OPERATING ROOM

NURSING
 Part 1 - Learning Objectives

After studying this COURSE the learner will be able to:

1. Outline the history of surgery

2. Define perioperative nursing and operating room nursing.
3. Describe phases of the perioperative period.
4. Discuss the layout of a typical operating room (OR).
5. Discuss common equipment and furniture in the OR.
6. Describe the common of surgical instrument.
5. Describe the Roles and FUNCTIONS of the members of the
operating room team.
6. Describe and practice surgical scrubbing, gowning and
gloving,
• Surgery is
– an invasive method of treatment that
– may be planned or unplanned,
– major or minor, and that may
– involve any body part or system.
• Perioperative nursing is provision of nursing care
throughout the total surgical experience of the
patient.
• Peri-operative care involves skillful and
knowledgeable nursing care for the surgical Patient
throughout the 3 phases of their surgical experience
(whether surgery is done on an outpatient basis or in the ideal
operation room).
 Types of surgery

• Elective--- the approximate time for surgery is at the

convenience of the patient e.g. Knee surgery,
Prostatectomy
• Emergency--- situation requires immediate surgical
attention without delay e.g. Intestinal obstruction,
Obstructed labour, fetal hypoxia
• Urgent--- the surgical problem requiring attention within
24-48 hours e.g. Cancer of the thyroid
• Required surgery – the condition requires surgery within a
few weeks e.g. Cataract extraction
• Ambulatory (day) surgery( same day surgery- outpatient
surgery e.g. Circumcision, I & D
• Optional– surgery is scheduled completely at the
preference of the patient e.g. Cosmetic surgery
 History of Surgery
Operating Room (OR) nursing has developed
along side the history of surgery.
Surgery is an old form of treatment that can be
traced back through the history of man
In the past there were no theatres. No trained
personnel, No anesthesia and No equipment.
Healers performed surgical Operations in the
patient’s home – often using crude ordinary tools
and instruments.
Problems of surgery during this time included
infection, bleeding and pain
 History of Surgery

To solve those problems (bleeding, pain, infection), in 17 th century

BCE, alcohoL and opium were used to relieve pain especially during
amputations.

In 1772 Joseph Priestly discovered the use of Nitrous oxide as

anesthesia, and in 1842 Dr. Crawford discovered the use of Ether. In
1847 James Young began to use Chloroform

In the 18th century a great breakthrough was made with the discovery
and use of muscle relaxants: Trilene, Thiopentone, Clytopopaine and
Curare.
By the end of 19th century pain relieve was an integral part of surgical
operations.
 History of Surgery

• In order to control bleeding the ancient Greeks and

Romans, as far back as the 16th century BCE used
strings and ligatures.
• Later on during the Middle Ages, healers came up
with the use of hot iron. The idea has been
developed into the use of cautery diathermy to
control bleeding.
• By the beginning of the Twentieth century many
types of ligatures were available prepared from
metal, animal tendon, nylon and cotton.
 History of Surgery

• The control of infection dates back to the efforts of

Louis Pasteur who proved that bacteria caused
infection.
• In 1865 Joseph Lister used carbonic acid to reduce
the growth of bacteria in wounds
• In 1886 Von Bergemen introduced sterilization of
dressing materials.
• In 1890 gloves were introduced in surgery.
 PERIOPERATIVE NURSING
• Perioperative nursing is the nursing care provided THROUGHOUT
the total surgical experience of a patient;
1) Preoperative
2) Intraoperative
3) Postoperative
• Preoperative phase----- from the time the decision is made for
surgical intervention to the transfer of the patient to the operating
room
• Intraoperative phase---- from the time the patient is received in
the operating room until admitted to the recovery room
• Postoperative phase---- from the time of admission to recovery
room to the follow up/ home/ clinic evaluation
 PERIOPERATIVE CARE
Utilizes All phases of the Nursing process:
– to make assessments,
– arrive at a diagnosis,
– make appropriate plans and
– provide interventions necessary to:
• Promote the recovery of health,
• Prevent further injury or illness, and
• Facilitate coping with alterations in physical structure
and function.
• The three phases of the patient’s perioperative experience:
• The preoperative phase,
• The intraoperative phase, and
• The postoperative phase.

• Preoperative phase – from the time the decision is made for

surgical intervention to the transfer of the patient to the
operating room.

• Intraoperative phase – from the time the patient is received

in the operating room until s/he is admitted to the recovery
room.

