Written Requirements of Assigned Readings

As a neophyte in the Operating Room, the following basic concepts are necessary for effective
learning to take place. Remember to cite references used as you complete one of the needed
requirements. (You may use the back pages should you need more space).

1. Define ASEPSIS

A condition of asepsis occurs when there are no active pathogenic microorganisms. Asepsis refers to all
practices that use sterile tools, sterile draping, and the gloved "no touch" technique to lower the danger of
bacterial, fungal, or viral contamination

2. Explain ASEPTIC TECHNIQUE

An aseptic technique is used to carry out a procedure in a way that minimizes the risk of contaminating an
invasive device, e.g. urinary catheter, or a susceptible body site such as the bladder or a wound.

3. Differentiate the STERILE Technique from the ASEPTIC technique.

The aseptic technique is intended to minimize contamination from pathogens. While the sterile technique
is used to create an area free from any microorganisms, pathogenic or otherwise.

4. Enumerate 12 Principles of Sterile Technique

• Sterile items are used within the sterile field
• Sterile individuals are gowned
• Tables are only sterile at table level
• Sterile individuals touch sterile items, and unsterile individuals touch unsterile items
• Unsterile individuals need to avoid reaching sterile fields, as well as sterile
individuals, need to avoid touching unsterile fields
• Edges of anything that encloses sterile contents are considered unsterile
• If unsure of sterility, consider it unsterile
• Sterile field is set up just before a surgical procedure
• Sterile areas are continually kept in view
• Sterile individuals keep in the sterile field
• Destruction of the integrity of microbial barriers results in contamination
• Microorganisms must be kept at a minimum
5. Enumerate the Five (5) Phases of the INTRAOPERATIVE PERIOD and give a brief
explanation for each phase.

Phase I – Preparation Sequence

1. Selection and preparation of procedure room and supplies

2. Pre-incisional count like, sponges, sharps and instruments, sutures etc.

Phase II – Preincisional Sequence

1. Transferring of the patient to the procedure room and positioning

2. Induction of anesthesia
3. Prepping and Draping
4. Establishment and verification of suction and electrosurgical capabilities

Phase III – Operative Sequence

 • Incision - The skin and subcutaneous tissue are incised with the skin knife, which is then placed
on the back table.
• Hemostasis – Subcutaneous bleeders are clamped with a curved hemostat and ligated/
cauterized according to the surgeon’s preference. The area is periodically sponged by the
assistant to aid in the visualization of further sources of bleeding.
• Dissection and Exposure – A clean knife, curved cutting scissors (Metzembaum), or cautery is
used to incise the deep fascia and peritoneum prior to incising it, as this will prevent inadvertent
damage to the underlying bowel
• Exploration and Isolation – Prior to definitive surgery, the entire abdomen is explored, and the
pathology is isolated for further action. Very often the operative site is obscured by surrounding
viscera, making dissection of intended pathology dangerous. In this case, the surgeon will
“pack” the abdomen using large moist lap sponges and insert a self–retaining abdominal
retractor (Balfour) to maximize exposure.
• Surgical repair: Excision or Revision - Depending on the purpose of the surgery and local
anatomy, each surgical procedure will require a certain amount of dissection of surrounding
tissue. For most abdominal cases, Metzembaum scissors, smooth tissue forceps, and sponges
are required. As depth increases, the length of the instrument also increases. The surgeon has
their own instrument that they prefer, and scrub nurses must anticipate what instrument the
surgeon uses.
• Hemostasis and Irrigation – In preparation for closing, the surgeon will survey the operative
site for bleeders, control the bleeding via ligation/ cauterization, and irrigate the wound with
warmed normal saline (with or without antibiotic) If a drain will be needed, the site is prepared,
and drain is inserted.
• Collection and verification of Specimen – With permission from the surgeon, specimens for
routine analysis are removed from the surgical field and passed off to the circulator for
processing

PHASE IV – Closing Sequence

• Closing Counts – The scrub nurse anticipates closure and begins the first closing count with the
circulating nurse. Sponges, sharps and instruments are counted prior to closure of the peritoneal
cavity.
• In the case of a laparotomy, sponges and retaining instruments are removed, the wound is irrigated,
and Kocher clamps used to grasp the edges of the peritoneum. The peritoneum and fascia will be
closed serially. Then the second closing count is performed; sponges and sharps only, and the skin
is closed using either sutures or skin staples.
• Anesthesia Reversal and Stabilization
• Application of Dressing/ Tape – The dressing is applied by the surgeon and assistant following the
surface cleaning of the incision and removal of dried surgical prep solution. The drape sheets are
removed, and the tape is applied by the circulating nurse

