2. OR Team and Relationships.pptx

July, 2021 © Haramaya University, CHMS,
Department of Emergency and Critical Care Nursing
Introduction to OR Technique
By:- Ame Mehadi (BSc, MSc)
OR Team and Relationships

By:- Ame Mehadi (BSc, MSc-EMCCN)
Objectives
Discuss the surgical team composition
Discuss the responsibilities of each surgical team member
Discuss the responsibilities of Unsterile team members
Discuss the responsibilities of sterile team members
List the responsibilities of scrub nurse
List the responsibilities of circulator nurse

Surgical Team
Definition:
►A group of professionals providing the continuum of care during:-
 pre-operative.
 intra-operative and
 postoperative and recovery
4

OR Personnel Organization
Just as there is a logical order to the physical design, there is a logical
division of duties among the OR staff.
OR Team
►has specialized members including:
 Surgeon,
 Assistants (One or two),
 Anesthesia provider (Anesthetist/Anesthesiologist),
 Scrub,
 Circulator/runner,
 Janitor/cleaner,
 Others

These individuals,
►each with specific functions to perform,
►form the operating team.
►works in harmony with each other for
the successful accomplishment of the expected patient
outcomes.
When the patient arrives the OR, he/she is received and surrounded by
this team.
This team literally has the patient’s life in hands.

is subdivided according to the functions of its members as
Sterile Vs Unsterile

Sterile Team
 those persons working together in the sterile field during operation.
►wash (scrub) their hands and arms,
►put on (don) a sterile gown and gloves, and
►enter the sterile field,
►work within limited area (only sterile field) and
►handle only sterile items.
►the sterile field
 is the area of the OR that immediately surrounds and
 is specially prepared for the patient.
 established by all sterilized items needed for the surgical
procedure.
 Consists
►Surgeon
►Assistant surgeon
►Scrub nurse
►The patient
OR team members while
performing operation

Non-Sterile/Clean Team
 those persons working together out of sterile field in the OR during the operation.
►do not enter the sterile field;
►work outside and around the sterile field.
►assume responsibility for maintaining sterile technique during the surgical
procedure, but
►handle supplies and equipment that are not considered sterile.
►follow the principles of aseptic technique,
►keep the sterile team supplied,
►provide direct patient care, and
►handle other requirements that may arise during the surgical procedure.
 Consists of:
►Anesthetist/anesthesiologist
►Circulator/Runner
►Cleaner/janitor
►Others, such as students, cleaners and those who may be needed to set up
and operate specialized equipment or monitoring devices.
9

Responsibilities of Each Surgical Team Members
Anesthesia provider
The surgeon
The surgeon’s Assistants
Scrub Nurse
Circulator/Runner Nurse

Responsibilities of the Anesthesia Provider
Anesthesia provider(AP) can be
►Anesthesiologist
 is a physician specialized in anesthesia.
►Anesthetist
 a university or college graduate in anesthesia
►Nurse anesthetist
 a registered professional nurse who is trained
in administering anesthetics.

Responsibilities of the Anesthesia Provider…….
Anesthesia and surgery
►are two distinct, but inseparable disciplines;
►are two parts of one entity.
Anesthesia provider
►is an indispensable member of the OR team.
►functioning as a guardian of the patient,
►should observe the principles of aseptic technique.
Adequate communication b/n surgeon & AP is the patient’s greater
safeguard.

Fluid and electrolyte administration
Selecting the anesthetic agents,
Administering anesthetic agents
Intubating the patient, if necessary,
Providing a smooth induction of anesthesia – to prevent pain.
Maintaining anesthesia at the required levels
►Maintaining satisfactory degrees of relaxation of the pt for
duration of surgical procedure.
Monitoring vital functions and parameters

Continuous monitoring to the physiologic status of the patient.
►oxygen exchange, circulatory functions, systemic circulation, vital
signs.
Managing untoward rxns to anesthesia throughout the surgical procedure.
managing technical problems related to the administration of anesthetic
agents,
supervises the patient’s condition throughout the surgical procedure.
monitoring of anesthesia while maintaining the overall well-being of the
patient.
must be constantly aware of the surgeon's actions.
Advising the surgeon about impending cxns & independently intervening as
necessary.

Responsibilities of the surgeon
is team leader
has ultimate responsibility for performing the surgery in an effective and
safe manner.
is dependent upon other members of the team.
coordinate the team for the patient's emotional well-being and
physiologic monitoring.
must do every thing possible to ensure the safety of the patient.
reduce the stress of the operation.
pre op Dx & care
selection & performance of the surgical procedure
post op mgt

Responsibilities of the Assistant Surgeons
Under the direction of the operating
surgeon, one or two assistants help to:
►maintain visibility of the surgical site
►control bleeding
►close wounds and
►apply dressings

Responsibilities of the Scrub Nurse
Scrub is the term used to designate the
member of the surgical team who assists the
surgeon by providing sterile instruments,
sutures, and supplies within the sterile field.
Perform Check list before scrubbing
►Check Consent
►Confirm Surgical Procedure
►Check Instruments
►Check Supplies
dons conductive shoes, greens (pants and
shirt), cap, and mask.
then scrub hands and arms

Responsibilities of the Scrub Nurse……
gowns and gloves other members of the sterile team.
Work with the surgeon.
is guided & directed constantly by what the surgeon is
doing.
must have a constant attention to the operation field.
works primarily with instruments and equipment.
arranges the sterile supplies and assumes responsibility
for the sterility of the items for use within the operative
field both before and during the surgical procedure.