• Postoperative phase – from the time of admission to the

recovery room to the follow-up home or clinic evaluation.
 Design of the operating room

Principles in design
• The universal problem of environmental control to
prevent wound infection exerts a great influence on the
design of the operating room (OR) suite. Clean and
contaminated areas should be well differentiated.
Architects follow two principles in planning the physical
layout of the OR suite:
1. Exclusion of contamination from outside the suite with
sensible traffic patterns within the suite.
2. Separation of clean areas from contaminated areas
within the suite.
 Design of the operating room

• The basic design principles which are common to all operating

rooms must fulfill the following criteria:

1. The design must always be simple and easy to keep it clean

2. Wall and floor surfaces should be smooth and made of nonporous
materials
3. In order to prevent cross – contamination (the transfer of disease
causing microorganisms from one source to another), there should be
separate rooms for clean or sterile instruments and soiled ones.
4. There should be sufficient space to ensure the safe transportation of
patients and staff.
5. The layout of the department should be convenient for the
supervisor to control the incoming and outgoing traffics.
6. The recovery room should be near the operating room, so that
patients can be transported safely and quickly following surgery.
• Space is allocated within the OR suite to provide for the work to be
done, with consideration given to the efficiency with which it can be
accomplished.
• The OR suite should be large enough to allow for correct technique,
yet small enough to minimize the movement of patients, personnel,
and supplies.
• Provision must be made for traffic control. The type of design
• All persons – staff, patients, and visitors – should follow the
delineated patterns in appropriate attire.
• Signs should be posted that clearly indicate the attire and
environmental controls required.
• The OR suite is divided into three areas that are designated by the
physical activities performed in each area.
 Zone A: Unrestricted Area

1. Street cloths are permitted.

2. A corridor on the periphery accommodates
traffic from outside, including patients.
3. This area is isolated by doors from the main
corridor and from other areas of OR suite.
4. It serves as an outside-to-inside access area.
5. Traffic, although not limited, is monitored at
a central location.
 Zone B: SEMI-restricted area
1. Traffic is limited to properly attired (dressed)
personnel
2. Body and head coverings are required
3. This area includes peripheral support areas
and access corridors to the operating rooms.
4. The patient may be transferred to a clean
inside stretcher on entry to this area
5. The patient’s hair must be covered
 Zone C: Restricted area
1. Masks are required to supplement surgical
attire
2. Sterile procedures are carried out in this area
3. The area includes the operating rooms, scrub
sink areas and substerile rooms or clean core
area(s) where unwrapped supplies are
sterilized.
Areas within the operating room
• The supervisor’s Office (A) has direct access to the outside of
the operating room. The supervisor may need to receive visitors
and significant others who are not dressed in scrub attire.
• Dressing rooms (B) for operating room personnel have a door to
the outside corridors so that personnel may enter there, change
into scrub attire and go directly into the operating room.
• The holding area (C) is on area designated for the parking of
stretchers with patients awaiting surgery. This is the area where
the health care givers properly identify the patient and make
sure that all preoperative cares are carried out and other
important data are in the patient’s chart.
• Scrub sink areas (D) are located in several places close the
operating suites. Scrub brushes, Caps, Soaps, masks are
located at each scrub station/
• The workroom (E) is located so as to be away from the direct
traffic of the operating suites. It is divided into two separate
areas, one for clean instruments and supplies and one for
soiled equipment.
• The sterile supply room (F) serves as a supply depot for
wrapped sterile articles. This area should be dusted
frequently with a damp cloth and have storage cabinets with
doors to minimize exposure of the supplies to room air and
dust.
• Storage areas (G) for extra equipment and supplies
are used to store these extra instruments and
supplies for each unit.
• The recovery room (H) has an access to the outside
of the operating room for transporting patients
back to their rooms.
• The operating suites (I) are rooms where surgery is
performed. These rooms are wide enough to allow
scrub personnel to move around non sterile
equipment without their contamination.
 OR Doors

• Ideally, sliding doors should be used in the OR. They

eliminate the air currents caused by swinging doors.
• Microorganisms that have previously settled in the room are
disturbed with each swing of the door. The microbial count
is usually at its peak at the time of the skin incision because
this follows disturbance of air by gowning, draping,
movements of personnel, and opening and closing of doors.
• During the surgical procedure, the microbial count rises
every time doors swing open from either direction.
• Also, swinging doors may touch a sterile table or person. The
risk of catching hands, equipment cords, iv line tubing, or
other supplies is increased.
 OR Furniture & Equipment
Wall Clock
• Since time is often critical during surgery, each
room should have a wall clock that is easy to
read. The clock is used to time tourniquet
applications, administration of medications, the
duration of cardiac and respiratory arrests and
to note the time of events such as childbirth.
X-ray Viewing Boxes
• The surgeon may need to view an x-ray before or
during the procedure.
Lighting
• The overhead lights should specially designed to
provide a range of intensity. They should be freely
movable, shadowless and less heat emitting.
The Operating Table
• The table should be fully adjustable in all directions to
create postures needed for various surgical positions.
Mayo Stands
• This stand is used to hold instruments that will be
used frequently during a particular case.
Back Table
• The back table is used to place extra supplies and instruments used during surgery.

Ring Stand
• The ring stand is used to hold basins which contains normal saline or sterile water
during surgery.
Kick Bucket
• The kick bucket (a bucket on wheels) is used to place soiled sponges during
surgery.