PHASE V – Postoperative Sequence

• Preparation for Transfer – The intraoperative records are completed; a warm blanket is placed on
the patient; the circulator assists in transferring the patient from the operating table to the recovery
bed only when anesthesia personnel are ready.
• Transference to Post anesthesia Area – The circulating nurse accompanies the patient and
anesthesia personnel to the post anesthesia care area and give a verbal report to the nurse who
will continue to care for the patient.
• Postprocedural Routine – The postprocedural routine consists of the delivery of specimens and
records to a designated location by the circulating nurse, and assistance in the clean – up and
preparation for the next procedure performed in the room.
 6. Differentiate between the role of a scrub nurse versus that of a circulating nurse
Scrub Nurse Circulating Nurse
A. Before the surgery
Do hand hygiene, gowning, and gloving, and Assis the scrub nurse with hand hygiene,
prepare for the sterile materials to be used. gowning, gloving and opening the packages of
sterile materials to be used.
Keeping the sterility of its field. Ready the equipment to be used.
Counting of materials Re-counting/checking materials
Checks the special requests of the surgeon Records every material to be used
Helps surgeon to skin preparation Admits patient to surgical suite
B. During the surgery
Assist the doctor in the surgery. Assembles table Assist the whole team, for unsterile purposes.
to maintain sterility.
Passing the instrument to be used Opens a new pack of tools if needed and lets the
scrub nurse reach it.
Monitors dropped materials Picks up dropped materials and re-clean and re-
sterilized them.
Collects all materials while on surgery, and takes Counts sponges discarded.
note of the sponges, and packs used.
Makes sure that all sterile materials are working Does the paperwork for the procedure
Maintains internal count of sponges, packs, and Records the added supplies
instruments
C. After the surgery
Collects all materials after use. Take notes and recounts all the materials used.
Discards all sharp materials. Ready the bins to be used
Puts all the materials in the basket for cleaning Prepares the basket for material cleaning
Ungowns, and Discard gloves Assist the scrub nurse with doffing.
Cleans the materials to be used for the next
surgical procedure
Prepares terminal cleaning of instruments and Finalizes records and charges.
non-disposable supplies
Initially clean the soiled materials used Takes patient to PACU
Reports to the Nurse in charge Reports to the Nurse in charge
7. Identify surgical needles and sutures

Suture Illustration
Plain Gut - absorbable sterile surgical sutures
composed of purified connective tissue (mostly
collagen) derived from the serosal layer of beef
(bovine) or the submucosal fibrous layer of sheep
(ovine) intestines.

Chromic - Created from the submucosal fibrous

layer of sheep intestines or the serosal layer of beef
Chromic Gut sutures are made of purified
connective tissue. The tissue used is mainly
collagen and chemically treated. Strands of the
membrane are woven together.
 Coated Vicryl - is a synthetic absorbable suture
coated with a lactide and glycolide copolymer plus
calcium stearate.

Surgical Silk - protein derived from silkworms that

is coated to minimize friction and water absorption.
Has good tensile strength, easy to handle and
excellent knot security

Ethilon Nilon - non-absorbable monofilament

suture materials which provide good tensile
strength with low tissue reactivity and are therefore
widely used.

Prolene - use in general soft tissue approximating

and/or ligation, including use in cardiovascular,
ophthalmic procedures, and neurological
procedures.

Merselene

Common Surgical Needles

Curved and Straight Needles

Curved Needles

o Manipulated with needle holders

o rotating the wrist in an arc similar to that of the needle is the
easiest and most efficient
o curvature is described by the amount of the circumference of a
circle
o most common curves are 3/8 and ½
o wider curves are useful when suturing thick tissues or in deep or
poorly accessible locations
o it is most commonly used by surgeons

Straight Needles
 o used on near-surfaces such as skin
o inserted through tissues with fingers not needle holders
o usually combined with hand ties

Tapered Needles – The needle is round and tapers to a simple point. Most commonly used in softer tissue
such as the intestine but may also be used in tougher tissue such as muscle.

