument.
• Only 1 scalpel blade should be opened and used on the cutting area at any time.
A new blade should be procured only after the old blade has been properly
discarded.
• Drop a used blade into the sharps container. Do not pushed into the sharps
container. Sharps containers should be emptied regularly to avoid overfilling.
• Ensure adequate supplies of blades and a sharps container before starting.

PROCEDURE

1. Get the correct size blade for the The size is on both the blade handle
blade holder. and the blade itself to prevent
cutting and easy to install.

35
2. With the blade pointing away from To prevent cutting the skin and for
you, open the bade packet exposing easy visualization of blade packet.
the blade lock hole.
3. Grip the blade at the non-cutting
edge away from the slanted edge,
with a non-toothed forceps, needle
holder or artery forceps without
covering the blade lock hole.
Carefully pull the blade out.
4. Align the blade with the blade holder. The slanted edge of the blade
should be in the same alignment as
the blade holders slanted edge.
5. Place the blade into the grooves on
both sides of the blade.
6. Slide the blade over the blade key For safety purposes.
until the whole blade locks in place.

7. With the blade pointing away from you

and anyone else, grip the blade at the
slanted edge at the part of the blade
that juts out with a non-toothed
forceps, needle holder or artery
forceps hole.
8. Carefully lift the blades end until the
blade lock hole lifts up from the blade
key . Carefully push the blade out.
9. Once totally out from the blade holder,
dispose of the blade into the sharps
bin.

36
 Republic of the Philippines
University of Southern Mindanao
College of Health Sciences
Department of Nursing
Kabacan, Cotabato

PERFORMANCE CHECKLIST

Placing Needle to Needle Holder

Placing and Removing Blade to Blade Holder

Name of Student: ______________________________________ Date: _______________

Clinical Instructor: __________________________________ Year and Section: _________

37
 PERFORMED
PROCEDURE MASTERED COMMENTS
YES NO

PLACING NEEDLE TO NEEDLE HOLDER

1. Select an approximate size

for the given needle.

2. Hold the needle holder tightly

by squeezing it until the first
ratchet catches. The needle
is hold vertically and
longitudinally perpendicular
to the needle holder.

2. Hold the needle holder by

placing the thumb and the
fourth finger into the loops
and by placing the index
finger on the fulcrum of the
needle holder.

4. Open the suture with needle

packet with one tear to
reveal the needle.

5. Grasp the needle two-thirds

the distance from its pointed
end.

6. Avoid grasping the needle at

its proximal or distal
extremities since this will
prevent damage to suture.

38
 7. Use the ratchet lock to
secure the position of the
needle.

PLACING BLADE TO BLADE HOLDER

8. Get the correct size blade for

the blade holder.

9. With the blade pointing away

from you, open the bade
packet exposing the blade
lock hole.

10. Grip the blade at the

non-cutting edge away from
the slanted edge, with a
non-toothed forceps, needle
holder or artery forceps
without covering the blade
lock hole. Carefully pull the
blade out.

11. Align the blade with the

blade holder.

12. Place the blade into the

grooves on both sides of the
blade.

13. Slide the blade over the

blade key until the whole
blade locks in place.

REMOVING BLADE TO BLADE HOLDER

39
 14. With the blade pointing away
from you and anyone else,
grip the blade at the slanted
edge at the part of the blade
that juts out with a
non-toothed forceps, needle
holder or artery forceps hole.

15. Carefully lift the blades end

until the blade lock hole lifts
up from the blade key.

16. Carefully push the blade out.

17. Once totally out from the

blade holder, dispose of the
blade into the sharps bin.

Percentage Score: ______________

REPORTING INSTRUMENTS PRIOR TO CLOSURE OF SURGICAL SITE

SURGICAL COUNT POLICY

40
 To ensure patient safety and accountability for all items used during a surgical
procedure a surgical count is required.

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

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

EXCEPTIONS

41
When counts, particularly instrument counts, cannot be done with complete accuracy and
confidence due to large amount of complex instrumentation, speed of closure or the
emergency nature of the surgery:
● An x-ray is taken
● The x-ray is read by the surgeon prior to closure of the patient
● An incident report is completed

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

An instrument count is not performed when a cavity is not entered or the incision/cavity is
deemed to be of a size that does not present a risk of instrument loss.

PROCEDURE
1. Perform the closure count from the items
off the sterile field -> back table -> mayo
stand ->operative field.

2. Systematically move across the back table in

one consistent direction (may be either
Right to Left of Left to Right.)
3. Confirmed the closure count with the
Circulating Nurse.
4. If complete, results of counts are announced
audibly to the surgeon, anesthesiologist
and the other members of the surgical
team.

“Excuse me Dr._____________ (Surgeon), Dr.

__________ (Anesthesiologist) and the rest
of the Team. All sponges, instruments, and
needles are complete as counted, you may
now proceed to the closure of the incision
site”

5. Receives a verbal acknowledgement from the

Surgeon.

42
 Republic of the Philippines
University of Southern Mindanao
College of Health Sciences
Department of Nursing
Kabacan, Cotabato

PERFORMANCE CHECKLIST

Reporting of Instruments Prior to Closure of Surgical Site

Name of Student: ______________________________________ Date: _______________

Clinical Instructor: __________________________________ Year and Section: _________

PERFORMED
PROCEDURES MASTERED COMMENTS
YES NO

1. Perform the closure count from the items off the

sterile field -> back table -> mayo stand
->operative field

2. Systematically move across the back table in one

consistent direction (may be either Right to Left of
Left to Right.)

3. Confirmed the closure count with the Circulating

Nurse.

Note:
When count discrepancy occurs,

- Recount
- Notify surgeon
- Surgeon checks incision
- Search laundry, garbage, drapes, floor, etc

4. If complete, results of counts are announced

audibly to the surgeon, anesthesiologist and the
other members of the surgical team.

“Excuse me Dr._____________ (Surgeon), Dr.

__________ (Anesthesiologist) and the rest of
the Team. All sponges, instruments, and
needles are complete as counted, you may
now proceed to the closure of the incision
site”

5. Receives a verbal acknowledgement from the

Surgeon.
Percentage Score: __________________

43
 References

Some general information of this revised manual was adopted from:

❖ San Pedro College Nursing Department Manual of Nursing Procedures,

2004-2005, (1st Edition)
❖ Davao Doctors College Nursing Department Manual of Nursing Procedures,
2001-2002, (2nd Edition)
❖ University of Southern Mindanao, College of Health Sciences, Manual of
Nursing Procedures, 2004-2005, (1st Edition)

The Development learning tips in the development of this revised manual were
patterned from:

❖ Ateneo De Davao University Manual of Nursing Procedures

❖ De La Salle Medical and Health Sciences Institute Manual of Nursing
Procedures
❖ San Pedro College Nursing Department Manual of Nursing Procedures
❖ Angeles University Foundation College of Nursing

44