Supply Cabinets
• These cabinets are used to store frequently used items such as drapes, dressings,
solutions, sutures, etc. Cabinets with doors are preferred to those without so as to
reduce exposure of the content to dust.
Anesthesia Equipment
• Equipment, including the gas machine, physiological monitor, anesthesia supply
cart, and sitting stools, is located in each room.
 Operating Room STAFF

Just as there is a logical order to the physical design, there is a logical

division of duties among the operating room staff.

Operating Room Team

• When the patient arrives to the operating room, she is received and
surrounded by a surgeon, one or two assistants, an anesthesia
provider, a scrubbed nurse, a circulating nurse etc.
• These individuals, each with specific functions to perform, form the
operating team.
• This team literally has the patient’s life in its hands.
• The operating team works in harmony with colleagues for the
successful accomplishment of the expected outcomes of the patient.
 The OR Team
The operating room team is subdivided according to the
functions of its members:

1. The sterile team consists of:

– a. Surgeon
– b. Assistants to the surgeon
– c. Scrub nurse

2. The unsterile team includes:

– a. Anesthesia provider
– b. Circulator/ Runner nurse
– c. Others, such as students, cleaners and those who may be needed
to set up and operate specialized equipment or monitoring devices.
 Responsibilities of Each OR Team Members

• Sterile team members wash (scrub) their hands and arms, put on (don) a
sterile gown and gloves, and enter the sterile field, the sterile field is the area
of the operating room that immediately surrounds and is specially prepared
for the patient.

To establish a sterile field, all items needed for the surgical procedure are
sterilized (a process by which all living microorganisms are killed). After this
process, the scrubbed and sterile team members function within this limited
area and handle only sterile items.

• Unsterile team members, on the other hand, do not enter the sterile field;
they function outside and around it. They assume responsibility for
maintaining sterile technique during the surgical procedure, but they handle
supplies and equipment that are not considered sterile.
Following the principles of aseptic technique, they keep the sterile team
supplied, provide direct patient care, and handle other requirements that may
arise during the surgical procedure.
 Responsibilities of the Surgeon

• The surgeon must have the knowledge, skill, and

judgment required to successfully perform the
intended surgical procedure and any deviations
necessitated by unforeseen difficulties.
• The surgeon’s responsibilities include, but are not
limited to, the following:
1. Preoperative diagnosis and care
2. Reviews anatomy, physiology, and the surgical
procedure.
3. Selection and performance of the surgical procedure
4. Postoperative management of care
 Responsibilities of the Assistant Surgeons

• Under the direction of the operating surgeon,

one or two assistants help to:
1. maintain visibility of the surgical site
2. control bleeding
3. close wounds and apply dressings
 Responsibilities of the Scrubbed nurse
The SN is guided and directed constantly by what the surgeon is doing. This means that the "scrubbed“ nurse
must have a constant attention to the operation field.

The activities of the "scrubbed" nurse include, but are not limited to, the following:
1. Reviews anatomy, physiology, and the surgical procedure.
2. Assists with preparation of the room.
3. Scrubs, gowns, and gloves self and other members of the sterile surgical
team.
4. Passes instrument to the surgeon in a prescribed manner.
5. Maintains sterile and an orderly surgical field.
6. Assists with the draping procedure.
7. Keeps track of irrigation solutions used for calculation of blood loss.
8. Keeps the instrument table neat so that supplies can be handed quickly and
efficiently.
9. Anticipates and meets the needs of the surgeon by watching the progress of
the surgery and knowing the various steps of the procedure.
10. Takes part in sponge, needle, and instrument counts.
11. Identifies and preserves specimens properly.
 Responsibilities of the Circulating Nurse

