UNIT- 2

INTRA OPERATIVE CARE

Organization and physical set up of operation theatre (OT)
OT is a facility within a hospital where surgical operations are carried out in a sterile
environment.
The term “operating theatre” referred to a non-sterile, tiered theatre or amphitheatre in which
students and other spectators could watch surgeons perform surgery.
Purpose of OT
OT’s are designed and built to carry out investigative, diagnostic, therapeutic and palliative
procedures of varying degrees of invasiveness.
Aim
 To provide the maximum benefit for maximum number of patients arriving to the OT
 Both the present as well as future needs should be kept in mind while planning
Different Zones of OT complex
4 zones can be described in an OT complex, based on varying degrees of cleanliness
1. Protective Zones
 Change rooms for all medical and Para medical staff with conveniences
 Transfer bay for patient, material and equipment’s
 Rooms for administrative staff
 Stores and records
 Pre and post operative rooms
 ICU and PACU
 Sterile stores
2. Clean Zone
Connects protective zone to aseptic zone and has other areas like:-
 Stores and cleaner room
 Equipment store room
 Maintenance work shop
 Kitchenette (pantry)
 Fire fighting device room
 Emergency exits
 Service room for staff
 Close circuit TV control room
3. Aseptic Zone includes operation rooms (sterile)
4. Disposal Zone areas from each operation room and corridor lead to disposal zone.
Classification
1. Extent of surgery involved
Minor OT
Major OT
2. Type of service provided
Outpatient OT
Inpatient OT
3. Sharing of OT
a) Decentralized
 Neurosurgery
 Orthopedic
  CTVS
 Eye
 ENT
 General Surgery
 Gynec
 Rental
b) Centralized
4. Urgency Situation
 Emergency OT
 Elective OT
OT Design
Principles to be taken into consideration while planning an O.T.
1. Location separated from the main flow of hospital traffic and easily accessible from
surgical wards and emergency rooms.
2. Adequate & appropriate space allotted as per utility of the area
3. Provision for emergency exit
4. Provision for ventilation & temperature control, keeping in mind the need for laminar
flow, HEPA filter air conditioner etc.
5. Operation rooms: The number & size can be as per the requirement but recommended
size is 6.5 m x 6.5m x 3.5 m. Glass windows can be planned on one side only.
Doors: Main door to the OT complex has to be of adequate width (1.2 to 1.5 m). The
doors of each OT should be spring loaded flap type, but sliding doors are preferred as no
air currents are generated. All fittings in OT should be flush type and made of steel.
The surface / flooring must be slip resistant, strong & impervious with minimum joints
(eg. mosaic with cop-per plates for antistatic effect) or joint less conductive tiles/
terrazzo, linoleum etc. The recommended minimum conductivity is 1m ohm and
maximum 10m Ohms.
Walls- Laminated polyester or smooth paint provides seamless wall; tiles can break and
epoxy paint can chip out. Collusion corners to be covered with steel or aluminum plates,
color of paint should allow reflection of light and yet soothing to eyes. Light color (light
blue or green) washable paint will be ideal. A semi-matt wall surface reflects less light
than a highly gloss finish and is less tiring to the eyes of OT team.
Operation table: One operation table per OT
Electric point: Adequate electric points on the wall (at < 1.5 m height from the floor)
6. X-Ray illuminators: There should be X-ray film illu-minators preferably recessed into the
wall.
Scrub area: to be planned for at least for 2-3 persons in each OT.
7. There has to be a preparation room in clean zone
8. Corridors not less than 2.85 m width for easy movement of men, stretcher & machines
9. Separate corridors for uses other than going into OT.
10. Rooms for different persons working in OT & for different purpose (it should be as per
zone & size)
11. Gas & suction (control, supply & emergency stock) for all OTs & areas where patients
are retained. Oxygen, gas and suction pipe to be connected with central facility and
standby local facility should also be available.
12. Provision for adequate & continuous water supply:
 Besides normal supply of available water at the rate of 400 liters per bed per day, a
separate reserve emergency over head tank should be provided for operation theatre.
Elbow taps have to be 10 cm. above wash basins.
13. Proper drainage system.
14. Pre-operative area with reception with separate designated area for pediatric patients is
desirable.
15. Adequate illumination with shadow less lamps of 70,000-120,000 Lumens intensity, for
assessing patient color and tissue visibility
16. The safety in working place is essential, and fire extinguishers have to be planned in
appropriate zone.
17. Provision for expansion of the OT complex should be borne in mind during planning
stages itself. Recommendations on the number of OTs required
18. It is observed that out of all surgical beds, of the hospital, 50%of patients are expected to
undergo surgery. Thus for 100 beds, with average length of stay of 10 days for each
patient, 10 operations per day can be performed.
19. In general, multiuse OTs, instead of multiple OTs offer advantages of efficient man
power utilization, economical maintenance and better training of supporting staff.
20. Thus, in a 300 bedded hospital (with 150 surgical beds), one OT complex with 3 OTs for
General Surgery, Gynaecology, Orthopaedics/ENT, one for Endoscopy and one for
Septic.
21. The temperature is maintained at 21+/-3 degree Celsius inside the OT all the time with
corresponding relative humidity between 50 to 60%. Appropriate devices to monitor and
display these conditions inside the OT are installed.
22. Ventilation should be on the principle that the direction of air flow is from the operation
theatre towards the main entrance. There should be no interchange air movement between
one OT and another. Efficient ventilation will control temperature and humidity in OT,
dilute the contamination by micro-organisms and anesthetic agents.
Pendant services
 Two ceiling pendants for pipeline services should be designed; one for surgical team and
one for anesthetist.
 Anesthetic pendant should be retractable and have limited lateral movement and provide
a shelf for monitoring equipment. It should have oxygen, nitrous oxide, four bar pressure
medical compressed air, medical vacuum, scavenging terminal outlets and at least four
electric sockets.
Piped gases and other lines in the OT
1. Automatic / semi-automatic fail safe manifold room to be designed.
2. Two outlets for O2 and suction and one for N2 O are a minimum in each OT.
3. Pipeline supply system should be able to cut off from mainline if the problem occurs
anywhere along the delivery tubing.
4. Wall outlets to be installed 1.5 m above ground
5. Use of explosion proof plugs.
6. Multiple outlets from different electrical line sources should be available.
Electrical
Following criteria are ideal with respect to electricity in OT complex:
1. Use of circuit breakers / interrupters is desirable if there is an overload or ground fault.
 2. Emergency power: OT electrical networks need to be connected to the emergency
generators with automatic two way changeover facility.
3. Power line of 220 Volts
4. Electrical load calculation should be based on, equipments likely to be used and
appropriate current carrying capacity cords to be used.
5. Suspended ceiling outlets should have locking plugs to avoid accidental disconnection.
6. Insulation around ceiling electrical power sources should withstand frequent bendings
and flexing. They should not develop cracks and should not damage wires.
Lighting
Some natural daylight is preferred by staff. Where possible, high level windows which give a
visual appreciation of the ′outside world′ can be considered in the OT. Color corrected
fluorescent lamps (recessed or surface ceiling mounted) to produce even illumination of at least
500 lux at working height, with minimal glare are preferred.