Conventional Cutting – The needle is triangular with sharp edges, and one edge faces the inside of the
curved needle. Used for tougher tissues such as skin

8. Draw the parts of a surgical needle and label them accordingly.

 9. Illustrate the surgical forceps and surgical scissors and label them accordingly.

Instrument Illustration
Mayo scissors Curved – use to cut thick
tissues

Mayo scissors straight – heavy scissors for

multiple varieties, for cutting sutures

Metzenbaum Scissors (Metz) - Lighter

scissors used for cutting delicate tissue

Tissue Forceps (Non toothed) - used for

fine handling of tissue and traction during
dissection

Adson Forceps - Forceps toothed at the tip

used for handling dense tissue, such as in
skin closures

DeBakey forceps - Used for atraumatic

tissue grasping during dissection.
Allis Clamp - Slightly rounded jaws, both
used for grasping the intestine and for a
towel

Towel Clamp – used for grasping the towel

Crile Hemostat - aka “snap,” atraumatic

and non-toothed clamp used to grasp tissue
or vessels that will be tied off. Also used in
blunt dissection.

Kelly Clamp - Larger size variation of

hemostat with a similar function for grasping
larger tissues or vessels.

Kocher Clamp - Traumatic toothed clamp

used to hold tissue that will be removed.

Derf Needle Holder – use to hold needles

 10. Layers of the abdomen with their corresponding sutures and needles (ZCMC OB-GYNE
practice)
LAYERS of the Sutures Color of the Sutures Needle
Abdomen
Organ of Uterus
• Endometrium Chromic 1 Brown
RN - ATN
• Myometrium Chromic 1 Brown
• Perimetrium Plain 2/0 Yellow
Peritoneum Plain 2/0 Yellow RN – ATN
Fascia Polysorb/Safil/Vicryl 1 Violet RN – ATN
Subcutaneous Plain 2/0 Yellow RN – ATN
Skin Polysorb/Safil/Vicryl 3/0 Violet CN – ATN

11. Explain the World Health Organization (WHO) Surgical Safety Checklist. Include the diagram.
It is a 19-item checklist to reinforce an accepted practice in an institution and creates a better
communication and teamwork environment among different clinical practitioners. This checklist is
completed in under 2 minutes only. This aims to be used as:

• Tool for use by clinicians interested in improving the safety of their operations and reducing
unnecessary surgical deaths and complications.
• Surgical safety checklist to reduce complications and mortality perioperatively by 30%.,
• Improvements could be made in the safety of surgical care such as surgical site infection prevention,
safe anesthesia, safe surgical teams, and measurement of surgical services.

12. Types of Surgical Incision and organs involved.

Incision Organs Involved

Midline Incision Abdominal Viscera or Intra-abdominal access.
Kocher Incision (Subcostal) Gallbladder and biliary tree
Para-median Incision Expose lateral viscera. Intra-abdominal access.
Gridiron Incision (McBurney Incision) Open appendectomies.
Lanz (Rockey-Davis) Incision Open appendectomies but horizontally.
Thoracoabdominal Pleural, distal esophagus, and peritoneal cavity. Left incision:
stomach, distal esophagus, Right incision: hepatic region, right
kidney
Chevron Hepatic, pancreatic, upper gastrointestinal region, adrenal and
renal.
Pfannenstiel (Kerr/Pubic) Incision Pubic region
McEvedy Incision Peritoneum, femoral canal
Subclavicular Incision Access to subclavian vessels (vertebral artery, thyrocervical
trunk, internal thoracic artery, costocervical trunk, dorsal
scapular artery)
Supraclavicular Incision Subclavian vessels + exposure to cervical/thoracic anatomy
Median Sternotomy Sternum, pleural cavity, aorta, branches of head and upper
extremities, epigastric region.
Trapdoor Incision Pleural space, mediastinum, cervical vasculature, heart
Clamshell Lungs, chest wall, hilum, descending aorta
Mercedes-Benz Same as chevron
Supra-umbilical/Infra-umbilical Umbilical region, peritoneum
Pararectus Abdominal access for appendix, pelvic and colon with extension
Maylard Incision Upper abdomen, lateral pelvic wall, usually for caesarian.
Gibson For gynecological/urological procedures
Inguinal Inguinal canal
 Carotid/Thyroidectomy/tracheostomy Clavicles, carotid, jugular veins, trachea
Laparoscopic incision Umbilicus region

13. Enumerate 9 common Surgical Positions and briefly explain

Fowler’s Position - also known as the sitting position, is typically used for neurosurgery and shoulder
surgeries. The beach chair position is often used for nasal surgeries, abdominoplasty, and breast reduction
surgeries. When positioning a patient in Fowler's position, the surgical staff should minimize the degree of
the patient's head elevation as much as possible and always maintain the head in a neutral position.
Supine Position - also known as Dorsal Decubitus, is the most frequently used position for procedures.
In this reclining position, the patient is face-up. The patient's arms should be tucked at the patient's sides
with a bedsheet, secured with arm guards to sleds. Supine position is commonly used for the following
procedures: intracranial, cardiac, abdominal, endovascular, laparoscopic, lower extremity procedures,
and ENT, neck, and face

Prone Position - the patient is face-down with their head in a neutral position without excessive flexion,
extension, or rotation. A face positioner is used when the patient's head is in the midline. The prone position
is often used for spine and neck surgeries, neurosurgery, colorectal surgeries, vascular surgeries, and
tendon repairs.