• The circulating nurse is responsible for

maintaining a neat, quiet, well-organized OR
and must be able to anticipate and meet the
needs of the other team members such as –
the scrub nurse, the anesthesia provider, the
surgeon and above all the patient.
• The activities of the circulating nurse include,
but are not limited to, the following:
1. Reviews anatomy, physiology, and the surgical procedure.
2. Assists with preparing the room, observes aseptic technique at all times
to see that it is maintained properly.
3. Identifies and assesses the patient. Then plans and coordinates the
intraoperative cares.
4. Admits the patient to the operating room and assumes responsibility
with the other members of the team for the comfort and the safety of
the patient.
5. Keeps the "scrub" nurse with supplies e.g. suture materials, dressings
etc.
6. Opens sterile supplies before and during the case, replace saline or
water in basins as necessary.
7. Positions the patient on the surgery table
8. Assists the anesthetist when required
9. Takes part in sponge and instrument counts and their documentation,
10. Ties the gowns of scrubbed personnel
11. Adjusts the surgical lights; attaches the suction apparatus
and check to see its function; participates in insertion and
application of monitoring devices.
12. Wipes the surgeons' brows as needed
13. Handles all nonsterile equipment in the room during
surgery, places buckets properly to receive discarded sponges.
Accompanies the patient to the recovery room.
14. Checks the chart and relates pertinent data
15. Measures blood and fluid loss
16. Documents and preserves any specimens received during
surgery
17. Reports pertinent information to the recovery area
nurses.
Responsibilities of the Anaesthetist
The main activities of the anesthesia provider
are:
1. Monitoring vital functions and parameters
2. Fluid and electrolyte administration
3. Administering anesthetic agent/anesthesia
4. Maintaining anesthesia at the required levels
5. Managing untoward reactions to anesthesia
throughout the surgical procedure.
 Sponge, Sharp, and Instrument Count
• Items are counted before and after use.
• The operating team members should be accountable for
the performance of quality patient care.
• Accountability is a professional responsibility. The
surgeon and patient rely on the accuracy of this
accountability by the team. Item counts are performed
for patient and personnel safety, infection control, and
inventory purposes.
• An item left in the wound after closure is a possible
cause for a lawsuit following a surgical procedure.
• A foreign body unintentionally left in a patient can be
the source of wound infection or disruption.
Consequences of foreign body left in the
patient’s body will be:
1. Formation of an abscess and development of
fistula between organs
2. Foreign body reaction may be immediate or
delayed for years
3. Sometimes difficult and costly to diagnose
4. Removal of the object usually requires major
surgery
 Counting Procedure of
Sponges, Sharps, and Instruments

• A counting procedure is a method of accounting

for items put on the sterile table for use during
the surgical procedure.
• Sponges, sharps, and instruments should be
counted and/or accounted for on all surgical
procedures. This includes any material
introduced into the patient during the procedure.
• A counting procedure is made three times in a
surgical procedure.
First Count
• The First Count is done before the start of a
surgical procedure.
• The person who assembles and wraps items
for sterilization will count them.
• In commercially prepackaged sterile items, the
count is performed by the manufacturer.
Second Count
• The scrub nurse and the circulator together count all items before the
surgical procedure begins and during the surgical procedure as each
additional package is opened and added to the sterile field. These initial
counts provide the baseline for subsequent counts. Any item initially
placed in the wound is recorded. A useful method for counting is as
follows:
• As the scrub nurse touches each item, he and the circulator number each
item aloud until all items are counted.
• The circulator immediately records the count for each type of item on the
count record.
• Additional packages should be counted away from counted items already
on the table, incase it is necessary to repeat the count or to discard an
item.
• Counting should not be interrupted. The count should be repeated if there
is uncertainty because of interruption, fumbling, or any other reason.
Third Count
Counts are taken in three areas before the surgeon starts the
closure of a body cavity or a deep/large incision:

1. Field Count. Either the surgeon or the assistant assists the scrub
nurse with the surgical field count. Additional items are
accounted for at this time.
2. Table Count. The scrub nurse and the circulating nurse together
count all items on the Mayo stand and instrument table. The
surgeon and assistant may be closing the wound, while this
count is in process.
3. Floor Count. The circulating nurse counts sponges and any
other items that have been recovered from the floor or passed
off the sterile field to the kick buckets. These counts should be
verified by the scrub nurse.
 Qualities of an Operating Room Nurse

Stamina
• Since the job requires long hours of standing,
lifting heavy instrument trays, positioning
patients, and many other physical tasks, the
OR nurse should be in good physical condition
and have the energy to complete her daily
work in a safe and efficient manner.
Team spirit
• The ability to work with team members toward a
common goal is at the core of surgery. The patient
expects and should receive the undivided attention of all
who care for him. To accomplish this, the nurse should
recognize the critical role/function of not only of her
own job, but also of those of the other team members.
• She should either put personnel problems aside or bring
them to the attention of the supervisor, who might able
to resolve them.
Emotional stability
• The operating room work is stressful. The nature of the work
can cause team members to be tense or to display aggressive
behavior while working. The operating room nurse must be
able to cope with her/his own tension and with that of her/his
teammates.
• Occasionally, the surgeon may express feelings of stress by
being verbally abrupt or harsh. While extremely inappropriate
behavior should not be tolerated by the operating room
supervisor, all team members must appreciate the
responsibility that rests on the surgeon and not become
personally offended by occasional outbursts.
Respect
• Respect for the patient’s rights for privacy, for
other team members, and for himself is an
crucial quality of the operating room nurse.
• The operating room relies on chain of
command for efficient and safe patient care.
Those who experience problems in responding
to authority should not work.
Stable health
• The surgery department relies upon the daily presence
of its employees. If one person is ill, the workload of
other team members is increased because they must
perform the work of the absentee. Cases are generally
not cancelled because of absenteeism.
• Since the operating room is a stressful situation and
because stress can contribute to ill health, the nurse
must be careful to guard against illness and injury.
Particularly prevention of injury to the back and
maintenance of healthy skin and respiratory tract
(common areas of illness).
Good Humor
• In a difficult and demanding environment such as
the operating room, it is important to have a proper
perspective on the day’s events and to share in good
spirit. It is a senseless waste of energy for a team
member to allow one distressing episode to
influence an entire day’s work.
• Team members who are consistently sullen can
lower the morale of the whole department, while
those who are cheerful can raise everyone’s spirit.
Co-operation