Anaesthesia equipment and monitoring needs
At least one anesthesiologist should be in the team involved in planning an OT. It is imperative
that certain mandatory considerations with respect to the anesthetic equipment and monitors be
planned during the planning and design stage itself. Personal, practice and cost preferences may
influence the plans.
Communications
Telephones, intercom and code warning signals are desirable inside the OT. One phone per OT
and one exclusively for use of anesthesia personnel is desirable. Intercom to connect to control
desk, pathology and other OTs as well as use of paging receivers (bleeps) is also ideal.
Catering
Basic services such as preparation of beverages and some snacks, use of vending machines may
be planned, augmented by provision of hot and cold meals from main hospital kitchen.
Cleaning
The construction materials selected for the OT complex should aim to minimize maintenance
and cleaning costs.
Data management
Customized network connections should be put in place or a conduit should be planned. A well
designed system can provide automated records, materials management, quality improvement
and assessment, laboratory tracking, etc6. The Software for OT management are costly and
hospitals are generally slow to adopt to changes. Customized OT soft-ware can be designed for
individual needs.
Staffing of OT
The staffing can be measured in many ways:
1. Total number of hours of cases
2. Hours associated with direct patient care
3. Workload calculation
4. Number of cases operated per day
5. Type of cases
6. Nature of cases
7. Prescribed norms and policies and procedures
Benefits of good staffing
1. Improves patient outcome
2. Lowers mortality rate
3. Increase OT efficiency
4. Reduce patient waiting time for surgery
5. Balance workload
Members of OT Team

Duties and Responsibilities of the nurse in OT

General Duties
1. Provide efficient and effective perioperative nursing care to patient.
2. Maintain surgical services in accordance with competency standards.
3. Complete all physician orders, administer medications and conduct treatments and tests for
patients in a timely manner.
4. Assist with patient care in recovery room, procedure room and operating room.
5. Develop and implement NCP for assigned patient.
6. Execute proper use, care and handling of surgical equipment to ensure safety of operating staff
and patient.
7. Maintain current and in-depth knowledge of sterile techniques.
8. Communicate continuously with operating team and other medical staff to meet needs for
patient care.
9. Assist in ordering, storing and maintaining surgical equipment and supplies.
10. Prepare operating room with surgical equipment, sterile linens and supplies that will be
needed during surgery.
11. Maintain order and cleanliness in operating room.
12. Prepare patients including cleaning and disinfecting body areas for surgery.
13. Prepare timely and accurate records of patient history and recovery charts.
Duties/ Responsibilities of scrub nurse
A nurse specially trained to assist surgeons in the operating room and serving as part of the
surgically
1. Preoperative nursing assessment and welcoming patient to OT
2. Ensure that the theatre has been cleaned before the trolley is set.
3. Prepare the instruments and equipment needed in the operation.
4. Prepare own self by using sterile technique like scrubbing, gowning and gloving.
5. When surgeon arrives after scrubbing provides assistance for gowning and gloving to the
surgeon and assistant surgeon as soon as they enter the operation suite.
6. Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap
sheet.
7. Assist the surgeon in draping the patient aseptically according to routine procedure.
8. Assist surgeon and assistants throughout operation by providing instrument’s and supplies
9. Maintain sterility throughout the procedure and aware of patient’s safety
10. Adhere to the policy regarding sponge/ instruments count/ surgical needle
11. Adhere and maintain sterile technique and watch for any breaks. If any breaks found then
inform immediately to the surgeon
12. Undertake count of sponges and instruments with circulating nurse and correlate with the
pre-surgery findings
Duties/ Responsibilities of circulating nurse
1. Coordinate the needs of the surgical team with other care providers necessary for completion
of surgery
2. Observe the surgery and the surgical team and assists the team to create and maintain a safe
and comfortable environment for the patient
3. Assesses the patient’s condition before, during and after the operation to ensure an optimal
outcome for the patient.
4. Anticipate the scrub nurse’s needs and be able to open sterile packs, operate machinery and
keep accurate records.
5. Checks all equipment for proper functioning such as cautery machine, suction machine, OT
light and OT table.
6. Make sure that theatre is clean.
7. Help Scrub Nurse with setting up the theatre. Assist with counts and records
8. Assist the anesthetist.
9. Assist with final sponge and instruments count and documented
10. Maintain all records of the theatre
11. Ensures that the entire specimen are properly labeled and signed
12. Make arrangement for preparation of theatre for the next case
Position for common surgical procedures
Aim and objectives
 To provide knowledge on common surgical position of patient in during surgery
 To identify and develop awareness of potential complication in patient positioning
 To practice measure to avoid injuries and others complication to patient during surgery
 To promote safety and safeguarding patient well-being during intra-operative period
Goal of patient positioning
 Providing adequate exposure
 Maintenance of patient’s dignity
 Optimal ventilation and airway management
 Providing adequate access
 Avoiding poor perfusion
 Protecting fingers, toes, genitals
 Protecting Muscles, nerves, bony prominences
The team should assess the following prior to positioning of the patient
 Procedure length
 Surgeon’s preference of position
 Required position for procedure
  Anesthesia to be administered
 Patient’s risk factors; age, weight, skin condition, mobility /limitations, pre-existing
conditions, airway etc.