Lithotomy Position - In the Lithotomy position, the patient can be placed in either a boot-style leg holder
or stirrup-style position. Modifications to this type of position include low, standard, high, exaggerated, or
hemi. This position is typically used for gynecology, colorectal, urology, perineal, or pelvis procedures.

Sim’s Position - a variation of the left lateral position. The patient is usually awake and helps with
positioning. The patient will roll to his or her left side. Body restraints are used to safely secure the patient
to the operating table.
Trendelenberg Position - used for lower abdominal, colorectal, gynecology, and genitourinary surgeries,
cardioversion, and central venous catheter placement. In this type of position, the patient's arms should be
tucked at their sides, and the patient must be secured to avoid sliding on the surgical table.

Reverse Trendelenberg Position - used for laparoscopic, gallbladder, stomach, prostate, gynecology,
bariatric, and head and neck surgeries. Padded footboards should be used to prevent the patient from
sliding on the surgical table and reduce the potential for injury to the peroneal and tibial nerves from a foot
or ankle flexion
Lateral Position - Lateral position during back, colorectal, kidney, and hip surgeries. It's also commonly
used during thoracic and ENT surgeries, and neurosurgery. A pillow or head positioner should be placed
under the patient's head with the dependent ear assessed after positioning. The patient's physiologic spinal
and neck alignment should be maintained during the procedure, and a safety restraint should be secured
across the patient's hips.

Jack-Knife Position - also known as Kraske, is similar to Knee-Chest or Kneeling positions and is often
used for colorectal surgeries. This type of position places extreme pressure on the knees. While positioning,
surgical staff should place extra padding for the knee area.
 14. Identify the general skin preparation areas before surgeries

Skin Preparation Area Illustration

Abdominal Preparation

Chest and Breast Preparation

Hip Preparation or Lower
Extremity

Rectoperineal and Vaginal

Anterior Head and Neck

 Anterior Shoulder

Leg Preparation

Principles

• Start at the surgical site then move outward in a circular motion

• Do not go back
• Include areas larger then surgical site
• Always know that its purpose is to reduce transient microbial counts at the surgical site prior to
surgical incision. This is to minimize growth intra and postoperatively.
• Use appropriate solution prior to skin preparation based on institutional standards.
 15. Determine the responsibilities of an OR nurse during surgical counts of instruments,
sponges, and sharps.

• Initial Sponge count, and instrument counts should be performed and recorded on all procedures,
as they establish a baseline for subsequent counts. Established policies in the facility may define
when additional counts must be performed or may be deleted
• Accurately accounting for sponges and equipments throughout a surgical procedure is a primary
responsibility of the perioperative nurse and constitutes a proactive injury-prevention strategy
• Sponges should be separated, counted audibly, and concurrently viewed during the count
procedure by two individuals, one of whom should be a registered nurse circulator. Concurrent
verification of counts by two individuals lessens the risk of inaccurate counts. Separating sponges
during the baseline count helps to determine whether a sponge has been added to or deleted from
a sterilized package. Separating sponges after use minimizes errors caused by sponges sticking
together.
• When additional sponges are added to the field, they should be counted at that time and recorded
as part of the count documentation to keep the count current and accurate
• Perioperative personnel should count all prepackaged sterilized sponges for accuracy. Any
package containing an incorrect number of sponges should be removed from the field, bagged,
labeled, and isolated from the rest of the sponges in the OR. Containing and isolating the entire
package helps reduce the potential for error in subsequent counts
• Sponge counts should be conducted in the same sequence each time as defined by the facility.
The counting sequence should be in a logical progression. All sponges must be x-ray detectable.
The use of x-ray-detectable sponges as surface dressings may invalidate subsequent counts if the
patient is returned to the OR. X-ray-detectable sponges used as dressings may appear as foreign
bodies on postoperative x-ray studies
• Sharps should be unmounted first before throwing to red container or sharps container.
• Separate sharps, and needles accordingly.
• Group the instruments according to type so that its easier to visualize what is missing.
• As for the additional instruments added, document right away.
• Always count how many sutures have used.