• The team approach to care should be a coordinated effort that is

performed with the cooperation of all caregivers.
• Team members should communicate and should have a shared
division of duties to perform specified tasks as a unified body.
• The failure of any one member to perform her/his role can
seriously impact the success of the entire team.
• Performing as a team requires that each member exert an effort
to attain the common goals in a competent and safe manner.
• No one individual can accomplish the goal without the
cooperation of the rest of the team.
 Economical use of supplies and hospital Equipment

• The operation room is one of the most

expensive departments of a hospital.
• Adequate instruments and supplies are
necessary for patient care, and cost is not
always the primary consideration.
• Economy becomes a hazard when exercised
beyond the point of safety. Nevertheless,
supplies do not need to be used lavishly, just
because they are available.
 Economical use of supplies and hospital Equipment

• Most of the hospital equipment is being

imported from abroad and it is costly and,
therefore economical and proper usage of it is
mandatory.
• As the cost of supplies and equipment
increases, the OR team members should be
conscious of ways to eliminate wasteful
practices. For example, throw away disposable
items only. Avoid throwing away reusable items.
 Economical use of supplies and hospital Equipment

“Just Enough Is Enough”

• The varieties and numbers of instruments and supplies needed for each
surgical procedure can be kept to a minimum. Materials no longer used
can be eliminated. Items to “have available” are not opened
unnecessarily. The following procedures should be observed:
1. Pour just enough antiseptic solution
2. Follow the procedures for draping
3. Do not open another packet of sutures for the last stitch unless
absolutely necessary. A few leftover pieces are usually long enough to
complete the closure.
4. Supplies should be opened only as needed, not routinely “just in case”
they may be needed
5. Turnoff lights when they are not needed
 Time Economy in the OR

• Time is money; do not waste it.

• Know the policies and procedures, and follow them efficiently.
• Learn to do things right the first time and continue to do them
that way; time is wasted in correcting errors.
• Time is an important element in the OR. If time is wasted
between surgical procedures, the day’s schedule is slowed
down and later procedures are delayed. The patients and
families become anxious during these delays.
• By reducing time we can reduce the prolonged administration
of anesthetic agents, and other medication. The hazards of
surgery will also be decreased with reduced time.
INFECTION PREVENTION & CONTROL IN THE OR
 Infection prevention and control
principles and practice

• All persons who enter the semi-restricted and the restricted areas
of the surgical suite should wear surgical attire intended for use
within the surgical suite
• OR attire is a critical factor in controlling the potential spread of
infections to the surgical patients and to the population outside
the protected area
• The OR attire is composed of:
a. The scrub suit
b. A headgear
c. Protective barriers - gloves ( sterile or non sterile)
d. Eye wear( goggles or shield mask:
e. Shoe covers or calf -high boots
f. Liquid resistant aprons
g. Surgical masks
 FACE MASKS
• Masks must be changed between each procedure when it becomes
wet , moist or both
• While wearing a mask conversation should be kept to a minimal to
prevent moisture build up
• Masks should be removed by the strings and disposed before leaving
the procedure room
• Masks are never to be worn outside the OR
• Masks are either on or off - They should not be left dangling around
the neck or placed in the pocket for future use
• Masks should fit snugly around the nose and chin and should be tied
securely to prevent accidental slipping during the procedure
NB: surgical attire should only be worn in the OR - if it becomes
necessary to move from the OR the attire should be removed.
 Environmental sanitation in the OR
• Patients should be provided with a safe, clean environment free from
dust and organic debris
• Effective environmental sanitation programs must be put in place to
reduce the possibility of cross- contamination which may cause
surgical wound infection
• Bases for such programs is the concept of universal precaution which
states that;
• “ all patients should be considered potentially contaminated and
therefore treated alike regardless of the procedure being performed”
• Although the environment cannot be sterilized , appropriate cleaning
and disinfection procedures can reduce the possibility of transmitting
pathogens and maintaining an aseptic environment
• Sanitation practices must maintained by all members of staff who are
present in the OR suite before, during and after a surgical procedure ,
and require constant checks to maintain a safe, therapeutic
environment
 Daily cleaning of the OR