 Patient’s privacy and medical needs
Basic surgical positions
Supine position
 The patient lies flat on his back
 The arms may be placed beside the body, on an arm board or supported across the chest
by lifting up the gown which acts as sling
 Most common Operative position, such as in Laparotomy, certain Gynecological and
Orthopedic cases
Nursing precautions
 Head not Hyper extended
 To ensure that arms are not abducted < 90°
 Arm board is padded Hand in prone position
 Arms do not overlap or hang over table edge
 Patient protected from metal contact
 Bony prominences are protected (occiput, scapulae, thoracic vertebrae, olecranaon,
sacrum and coccyx, calcaneus)
Potential complications
 Backache resulted from unsupported lumbosacral curvature
 Paralysis of arm and hand due to over abduction
 Radial or Ulnar nerve palsy due to arm or elbow hanging or tight strapping
 Continuous pressure on the calves may caused venous stasis resulting thrombosis which
can lead to Pulmonary Embolisms
Prone Position
 The patient lying with abdomen on table surface
 Arms are placed above the head
 Pillows are placed under the shoulders, hips and feet
 Access for all surgeries involving posterior back (cervical spine, back, rectal area and
dorsal extremities)
Nursing precautions
 Pillow or towel under shoulders and hip facilitate chest expansion, reduce abdominal
pressure and venous oozing at operation site
 Head not hyper extended, placed on side and kept supported
 Pressure point are well protected with pad (cheek, ear, acromion process, breast,
genitalia, patella, dorsum of feet, toes)
Potential complications
 Lower neck and upper back pain resulting from hyperextension of head
 Radial and ulnar nerve palsy due to arm restrainer
 Hypotension resulted from pressure on inferior vena cava and pooling of blood in lower
limbs
 Shoulder dislocation during arm positioning
 Brachial plexus injury due to over extension of arm < 90°
Trendelenburg position
 Patient lying in supine position with knees over lower break of the table
  Head tilted down to 15° or according to the surgeon preferences
 Arms may placed on the chest or arm board
 Common position for laparoscopic surgeries in pelvic or lower abdominal region
 Using of shoulder or knee braces may benefit patient from sliding
Nursing precautions
 Head not hyper extended and arm not abducted beyond 90°
 Hands on padded armboards are supinated
 Arms not overlap the table edge or hang over
 Patient is protected from metal contact
 Bony prominences are well protected (occiput, scapulae, thoracic vertebrae, olecranon,
sacrum and coccyx and calcaneus)
 Returning leg first to reverse venous stasis
Potential complications
 A 30° Trendelenburg position may caused changes in blood pressure, cerebral edema,
congestion of face and neck
 A too steep position may result in cyanosis due to alteration on diaphragmatic extension
and lung expansion
 Shearing of skin may occurred during positioning
Reverse trendelenburg position
 Patient in supine position with arms by sides or on arm board
 Table tilted to 5-10° raising the head
 A sand bag may used below the neck and the shoulder blade for extension of neck (RUSS
TECHNIQUE)
 The head stabilized by head ring
 Position often used for head and neck surgery to reduce venous congestion
 To prevent stomach regurgitation during induction of anesthesia
Nursing precautions
 Head not hyper extended and arm not abducted beyond 90°
 Hands on padded arm boards are supinated
 Arms not overlap the table edge or hang over
 Patient is protected from metal contact
 Bony prominences are well protected (occiput, scapulae, thoracic vertebrae, olecranon,
sacrum and coccyx and calcaneus)
 Anti embolic stocking may be used to prevent blood pooling
 Foot bracket may used to prevent sliding
Potential complications
 Backache may result from unsupported lumbosacral curvature
 Paralysis may occurred due to over abduction of arm
 Ulnar and radial palsy due to elbow or arm hanging over the table or tight restraint
 Pulmonary embolisms as a result of venous stasis
 Cardiovascular overloaded due to quick return
 Skin shearing due to sliding down
Lithotomy position
 Patient lies in supine position with buttocks at the lower break of the table
 Lithotomy stirrups placed in position level with patient ischial spine
 Arms placed over the chest or on an arm board
 Legs are lifted together upwards and outwards and feet placed in knee crutch or candy cane
 Common position for Urology, Gynecology, perineal or rectal operations
Nursing precautions
 Two person required to raised the legs simultaneously by grasping the sole and other hand
supporting the calf
 Stirrups bars must be checked and secure before use and its height must be similar and not
suspend the patient weight
 The buttock must be even with the edge of bed to prevent lumbosacral strain
 Anti embolic stocking may used to promote venous return
 Bony prominences protected
Potential complications
 Severe backache caused by too high stirrups
 Calf holder may resulted perineal or femoral obturator nerve damage
 Osteoarthritis or stiff hips due to rough handling
 Too quick of lowering the legs may cause hypotension
 Femoral nerve damage due to acutely flexed thighs
 Hip dislocation or fracture as a result faulty stirrups
Lateral or kidney position
 Patient lying with one side facing operative side uppermost
 The legs flexed to 90°° and a pillow is placed in between
 Upper arm rested on elevated arm rest and the other remains flexed on the table or arm board
 A roll bags may used below the hip/kidney to increased exposure of iliac region
 Position is maintained by use of sandbags or braces attached to the side of bed
 Head supported on a pillow
Nursing precautions
 If table break is used, it must be correctly level with iliac crest to prevent alteration in
respiration and severe post- operative backache
 Ensure ear is not trapped when supporting the head
 Arms are supported with adequate padding to prevent pressure necrosis
 Bony prominences are fully protected (ribs, iliac crest, greater trochanter, medial and lateral
femoral epicondyles, Tibial condyles, Malleous)
Potential complications
 If the kidney rest raised too much, the lungs will not expand adequately which will result in
cyanosis and hypotension
 Injuries to brachial plexus, median, radial and ulnar nerves can occur if upper arm is not
supported
 If the head is not supported adequately, brachial plexus can get stretched
 Perineal nerve damage may resulted from compression on the down knee against hard
surface
Semi-Fowler’s and Fowler’s position
 The patient positioned in supine with the upper body part is flexed to 45° or 90° and the
knees slightly flexed and legs lowered
 Arms may be placed over the laps or arm board
 A footrest is used to prevent foot drop and head spike to stabilized head
 Useful position for craniotomies, shoulder or breast reconstruction and ENTS’
Nursing precautions
 The cervical, thoracic and lumbar section of spine must be aligned once position established
 Extra padding are requires over bony prominences (coccyx, ischial tuberosities, calcaneus,
elbows, knees and scapulae)
 The use of anti-embolism stocking may necessary to assist venous return
 Reposition after surgery must be done gently and slowly
Potential complications
 Orthostatic hypotension due to blood pooling at lower extremities
 Risk of venous thrombosis and embolisms as a result of impended venous return
 High risk of development of skin pressure over affected bony prominences
 Alteration on chest movement due to restriction from rested arms or tight straps
Draping for common surgical procedures
Surgical Draping
The procedure of covering a patient and surrounding areas with a sterile barrier to create and
maintain a sterile field during a surgical procedure is called draping. The purpose of draping is to
eliminate the passage of microorganisms between non sterile and sterile areas. Draping materials
may be disposable or non disposable. Disposable drapes are generally paper or plastic or a
combination and may or may not be absorbent. Non disposable drapes are usually double-
thickness muslin. Drapes, of course, must be sterile. Draping procedures create an area of a
sepsis called a sterile field.
Draping Materials
 Are selected to create and maintain an effective barrier that minimizes the passage of
microorganisms between non sterile and sterile areas
 To be effective, a barrier material is resistant to blood, aqueous fluid and abrasion as lint free
as possible
 Maintain isothermic environment that is appropriate to body temperature
 Meet the requirements of the current National Fire Protection Association Standards so that
no risk from a static charge exists
 Fabric draping materials must be penetrable by steam under pressure or by gas to acheive
sterilization within hospital facilities
Aim of surgical draping
 To prevent contamination of the wound
 To maintain sterility in surgical field
Importance of surgical draping
 Provide appropriate barriers to microorganisms, particulate matter and fluid
 Be appropriate to methods of sterilization; resist tears, punctures, fiber strains and
abrasions; be free of toxic ingredients; have positive cost, benefit be used and processed
according to manufacturers written instructions.
The principles of surgical draping
1. Only sterile surgical drapes can be used in the sterile field.
2. Check the surgical drape for no holes, punctures and tears to prevent microbial
contamination of the sterile field.
3. When handling the surgical drape before placing it on the patient, it should not be allowed to
unfold.
4. Non-porous towel clips should be used to hold towels or surgical drapes in place.
 5. Once the surgical drape is placed, it should not be repositioned. Repositioning may introduce
non-sterile portions of the drape into the sterile field, causing contamination, and may transfer
microorganisms to the sterile field, putting the patient at risk of infection.
6. Members of the sterile team should have as little contact with surgical drapes as possible.
7. Disposable and non-disposable contaminated surgical drapes should be properly kept at the
end of the operation. Surgical drapes should be placed in impermeable bags with the biohazard
symbol.
8. The correct placement of surgical drapes and instruments before each operation can provide
the best protection for the operation.
Purpose
 To maintain the sterility of surface on which sterile instruments and gloved hands may be
placed during the operation.
 To create a sterile field by means of the appropriate and careful placement of linen before
surgery begins.
Reusable Drapes
 The performance characteristic of primary concern for drapes (or gowns) to be used
repeatedly is fluid impermeability under the conditions of use
 The process of steam sterilizing and laundering swells the fabric whereas drying and
ironing shrinks the fibers
 This cycle increases the propensity for loosened fibers that alter the fabric structure
 Most manufactures report a loss of barrier quality after 75 laundry and/or sterilization
cycles
 A system to monitor the number of times an item has been laundered is essential for
barrier quality control
Disposable drapes
 Disposable drapes reduce the hazards of contamination in the presence of known infectious
microorganisms in body fluids and excretions and in situations in which laundering of
grossly contaminated textiles is a problem
 Lightness and compactness of synthetic drapes prevent heat retention by patients, contribute
to ease in handling and storage and conserve storage space and personnel´s time
 Successful drapes are soft, lint, free, lightweight, compact moisture resistant, nonirritating,
and static free
 Prevent bacterial penetration and fluid breakthrough
 Incineration (burning) is a method for destroying waste disposables- but must properly
managed to prevent environmental contamination
 Collection, transportation and storage of waste materials can be a problem
Plastic Incisional Drapes
 Impermeable polyvinyl sheeting are available in the form of sterile, prepacked surgical
drapes
 The incision is made directly through the adherent plastic drape
 Facilitates draping of irregular body surfaces as neck and ear regions, extremities and joints
Standard Drapes
 A whole or plain sheet is used to cover instrument tables, operating tables, and body regions
 The sheet should be large enough to provide an adequate margin of safety between the
surrounding physical environment end the prepared operative field
 Surgical towels in one or two sizes should be available to drape the operative site. Four
surgical towels are sufficient
 Fenestrated or slit sheets are used for draping patients. They leave the operative site exposed,
use for (laparatomy draping)abdomen, chest, flank, back, other size for limb, head and neck
A Perineal Drape
 For operations on the perineum and genitalia with the patient in lithotomy position
 A lithotomy drape consists of a fenestrated sheet and two triangular leggings
 A commercial disposable lithotomy drape back, is suitable for delivery, cystoscopy,
hemorrhoidectomy and vaginal procedures
Draping Procedure
 Carry the folded drape to the operative site, where the drape is carefully unfolded and placed
in proper position after a drape has been placed, it should not be moved
 Hold sterile drapes above waist level until properly placed on the patient or object being
draped. If the end of a drape falls bellow waist level, it should not be retrieved because the
area below the waist is considered unsterile
 Protect the gown by distance and the gloved hands by cuffing drapes over them
 The scrub nurse should have all parts of the drape under positive control at all times during
placement and should use precise and direct motion
 Draping is always done from sterile area to an unsterile area and by draping nearest first
 The scrub nurse should never reach across an unsterile area to drape
 When the opposite side of the operating room bed must be draped , the scrub nurse must go
around the bed to drape
 Do not flip, fan or shake drapes. Rapid movement of drapes creates air currents on which
dust, lint and droplet nuclei may migrate
 Shaking a drape causes uncontrolled motion of the drape which may cause it to come in
contact with an unsterile surface or object
 A drape should be carefully unfolded and allowed to fall gently into position by gravity
 The low portion of a sheet that falls below the safe working level should never be raised or
lifted back onto the sterile area
 Drape the incision area first and then the periphery
 Use no perforating towel clamps or devices to secure tubing and other items on a sterile field
 When sterility of a drape is questionable, consider it contaminated
Draping rules
 Handle the drapes as little as possible
 Never flourish drapes (dust and lint are released into the air creating a vehicle for
airborne bacteria.
 If a drape become contaminated or has a hole in it discards it.
 The gloved hands are sterile but the skin is not.
 Never allow gloved hand to come into contact with patients prepared skin during the
draping process
 Whenever draping always provide a cuff for the gloves hand
 Never allow a drape to extend outside the sterile area unless it is to remain there.
 The drape must not be adjusted once it is placed
 If its place incorrectly it must be discarded and another drape must be used.
 Do not allow the drape to touch the floor or become tangled in floor equipment
  If the drape is so large that it touches the floor the bottom may be taped to form a make
shift items
 Plan ahead has the drapes ready before the procedure begins.
Instruments, Sutures and Suture Materials, Equipment for common surgical procedures
Instruments for common surgical procedures
The operating room contains a multitude of instruments fit for accomplishing a number of
procedures.
SCALPEL- Used for initial incision and cutting tissue. Consists of a blade and a handle.
Surgeons often refer to the instrument by its blade number.
SCISSORS- Used for cutting tissue, suture, or for dissection. Scissors can be straight or curved,
and may be used for cutting heavy or finer structures.
FORCEPS- Also known as nonlocking forceps, grasping forceps, thumb forceps, or pick-ups.
Used for grasping tissue or objects. Can be toothed (serrated) or nontoothed at the tip.
CLAMPS- Also called locking forceps, these are ratcheted instruments used to hold tissue or
objects, or provide hemostasis. Can be traumatic or atraumatic.
NEEDLES & SUTURE- Needles come in many shapes and cutting edges for various
applications. Suture can be absorbable, non-absorbable, and is available in different sizes.
RETRACTORS- In varying forms, retractors are used to hold an incision open, hold back tissues
or other objects to maintain a clear surgical field, or reach other structures. They can either be
hand-held or self-retaining via a ratcheting mechanism.
SUCTION- Suction tips, combined with a suction source, help to remove debris and fluid from
the surgical field. It can also be used to clear surgical smoke
STAPLERS AND CLIPS- Used for re anastomosis of viscera, vessel ligation, and excision of
specimens. Can be one-time use, reloadable, manual, or electronically powered. Staples come in
multiple sizes.
ENERGY SYSTEMS- Broad term used to describe various methods of cutting tissue or sealing
vessels. May use electricity or sonic waves. Available in open or laparoscopic forms.
LAPAROSCOPIC INSTRUMENTS- Many instruments are similar to those used in open
surgery, adapted to fit through narrow ports placed through the skin. Laparoscopic work is then
conducted via the ports.
Sutures
Introduction
Suture means to sew or seam. Sutures are used to close wounds of skin or other tissues. While
sutures a wound, use a needle attached to a length of “thread” to stitch the wound shut. There are
a variety of available materials that can be used for suturing. doctor will choose a material that’s
appropriate for the wound or procedure.