Preliminary cleaning
– Preparation of the procedure room before the 1 st case is essential
– It is the responsibility of the scrub nurse and the circulating nurse to see that every thing is
ready
– Unnecessary clutter is avoided by removing furniture or equipment not needed. Before
bringing equipment and supplies required for the procedure dump dusting is done with a
disinfectant the floor cleaned
• Interim Cleaning - During the procedure all effort must be made to contain and
confine the contaminated items. if an instrument falls to the floor and requires
immediate sterilization, the item should be washed first to reduce the
microorganisms
• At the end of the procedure any soiled surface should be cleaned
• Terminal cleaning at the conclusion of the day’s schedule, operating rooms,
scrubbing/ utility area, corridors, furnishings and equipment are terminally cleaned -
A thorough cleaning should be performed at the end of the day
• Weekly and monthly thorough cleaning should be organized
• The procedure room is given careful attention by containment
in clear plastic bags of soiled sponges during the procedure

• Double bagging of all soiled linen and disposable items before

their removal at the conclusion of the procedure

• Immediate cleaning with an effective disinfectant solution of

spills and debris from the floor and walls

• Removing soiled shoe covers before leaving the procedure

room thus eliminating the tracking effect within the suite
• Clean and sterile items from other areas should be
transported in covered carts
• Soiled items and instrument used during a surgical procedure
and needing to be processed must leave the procedure room
covered.
• Soiled items and instrument should never be left uncovered
next to clean or sterile items for any length of time and should
be decontaminated immediately
• Frequent hand washing habit and techniques by all members
of the surgical team both between cases and before entry into
the suite is practiced for the prevention and control of
infections
• SURGICAL SCRUBBING
• GOWNING
• GLOVING
 Anaesthesia
Anaesthetics are agents which render the patient’s body to be
insensitive to pain during a surgical operation. There are two
categories of anaesthesia.
1. Local anaesthesia which induces insensitivity in the region or
part of the body where it is infiltrated e.g. Lignocaine
2. General anaesthesia causes the patient to loose consciousness
e.g. Thiopentone sodium, Ketalar and Halothane

• Patients who are to undergo a surgical operation under GA

should be Premedicated with IM Atropine 0.6 mgs( for adults)
administered ½ - 1 hour before operation so as to reduce
respiratory secretions and to prevent bradycardia. Children
should receive a reduced dose
 Anaesthesia
• IM Pethidine 50-100mg for adults which has
an calming relaxing effect on the patient, and
25-50 mg for children depending on age and
weight
• IM Morphine 10-15 mg can also be used
• Surgical operation
 Anaesthesia
Types of Anaesthesia agents:
1. Volatile agents
– Ether- a is highly inflammable gas that is easy to administer to the
patient. Is irritating to the respiratory tract, and It is dangerous in
presence of diathermy.
– Halothane- is very effective as induction agent, but it can cause
halothane hepatitis.
– Trilene – is not very effective as an induction agent but powerful in
the maintenance of anaesthesia. Side effects include tachypnoea
and vomiting. It is cheap and has analgesic effects post operative.
– A mixture of oxygen and nitrous oxide is one of the effective and
cheap way of maintaining anaesthesia.
 Anaesthesia
Intravenous agents
– Barbiturates---Thiopentone sodium – one of the most effective
induction agents which causes sleep very quickly
• Methohexitone can be used as an induction agent but
cannot be used without equipment for resuscitation and
is contraindicated in epilepsy
• Ketamine can be given IM OR IV. It has analgesic effect
and can be used alone for minor surgery
– Side effects include bad dreams and elevated BP
– Ketamine is also used with diazepam for minor surgery.
– Ketamine is contradicted in hypertension
 Anaesthesia
Muscle relaxants --- these are in two categories
• Short acting depolarizing relaxants such as
Suxamethonium (scoline). It is mainly used for
intubation . Its main side effect is to cause
bradycardia
• Long acting non- depolarizing relaxants such as
Curare, Flaxedil and Pancuronium. The action of
these agents has to be reversed in the patients
by giving Neostigmine or Atropine sulphate
 spinal anesthesia
• Etymology: L, spina, backbone; Gk, anaisthesia, lack of feeling
• a state of lack of sensation in the lower part of the body produced by injecti
on of a local anesthetic drug into thesubarachnoid cerebrospinal fluid space.
May be combined with narcotics such as preservative-free morphine, and/
orFentanyl for postoperative analgesia. Also called
subarachnoid block anesthesia.

• ă)1. Loss of sensation produced by injection of local anesthetic solution(s) in

to the spinal subarachnoid space.
• 2. Loss of sensation produced by disease of the spinal cord.
Synonym(s): spinal anaesthesia.