Definitions
Suture is a any strand of material utilized to ligate blood vessels or approximate tissues. -
Silverstein L H Suture is a stitch or series of stitches made to secure opposition of the edges of a
surgical /traumatic wound. - WILKINS
Purposes of suturing
• Maintain hemostatsis • Provide adequate tension • Promote healing • Provide support to tissues
• Reduce pain • Permit proper flap position • Prevent bone exposure • Prevent infection
Equipment/articles
Equipment required for suture closure of a wound includes the following:
• Tray • Suture material • Needle • Needle holder
 Suture qualities
 It is sterile
 It is suitable for all purposes (ie, is composed of material that can be used in any surgical
procedure)
 It causes minimal tissue injury or tissue reaction (ie, is non-electrolytic, non-capillary, non-
allergenic, and non-carcinogenic)
 It is easy to handle
 It holds securely when knotted (ie, no fraying or cutting)
 It has high tensile strength
 It possesses a favorable absorption profile
 It is resistant to infection
Suture classification
Sutures may be classified in terms of their origin, their structure, and their absorbability.
 Natural vs synthetic: Natural sutures can be made of collagen from mammal intestines or
from synthetic collagen (polymers). Tissue reaction and suture antigenicity lead to
inflammatory reactions, especially with natural materials. Synthetic sutures are made of
artificial polymers.
 Monofilament vs multifilament: Monofilament suture material is made of a single strand;
this structure is relatively more resistant to harboring microorganisms. It also exhibits less
resistance to passage through tissue than multifilament suture does. However, great care
must be taken in handling and tying a monofilament suture, because crushing or crimping
of the suture can nick or weaken it and lead to undesirable and premature suture failure.
 Absorbable vs non-absorbable: Absorbable sutures provide temporary wound support
until the wound heals well enough to withstand normal stress. Absorption occurs by
enzymatic degradation in natural materials and by hydrolysis in synthetic materials.
Hydrolysis causes less tissue reaction than enzymatic degradation
Types of sutures
The different types of sutures can be classified in many ways.
Absorbable or non-absorbable.
Absorbable sutures don’t require to remove them. This is because enzymes found in the tissues
of your body naturally digest them.
Non-absorbable sutures will need to be removed but later date or in some cases left in
permanently.
Types of absorbable sutures
 Gut: - This natural monofilament suture is used for repairing internal soft tissue wounds
or lacerations. Gut shouldn’t be used for cardiovascular or neurological procedures. The
body has the strongest reaction to this suture and will often scar over. It’s not commonly
used outside of gynecological surgery.
 Polydioxanone (PDS): - This synthetic monofilament suture can be used for many types
of soft tissue wound repair (such as abdominal closures) as well as for pediatric cardiac
procedures.
 Poliglecaprone (MONOCRYL): - This synthetic monofilament suture is used for general
use in soft tissue repair. This material shouldn’t be used for cardiovascular or
neurological procedures. This suture is most commonly used to close skin in an invisible
manner.
  Polyglactin (Vicryl): -This synthetic braided suture is good for repairing hand or facial
lacerations. It shouldn’t be used for cardiovascular or neurological procedures.
Types of non-absorbable sutures
These types of sutures can all be used generally for soft tissue repair, including for both
cardiovascular and neurological procedures.
Nylon: - A natural monofilament suture.
Polypropylene (Prolene): - A synthetic monofilament suture.
Silk: - A braided natural suture.
Polyester (Ethibond): -A braided synthetic suture.
Suture techniques.
Continuous sutures
This technique involves a series of stitches that use a single strand of suture material. This type
of suture can be placed rapidly and is also strong, since tension is distributed evenly throughout
the continuous suture strand.
Interrupted sutures
This suture technique uses several strands of suture material to close the wound. After a stitch is
made, the material is cut and tied off. This technique leads to a securely closed wound. If one of
the stitches breaks, the remainder of the stitches will still hold the wound together.
Deep sutures
This type of suture is placed under the layers of tissue below (deep) to the skin. They may either
be continuous or interrupted. This stitch is often used to close facial layers.
Buried sutures
This type of suture is applied so that the suture knot is found inside (that is, under or within the
area that is to be closed off). This type of suture is typically not removed and is useful when large
sutures are used deeper in the body.
Purse-string sutures
This is a type of continuous suture that is placed around an area and tightened much like the
drawstring on a bag. For example, this type of suture would be used in your intestines in order to
secure an intestinal stapling device.
Subcutaneous sutures
These sutures are placed in your dermis, the layer of tissue that lies below the upper layer of your
skin. Short stitches are placed in a line that is parallel to your wound. The stitches are then
anchored at either end of the wound.
Retension sutures
Interrupted non absorbable sutures are placed through tissue on each side of the primary suture
line and a short distance from it to relieve tension on it.
Traction suture
A traction suture may be used to retract a structure to the side of the operative field out of the
way
Suture removal
Sutures are removed will depend on where they are on the body. According to American Family
Physician, some general guidelines are as follows: • Scalp: 7 to 10 days • Face: 3 to 5 days •
Chest or trunk: 10 to 14 days • Arms: 7 to 10 days • Legs: 10 to 14 days • Hands or feet: 10 to 14
days • Palms of hands or soles of feet: 14 to 21 days
Suture materials
Surgical suture materials are used in the closure of most wound types. The ideal suture should
allow the healing tissue to recover sufficiently to keep the wound closed together once they
are removed or absorbed.
Classification of Suture Materials
Broadly, sutures can be classified into absorbable or non-absorbable materials. They can be
further sub-classified into synthetic or natural sutures,
and monofilament or multifilament sutures.
The ideal suture is the smallest possible to produce uniform tensile strength, securely hold the
wound for the required time for healing, then be absorbed. It should be predictable, easy to
handle, produce minimal reaction, and knot securely.

The different classifications and sub-classifications of suture materials.

Absorbable vs Non-Absorbable
Absorbable Sutures
Absorbable sutures are broken down by the body via enzymatic reactions or hydrolysis. The time
in which this absorption takes place varies between material, location of suture, and patient
factors. Absorbable sutures are commonly used for deep tissues and tissues that heal rapidly; as a
result, they may be used in small bowel anastomosis, suturing in the urinary or biliary tracts, or
tying off small vessels near the skin.
Non-Absorbable Sutures
Non-absorbable sutures are used to provide long-term tissue support, remaining walled-off by
the body’s inflammatory processes (until removed manually if required). Uses include for tissues
that heal slowly, such as fascia or tendons, closure of abdominal wall, or vascular anastomoses.
Synthetic vs Natural
Natural – made of natural fibers (e.g. silk or catgut). They are less frequently used, as they tend
to provoke a greater tissue reaction. However, suturing silk is still utilized regularly in the
securing of surgical drains.
Synthetic – comprised of man-made materials (e.g. PDS or nylon). They tend to be more
predictable than the natural sutures, particularly in their loss of tensile strength and absorption.
Monofilament vs Multifilament
Monofilament suture – a single stranded filament suture (e.g nylon, PDS*, or prolene). They
have a lower infection risk but also have a poor knot security and ease of handling.
Multifilament suture – made of several filaments that are twisted together (e.g braided silk or
vicryl). They handle easier and hold their shape for good knot security, yet can harbour
infections.
Suture Size
The diameter of the suture will affect its handling properties and tensile strength. The larger the
size ascribed to the suture, the smaller the diameter is, for example a 7-0 suture is smaller than a
4-0 suture. When choosing suture size, the smallest size possible should be chosen, taking into
account the natural strength of the tissue.