Side effects
• Common adverse reactions to spinal anesthesia include severe headache,
backache, bradycardia, headache, lowered blood pressure, and
urinary retention.
• ANALGESICS
• These are used to trlieve pain and includes
pethidine, sosagen, morphine and fentanyl
• The post- operative patient is given analgesia
for pain relieve e.g. Pethidine with Diazepam,
an antimetic e.g. Metoclopamide, Stemetil, or
Phenergan
 SURGICAL INSTRUMENTS
The basic instruments that every beginner member of the surgical
team should know are placed in the following categories:

1. Sutures & Ligatures, and Needles

2. Cutting and Dissecting
3. Clamping and Occluding
4. Grasping and Holding
5. Retracting and Exposing
6. Miscellaneous Instruments: These are instrument that do not fit into any
other category by virture of their use including towel clips, ring forceps,
suction tips probes, grooves, trocars, Probing and dilating instruments
 Ligatures and sutures

• A suture is a stitch or series of stitches use in surgery

to bring together living tissues until the normal healing
process takes place
• A ligature is a suture used for tying blood vessels to
arrest bleeding
• Sutures are of two types:
Absorbable - they dissolve in the tissue after some times e.g.
Catgut
Non- absorbable - the body tissue can not digest the material
used e.g. nylon, silk and metal. These sutures must be
removed once the wound has healed
 Surgical Needles
Surgical needles are made from plated carbon steel or stainless steel.

• The different parts of the needle are the eye, shaft and the point
• The needles are either curved or straight.
• There are different classes of needles:
• Cutting needles, which have a sharp edge, cut as they through the
tissues and are used on dense/tough tissues e.g. Skin, tendon and
muscles
• Round- bodied needles which are round and smooth. They cause
less tissue damage and make a puncture -They are used in delicate
tissues and organs.
• Atraumatic needle: These are either cutting or round bodied with
minimal traumatizing effect. These needles have no eye the suture
and needle are made together
Surgical Blades
Surgical Blade Handles
Cutting and Dissecting instruments
Size 7 handle with Size 15 blade (deep
knife) - Used to cut deep, delicate
tissue.

Size 3 handle with Size10 blade (inside

knife) - Used to cut superficial tissue.

Size 4 handle with Size 20 blade (skin

knife) - Used to cut skin.
Cutting and Dissecting instruments
Straight Mayo scissors -
Used to cut suture and supplies.
Also known as: Suture scissors.
Ligature scissors

Straight Mayo scissors

being used to cut suture.
Cutting and Dissecting instruments
• Curved Mayo scissors - Used to cut heavy
tissue (fascia, muscle, uterus, breast).
• Available in regular and long sizes.
Cutting and Dissecting instruments
• Metzenbaum scissors - Used to cut delicate
tissue. Available in regular and long sizes.
ANATOMY OF THE FORCEPS
Clamping and Occluding Instruments
 Clamping and Occluding Instruments
Clamping and occluding instruments are used to
compress blood vessels or hollow organs for
hemostasis or to prevent spillage of contents.
• A hemostat is used to clamp blood vessels or
tag sutures.
• Its jaws may be straight
or curved.
 Clamping and Occluding Instruments

Artery forceps
• Mosquito (Dunhill) forceps is used to clamp
small blood vessels. Its jaws may be straight or
curved.
Clamping and Occluding Instruments
Kelly’s forceps - is used to clamp larger vessels
and tissue.
• Available in short and long sizes.
• Other names: Rochester Pean
 Clamping and Occluding Instruments
• A burlisher forceps is used to clamp deep
blood vessels. Burlishers have two closed
finger rings. Burlishers with an open finger
ring are called tonsil hemostats.
• Other names: Schnidt tonsil forceps, Adson’s
forceps
 Clamping and Occluding Instruments
• A right angle is used to clamp hard-to-reach
vessels and to place sutures behind or around
a vessel.
• A right angle with a suture attached is called a
"tie”
• Other names: Lane’s/Mixter
 Clamping and Occluding Instruments

A hemoclip applier with hemoclips applies

metal clips onto blood vessels and ducts which
will remain occluded.
 Grasping and Holding instruments

Grasping and holding instruments are used to hold tissue, drapes or sponges.

An Allis is used to grasp tissue.

Available in short and long sizes.

"Judd-Allis" holds intestinal tissue;

"heavy Allis forceps holds breast
tissue.

A Babcock
is used to grasp delicate tissue (intestine,
fallopian tube, ovary).
Available in short and long sizes
 Grasping and Holding instruments
• A Kocher is used to grasp heavy tissue. May
also be used as a clamp.
• The jaws may be straight or curved.
• Other names: Ochsner.
Grasping and Holding instruments
• A Foerster sponge stick
• is used to grasp sponges.
• Other names: sponge forceps.

Sponge forceps holding a 4 X 4 and probang

Grasping and Holding instruments
• A dissector
• is used to hold a peanut.

Dissector holding a peanut.