Surgical Needles
The surgical needle allows the placement of the suture within the tissue, carrying the material
through with minimal residual trauma. The ideal surgical needle should be rigid enough to resist
distortion, yet flexible enough to bend before breaking, be as slim as possible to minimize
trauma, sharp enough to penetrate tissue with minimal resistance, and be stable within a needle
holder to permit accurate placement.
Commonly, surgical needles are made from stainless steel. They are composed of:
 The swaged end connects the needle to the suture
 The needle body or shaft is the region grasped by the needle holder. Needle bodies can
be round, cutting, or reverse cutting:
o Round bodied needles are used in friable tissue such as liver and kidney
o Cutting needles are triangular in shape, and have 3 cutting edges to penetrate
tough tissue such as the skin and sternum, and have a cutting surface on the
concave edge
o Reverse cutting needles have a cutting surface on the convex edge, and are ideal
for tough tissue such as tendon or subcuticular sutures, and have reduced risk of
cutting through tissue
 The needle point acts to pierce the tissue, beginning at the maximal point of the body
and running to the end of the needle, and can be either sharp or blunt:
o Blunt needles are used for abdominal wall closure, and in friable tissue, and can
potentially reduce the risk of blood borne virus infection from needlestick
injuries.
o Sharp needles pierce and spread tissues with minimal cutting, and are used in
areas where leakage must be prevented.
Common equipment list for one OT
OT table
OT light – ceiling double dome
Mayo stand
Surgical trolley
Equipment trolley
Emergency and drugs trolley
Anesthesia trolley (complete with Ambu bags and other Items)
Difficult airway trolley- bronchoscope, LMAs, and intubating bougie
Anesthesia work station
Electrical suction
Laryngoscope with 5 blades
Defibrillator (AED plus manual with ECG)
Flash autoclave – (Chamber capacity of app.20 liters / cycle)
Surgical diathermy – bipolar
ECG machine – 6 channels
Crash cart
Bowl sterilizers – different sizes
Oxygen cylinder D type
Washer disinfector 30-45 liters
Patient trolley
Blood warmer
IV stand
Glucometer
Disinfection and sterilization of equipment
Disinfection
The process of destroying all pathogenic microorganisms. It can refer to an action of antiseptics
as well as disinfectants. Disinfection is not a sterilizing process and must not be used as a
convenient substitute for sterilization. It is of 3 types
 Concurrent disinfection
 Terminal disinfection
 Pre-current (prophylactic) disinfection
Methods of achieving disinfection
1. Thermal disinfection: -This may be used for an instrument that is able to withstand the
process of heat and moisture and is not required to be sterile. The level of disinfection
depends on the water temperature and the duration of instrument is exposed to that
temperature
2. Chemical disinfection: -The performance of chemical disinfectants is dependent on a
number of factors including temperature, contact time, concentration and pH, presence of
organic or inorganic matter and the numbers and resistance of the initial bioburden on a
surface.
Sterilization of equipment
Sterilization is a process that destroys or eliminates all forms of microbial life and is carried out
in healthcare facilities by physical or chemical methods. Cleaning to remove visible soiling in
reusable equipment should always precede sterilization. Only wrapped / packed sterilized
materials should be described as sterile. Before any instrument or any equipment goes under the
process of steam sterilization, the following should be checked
 Ensure that the instrument can withstand the process (eg: steam under pressure)
 Ensure that the instrument has been adequately cleaned
 Ensure that the instrument does not require any special treatment
 Ensure that records of the sterilization process and for the traceability of instruments are
kept.
Methods of sterilization
1. Steam is the preferred method of sterilizing critical medical and surgical instruments that
are not damaged by heat, steam, pressure and moisture.
2. Sterilized by “dry heat”
3. Low temperature sterilizations technologies. Eg: ethylene oxide (ETO) are used for
reprocessing critical care patient equipment which are heat sensitive.
Preparation of sets for common surgical procedures
Refer textbook (ADULT HEALTH NURSING-1, VIKAS SHARMA, Page numbers – 64 to 69)
Scrubbing Procedures, Gowning, Masking and Gloving
Surgical Scrubbing Procedure
Introduction
Surgical scrub is a process of removing or decreasing bacterial count and resident skin flora from
hands and the forearms to a safe level of surgical acceptance by mechanical scrub with the help
of scrub brush and a chemical antiseptic soap.
Objectives
• To remove soil and transient microbes from the hands and forearms.
• To reduce the resident microbial count to as low a level as possible.
• To inhibit rapid rebound growth of microbes.
Characteristics of a Surgical Scrub
1. Anti-microbial action: An ideal agent must have a broad spectrum of anti-microbial activity.
2. Persistent activity: An agent offering persistent activity keeps the bacterial count low under the
gloves.
3. Safety: The ideal agent must be non- irritating and non-sensitizing. It must not be damaging to
the skin and environment.
Surgical Cap and Mask
 Nurse should wear a disposable Surgical Cap in such a manner that hair is covered
completely to avoid contamination of the sterile field by falling hair.
 A surgical mask is worn to protect the patient from bacteria exhaled by nurse and it is
mandatory for members of scrub team.
 A surgical mask should be covering the nose and mouth completely.
 A sterile mask should be donned immediately before the beginning of every scrub
procedure.
Hand Washing
Adequate scrubbing and hand washing facilities is provided for all operating team members.
Preferably, hands are foot operated. The sink is designed deep and wide enough to prevent
splashing. Scrub sinks are used only for scrubbing or hand washing.
Preparations for Surgical Scrub
General Preparations:
• All jewelry should be removed from the hands and forearms.
• Fingernails should be trimmed short to avoid glove puncture.
• Skin and nails are kept clean and in good condition. If hand lotion is used to protect skin, a
non-oil base product is recommended.
• No nail polish and artificial nails are allowed
• Hands and forearms should be free of open lesions and breaks in skin integrity.
• All hair is well covered by head gear
• Adjust disposable mask snugly and comfortably over nose and mouth
• Eye glasses and protective glasses are adjusted comfortably in relation to mask.
Surgical Scrub Procedure:
• The surgical scrub takes 3 minutes.
•To prevent contamination from the elbows and arms to the hands, the hands are always being
kept above elbow level.
• The scrub procedure takes place under running tap water’
• Wet hands and arms properly
• Apply antiseptic hand scrub or soap such as chlorhexidine or povidone iodine to the hands and
rub the hands together for one minute. Rinse in between
• Also wash in between fingers
• Wash hands to above elbows for one minute
• Rinse hands and take fresh soap / scrub solution
• Rinse from fingertips to elbows. Always keep hands above elbow level.
Drying of hands and arms
After scrubbing arms and hands are thoroughly dried before the sterile gown is donned to
prevent the contamination of the gown by strike through of organisms from skin and scrub attire.
Two huckaback or disposable paper towels are placed on top of the gown during packaging for
drying of hands.
 The circulating floor nurse opens the outer layer of the gown pack. Stand way from the
trolley. Water does not drip on the trolley
 The scrub nurse takes one huckaback or disposable paper towel in the right hand and start
drying the fingers, hand and arm up to the elbow of the left side. Keep away from the
body. We do not go back touching or drying the fingers.
 Surgeon/s follows same procedures as the scrubbing nurse/s
 Now take the second huckaback or disposable paper towel in the left hand and dry the
right side in the same manner as the left side
Note: During and after scrubbing keep the hands higher than the elbows to allow water to flow
from the cleanest area, the hands, to the marginal area of the upper arms
Gowning and Gloving technique
Gown and glove procedures are performed following the surgical scrub. It involves the donning
of a sterile surgical gown and gloves in such a way as to maintain sterility of the outside of both
gown and gloves. The gowning and gloving are important component of Aseptic technique.
These procedures avoid to the introduction of pathogens or disease-causing microorganism.
Maintaining asepsis in product preparation in critical for the specialized patient. The sterile gown
is put on immediately after the surgical scrub. The sterile gloves are put on immediately after
gowning
Definition (Gowning)
Gowning is the process of wearing special garments in order to control particulate
contamination.
Definition (Gloving)
Sterile or clean fitted coverings for the hands, usually with a separate sheath for each finger and
thumb. Clean gloves are worn to protect health care personnel from urine, stool, blood, saliva,
and drainage from wounds and lesions of patients and to protect patients from health care
personnel who may have cuts. Sterile gloves are worn when there is contact with sterile
instruments or a patient's sterile part.
Purpose
To provide a barrier that prevents transfer of microorganism to the surgical site.
To protect the operator from exposure to patient blood and exudate during the procedure.
General principle’s
 All articles used in an operation have been sterilized previously.
 Persons who are sterile touch only sterile articles; persons who are not sterile touch only
unsterile articles.
  Sterile persons avoid leaning over an unsterile area; non- sterile persons avoid reaching
over a sterile field. Unsterile persons do not get closer than 12 inches from a sterile field.
 Sterile persons keep contact with sterile areas to a minimum.
 Non-sterile persons — when you are observing a case, please stay in the room until the
case is completed. Do not wander from room to room as traffic in the operating room
should be kept as a minimum. Patient privacy needs to be respected.
Gowning steps
Picking up the gown
1. With one hand, pick up the entire folded gown from the wrapper by grasping the gown
through all layers, being careful to touch only the inside top layer which is exposed.
2. Once your hands are securely pinching the gown in these slots, step back from the shelf and
allow the gown to drop.
3. Make sure the gown does not touch any surrounding unsterile objects.
Inserting your arms on the sleeves of the gown
4. Grasp the inside shoulder seams and open the gown with the armholes facing you.
5. Carefully insert your arms part way into the gown one at a time, keeping hands at shoulder
level away from the body.
6. Slide the arms further into the gown sleeves and when the fingertips are level with the
proximal edge of the cuff, grasp the inside seam at the cuff hem using thumb and index finger.
Be careful that no part of the hand protrudes from the sleeve cuff.
Fastening of the gown
7. A theatre assistant will fasten the gown behind you, positioning it over the shoulders by
grasping the inside surface of the gown at the shoulder seam. The theatre assistant’s hands should
only ever be in contact with the inside surface of the gown.
8. The theatre assistant then prepares to secure the gown at the neck and upper back. Gowns
differ in how they are secured, but most with have either tie, buttons or velcro tabs.
Gloving steps
 Open the sterile glove wrapper while the hands are still covered by the sleeves.
 Pick the right hand glove with the left hand by holding it at the edge of averted cuff and
steps back from the field.
 Insert the right hand into the glove and explores the finger holes before inserting the
whole hand completely, leave the averted cuff as is.
 Slip the gloved right hand under the fold of the averted cuff. Inserts the left hand by
exploring the finger holes before inserting the whole hand completely. Leave the folded
cuff.
 Make a pleat at the left cuff of the gown and secures this place with your right thumb.
 Slip the four fingers of the right hand under the fold of the glove and pull it over the
pleated cuff of the sleeves. Fix the glove firmly.
 Repeat the procedure for the right hand.
Removal of Gowns
 Grasp the front of the gown at the shoulders below the neckline after the circulating nurse
unties the neck and the back ties.
 Pull the gown downward from the shoulders, turning the sleeves inside-out as it is. Pull
of the arm.
 Rolls the gown and discard it to the linen hamper.
Removal of Gloves
  Remove the first glove by grasping the palmar side of the gloves of the non-dominant
hand with the gloved fingers of the dominant hand and pulls it off inside out.
 Pull the first glove completely off by inverting or rolling the glove inside out.
 Hold continuously the inverted removed gloved by the fingers of the remaining gloved
hand. Place the first two fingers of the bare hand inside the cuff of the second glove.
 Pull the second glove off to the fingers by turning it inside out. This pulls the first glove
inside the second glove.
 Uses the bare hand, remove the gloves which are now inside out, & disposes them in the
infectious trash receptacle.
 Perform hand hygiene.
Masking
Facial PPE
A combination of PPE type is available to protect all or parts of the face from contact with
potentially infectious material. The selection of facial PPE is determined by the isolation
precautions required for the patient and / or the nature of the patient contact.
Face mask
 A mask should be worn if contamination of the oral or nasal mucous membrane is
anticipated by splashing of patient’s blood
 It should fully cover nose and mouth and prevent fluid penetration
Procedure of wearing a mask
The mask is placed over the mouth, nose and chin. The flexible nose piece is fitted to the form of
the nose bridge; the upper set of ties is then tied at the back of head and the lower set at the base
of neck.
Respirators
 A respirator is a device to protect the wearer from the inhalation of harmful atmospheres.
 These are used to protect health care workers from hazardous and infectious aerosols.
 Respirators that filter the air before it is inhaled should be used for respiratory protection.
 The most commonly used respirators in health care settings are the N95, N99 or N100
particulate respirators.
Procedure of wearing a respirator
A fit tested respirator is selected and placed over nose, mouth and chin; the flexible nose piece is
fitted over nose bridge. The bands are stretched over the head and secured comfortably. A fit
check should be performed, that is the respirator should collapse during inhalation and leakage
should be checked around the face during exhalation.
Procedure of removing a mask or respirator
The front of the mask/respirator is considered contaminated and should not be touched. Only the
ties or elastic bands are handled, starting with the bottom then top tie or elastic bands are
handled, starting with the bottom then top tie and elastic band. The mask or respirator is lifted
away from the face and discarded.
Eye wear and goggles
 Goggles should be used if blood or bloody fluid splashes are anticipated for eg: during
any surgery, endoscopic procedures, bone drilling or vascular injuries or laser surgeries
etc.
 It should fit snuggly over and around eyes
 Goggles provide barrier protection for the eyes; personal prescription lenses do not
provide optimal eye protection and should not be used as a substitute for goggles
  Goggles with antifog feature improves clarity of vision
Face shields
Face shields are personal protective equipment devices that are used by many workers for
protection of the facial area and associated mucous membranes (eyes, nose, mouth) from
splashes, sprays, and spatter of body fluids. a face shield will protect your entire face from
impact hazards, such as flying debris, chemical splashes and even electric arc flash. The face
shield should cover the forehead, extend below the chin and wrap around the side of the face.