Grasping and Holding instruments
• A Backhaus towel clip is used to hold towels
and drapes in place.
• Other name: Towel clip.
Grasping and Holding instruments
Pick ups, thumb forceps and tissue forceps are
available in various lengths, with or without
teeth, and smooth or serrated jaws.
 Grasping and Holding instruments

Pick ups, thumb forceps and tissue forceps are available in various lengths, with
or without teeth, and smooth or serrated jaws.
 Grasping and Holding instruments

• Adson’s pick ups are either smooth: used to

grasp delicate tissue or with teeth: used to
grasp the skin. Other names: Dura forceps.
 Grasping and Holding instruments

• Thumb forceps are used to grasp tough tissue

(fascia, breast).
• Forceps may either have many teeth or a
single tooth.
• Single tooth forceps are also called "rat tooth
forceps."
 Grasping and Holding instruments
• Mayo-Hegar’s needle holders are used to hold
needles. They may also be placed in the
sewing category.
• Needle holder with suture
 Retracting and Exposing instruments

• Retracting and exposing instruments are used

to hold back or retract organs or tissue to gain
exposure to the operative site.
• They are either "self-retaining" (stay open on
their own) or "manual" (held by hand).
• When identifying retractors, one should look
at the blade, not the handle.
Retracting and Exposing instruments
 Retracting and Exposing instruments

Deaver retractor (manual) is used to retract

deep abdominal or chest incisions.
 Retracting and Exposing instruments

Richardson retractor (manual) is used to retract

deep abdominal or chest incisions.
 Retracting and Exposing instruments

The Army-Navy retractor (manual) is used to

retract shallow or superficial incisions.
• Other names: USA, US Army
 Retracting and Exposing instruments

Goulet (manual) is used to retract shallow or

superficial incisions.
 Retracting and Exposing instruments
• A malleable or ribbon retractor (manual) is
used to retract deep wounds.
• May be bent to various shapes.
 Retracting and Exposing instruments

Weitlaner retractor (self-retaining) is used to

retract shallow incisions.
Gelpi retractor (self-retaining) is used to retract
shallow incisions.
 Retracting and Exposing instruments

Balfour retractor with bladder blade (self-

retaining) is used to retract wound edges during
deep abdominal procedures.
 SUTURES ANDLIGATURES
• SUTURING
LINEN, GAUZE & PACKS
SURGICAL POSITIONS
 SOME COMMON SURGICAL POSITIONS

Positioning on the operating table; (A) Supine, (B) Trendelenburg, (C) Lithotomy, (D)
modified Sim’s/ Kidney position. (E) Prone position (F) Reverse Trendelenburg
position
The supine position is the most frequently used. It may be employed for
procedures on the face (the Protection of the Patient in Surgery/Patient Safety
head may be stabilized on a donut), the neck (with a small pillow under the
neck to provide increased extension, improving access), the abdomen, the
upper extremities (a hand table may be needed), and the lower extremities.
Trendelenburg is a variation of the supine position. The head and the torso are tilted
downward (to a 30- to 45-angle), permitting gravity to pull the abdominal contents
toward the head (cephalad); this allows for better visualization of the pelvic contents
during surgery. (In Trendelenburg, blood pools in the torso and the head, increasing
blood pressure and intracranial pressure.) Trendelenburg is employed for abdominal
hysterectomy and other procedures in the pelvic area.
Reverse Trendelenburg is a variation of the supine position. The entire table is tilted
upward so that the head is higher than the feet. This position is employed for neck as
thyroidectomy, parathyroidectomy, and scalene node biopsy. It is also used to perform
laparoscopic procedures as cholecystectomy.
Fowler’s position is also a modification of the supine position; the patient appears to be
sitting on a chair. This position is employed for posterior craniotomy, selected shoulder,
and ear, nose, and throat (ENT) procedures. A traction device (e.g., Crutchfield tongs) is
used to immobilize the head during procedures on the brain and cervical spine.
Dorsal lithotomy position is also a modification of the supine position. Stirrup or strap
attachments, adjusted to equal height are secured on the table at the middle break. The
buttocks are positioned at the edge of the middle break in the table and the sacrum is
padded. Gives access to both the abdomen and the perineum. Therefore, this position may
be employed for low rectal resections.
In the Sims’ position, the patient is placed on his/her left side with the left thigh and
leg extended. The left arm is protected and secured at the patient’s side and the right
arm, supported by a pillow-padded Mayo stand, is placed over the patient’s body.
Sims’ position is employed for procedures
requiring
access to the vagina,
anorectum, and perineum.
Following the administration of anesthesia, the surgeon, with
adequate assistance, protectively transfers the patient to the
fracture table. This position is most often employed for
insertion of a hip prosthesis and total hip replacement.
The patient, depending on the selected anesthetic, is placed face down in the prone
position, with a padded donut to protect the face, or the head is turned to either side
with a donut or pillow to protect the face and ear from undue pressure. This position
may be employed for anorectal procedures. This position is primarily employed
for procedures on the upper urinary tract (e.g., kidney), and structures in the
retroperitoneal space.
After anesthesia is established, the patient is placed on the unaffected side with the
head on a padded donut (to protect the face and dependent ear). This position is
employed for procedures requiring thoraco-abdominal access.
Padding and support are altered accordingly.
The lateral chest position is employed for thoracotomy procedures.