Procedure for wearing eye and face protection
 Goggles should be positioned over face and secured on brow with head band and adjusted
to fit comfortably
 Face shield should be positioned over face and secured on brow with headband and
adjusted to fit comfortably
Procedure for removing eye wears and face shield
The ear or head pieces are grasped with ungloved hands and lifted away from face; these are then
placed in designated receptacle for reprocessing or disposal
Protective foot wear
Protective foot wear should be used when handling biomedical waste as unnoticed cuts and
wounds are quite common in the legs. Foot wear is also essential to protect legs from ‘sharps’
injury.
Monitoring of the patient during the procedure
Introduction
Monitoring the patient during Surgical procedure to Helps assess the integrity of neural
structures and consciousness during Surgical procedure. It includes both continuous monitoring
of neural tissue as well as the Localization of vital neural structures.
Definition
Monitoring the patient during surgical is a technique used during surgery to monitor the
condition of patient nervous system and vital Helps prevent damage to the spinal cord, Brain
Purpose
 To assess the general Health status of the patient
 To assess for any alteration in the health status
 Establish Baseline data.
 To check the peripheral circulation
 To Determine patient's Hemodynamic status
Most commonly monitoring
 BLOOD PRESSURE  HEART RATE  RESPIRATORY RATE  BODY TEMPERATURE
 ELECTROCARDIOGRAM  NEUROPHYSIOLOGICAL
Blood pressure
BP is the pressure of Blood against the walls of Blood vessels. Normal Blood pressure = 120/80
mmHg.
Heart rate
HR also known as pulse is the Number of Time your heart Beats per minute NORMAL HEART
RATE = 60 70 100 Beats per minutes.
Respiratory rate
Respiration is the process of Breathing and consists of Inspiration and Expiration. NORMAL
RESPIRATORY RATE: 18 TO 24
Body temperature
It involves measuring of the body -Temperature by using – Thermometer. NORMAL BODY
TEMPERATURE: - 98.6 F, 37 C
Electrocardiogram
ECG is a test that can Be used to check your Heart Rhythm and electrical activity
Neurophysiological
It is use to electrophysiological methods do Detect electroencephalography, electromyography,
and potential to monitor. The functional integrity of certain neural structures during surgery
Perioperative phase
When The decision to have surgery is made and ends when the client is transferred to OT table.
Check list of preoperative phase
 Patient identification
 Surgical consent
 History & physical examination
 Surgical site signature
 Teach to anesthesia
 Allergic reaction
 Consent form
Nursing responsibilities
 Make sure the patient has had no solid food for at least 6 Hours and No water at & Hours
before surgery.
 Make sure the chart contains all necessary Information, Such as. - signed surgical
consent
- diagnostic test results
 Tell to the patient to remove jewelry, makeup, hairpins, nail polish, dentures.
 Perform mouth care
 Ask the patient void
 Identified the name of band and case sheet
 Informed about the surgery, name of surgery and which doctor will do, and Duration of
surgery. Informed consent form in local language to the patient, and take signed by the
patient or responsible family member.
 Take and Record Vital sign
 The site of surgery should be Taken with a permanent marker by the surgeon
 Check for and carry out special orders (enema NGI insertion, Iv line)
 CROSS Check the Identification band.
 Administer preoperative medication as ordered.
 Transfer to operation theater to patient.
Intraoperative phase
The period during a surgical procedure. From the time the patient enters the operating room until
they are transferred to the post-anesthesia care unit (PACU)
Checklist of intraoperative
 Patient advocacy
 Preparing the operating room.
 Safety.
 Assisting the surgical team
 Monitoring vital signs.
 Documentation and Record
  Post-operative Handoff.
Maintenance of the therapeutic environment in OT
Therapeutic environment
Therapeutic environment can be defined as the total of all external conditions and influences
affecting an individual in the illness situation.
Rules to maintain therapeutic environment
1. Infection prevention in the operating room is achieved through prudent use of aseptic
techniques in order to prevent contamination of the open wound.
2. Isolate the operating site from the surrounding unsterile physical environment.
3. Create and maintain a sterile field in which surgery can be performed safely.
Achieving a therapeutic environment
1. Adequate comfort, food, cleanliness, and rest
2. Freedom from injury
3. Individualized patient care
4. Friendly, courteous, accepting atmosphere
5. Feeling of security and self-worth
6. Diversional activities for the patient
Application of principles of therapeutic environment
• method of vacuuming and dusting and other general cleaning should be done.
• all organic material should be removed from equipment or surfaces before disinfection process.
• cleaning and disinfection by chemicals that will not harm surfaces, materials should be
selected.
• cleaning and disinfection solution should be used in required concentrations for adequate time
and according to directions.
• use disposable equipments as much as possible.
Factors affecting an optimum environment
• temperature • humidity • air movement / ventilation • purity of air • lighting • low noise
• psycho-social environment
Steps to maintain therapeutic environment
• proper preparation of client • hand washing • surgical hand scrub • using barriers such as gloves
and surgical attires • maintaining a sterile field • using standard surgical technique • maintaining
safe environment in operating room
Maintaining a sterile field
• a sterile field must be established and maintained in order to reduce the risk of contaminating
surgical/procedure area.
• placing only sterile items within the sterile field.
• opening, dispensing, or transferring sterile items without contaminating them.
• considering items below the level of draped client to be unsterile.
• not allowing sterile personnel to reach across unsterile areas or vice versa or to touch unsterile
items.
• the neckline, shoulder, and back are considered to be unsterile areas of the gown.
• recognizing that the edges of a package containing a sterile item are considered unsterile.
• recognizing that a sterile barrier has been penetrated is considered contaminated.
• not placing sterile items near open windows or doors.
• sterile drapes should be used to establish a sterile field.
• items used within a sterile field should be sterile.
• a sterile field should be constantly monitored and maintained.
• moisture in sterile field should be avoided. If a solution soaks through a drape, then it should be
covered with another sterile drape.
• policies and procedures for basic aseptic technique should be written, reviewed annually and
readily available.
Principles in operation theatre
• doors and windows must be kept close as much as possible.
• ward nurse must handover patient to theatre nurse with all details like pre-medication details, iv
line.
• patient should be shifted to OT always in trolley. Patient should remove all jewelries and in OT
gown and cap.
• initially patient is kept in preoperative room and later shifted to theatre. Ideally anesthetist,
surgeon, and theatre nurse accompany patient.
• OT nurse should confirm consent form, case sheet, site and side of surgery.
• separate theatre shoes should be worn by surgeon, anesthetist, OT nurse, and assistants
• unnecessary movements, talking loudly, commenting, laughing should be avoided
• all person entering theatre should wear OT dress, cap, mask, footwear
• clothes, dress should be washed, ironed, and clean and kept ready for everyday use
• mobile phones should be switched off
• any public person or relatives should not be allowed inside operation theatre
• one senior nurse is made in charge of theatre in all activities
• OT nurse and assistant should accompany patient to postoperative nurse
• patient should be shifted outside OT once anesthetist confirm the fitness for shift
Conclusion
The operation room environment is a high-risk environment, the risk can be minimized by
adhering to strict rules and regulation framed by time to time based on evaluation of risk
encountered by the health care providers, clients and family and hospital administration