Check internal sterilization indicator controls.
Assemble instruments
►Arrange instruments and sterile supplies on back
table and Mayo tray.
Selecting instruments, equipment, and other
supplies appropriate for the surgery.
Select, collect special surgical instruments

Gown and glove the surgeon.
Prepares the setup
Preparing the sterile field
Setting up the sterile table
Prepare & Drape mayo stand
Prepare prep set first
Separate and arrange sterile basins
Assist surgeon in cleaning & draping patient

Identify and prepare appropriate
suturing materials and ligatures.
Maintaining the integrity and
sterility of the sterile field.
Assisting the surgeon and surgical
assistant.
anticipating the surgeon’s needs.
Proper draping exposes only the surgical
site, which decreases the risk for infection.

Anticipates and meets the needs of the surgeon by
watching the progress of the surgery and knowing the
various steps of the procedure.
Anticipating the required instruments, sponges, drains
and procedures.
Providing instruments, sponges, sutures, and supplies in
an appropriate and timely manner to surgeon.
Preparing sterile dressings
Assist surgeon with dressing.

Keeping the track of time, the pt is under anesthesia
and the wound opened.
Remove loose sponges from operative area as
necessary.
Collects specimen for pathology.
Identifies and preserves specimens properly.
Keep the principles of asepsis.
handle any emergency situation in the OR.

 Reviews anatomy, physiology, and the surgical
procedure.
 Assists with preparation of the room.
 Keeps track of irrigation solutions used for calculation
of blood loss.
 Make the surgical count.
►Count sponges with circulator
►Takes part in sponge, needle, and instrument counts
►Recount sponges with circulator.

Dispose of sharps
Cover the soiled instruments before sending them for
cleaning/autoclave
Remove supplies from room and put in proper place.
Prepare instruments and supplies, used and unused, for
clean up.
Cleaning and preparing instruments for terminal
sterilization.
Assist circulator in preparing for next operation.

Responsibilities of the circulator Nurse
 The circulator is the member of the surgical team who works outside the
sterile field,
 providing patient care,
 dons conductive shoes, cap, mask, and greens (pants & shirt).
 providing procedures needed supplies,
 assists surgical team members in performing the operation safely and
expeditiously.
 maintaining a neat, quiet, well-organized OR,
 anticipating & meet the needs of the other team members such as
► the scrub nurse, the anesthesia provider, the surgeon and above all the patient.

Responsibilities of the Circulator Nurse……
assembles & brings all packs, supplies, &
equipment needed for the case into the room;
Ties gowns for "sterile" members,
Sets up unsterile items of equipment;
Performs other unsterile duties.

Responsibilities of the Circulator Nurse……
 From the responsibilities listed, it is essential that the
circulator must posses the ability to:
►Organize activities and direct personnel with due
understanding of interpersonal relations,
►Anticipate needs,
►Differentiate b/n situations that demand immediate
attention and those of lesser importance,
►Maintain a quiet, neat and well equipped unit,
►Understand thoroughly the principles of asepsis,
►Teach actively and by the examples he/she sets.

Circulator Duties……
 manages the OR and protects the patient’s safety and health by
► monitoring the activities of the surgical team,
► checking the OR conditions, and
► continually assessing the patient for signs of injury and
► implementing appropriate interventions
► verifying consent,
► coordinating the team, and
► ensuring cleanliness, proper temp, humidity, lighting, safe function of equipment, and the
availability of supplies and materials
► observes aseptic technique at all times to see that it is maintained properly.
► Monitors aseptic practices to avoid breaks in technique
► Perform “surgical or pre-procedure pause” or timeout”

 liaison b/n scrubbed personnel and those outside of the OR.
►Communicating relevant info to other team members & to the patient’s family
 Assists with preparing the room,
 Identifies and assesses the patient.
 plans and coordinates the intra op cares.
 Admits the patient to the OR
 Providing comfort and the safety of the patient.
 Providing emotional support and psychological comfort to the patient prior to &
during induction of anesthesia.

Teaching patient and family
Coordinates the care of the patient,
Carry out the care plan
Developing and implementing a
plan of care
 Making initial ass’t of the patient and
continued monitoring.
Serves as the patient’s advocate
throughout the intra-op experience.
Performing ongoing patient
assessment
Formulating a diagnosis
Documenting patient care
Evaluating patient outcomes
Transfer the patient to the RR.

Strictly observes the team activities
Observing the surgical procedure
Anticipating the needs for equipment, instruments, medications, blood units.
Answer the team requests
Keeps the "scrub" with supplies
►e.g. suture materials, dressings etc.
Opens sterile supplies before and during the case, replace saline or water in
basins as necessary.
Obtaining appropriate surgical supplies and equipment

 Adjusts, focus the surgical lights over operative area.
 Attaches the suction apparatus and check to see its function;
 Insertion and application of monitoring devices.
 Handles all unsterile equipment in the room during surgery, places buckets properly
to receive discarded sponges.
 Checks the chart and relates pertinent data
 Measures blood and fluid loss
 Reports pertinent information to the recovery area personnel.
 Activities are directed toward assuring patient safety and achieving desired patient
outcomes.

 Administering drugs
 Implementing and enforcing policies and
procedures that contribute to pt safety,
such as
►surgical checklists, “time-out” protocols,
►surgical counts
►checking equipment
 Managing and implementing activities
outside the sterile field.
 Check mechanical and electrical equipment.
 Documents and preserves any specimens
received during surgery
►Prepare specimen for laboratory.
►Preparing and disposing of specimens
►Preparing labels for the patient specimens
►Submits to the laboratory for analysis.
 Creating and maintaining a safe
environment
►Damp dust all equipment and wet-vacuum
floor prior to a surgical procedure.

 Arrange furniture in functional order.
 Assemble, arrange, and open outer and
inner wrappers of sterile supplies.
 Check package integrity, expiration date,
and appearance of the indicating tape.
 Deliver supplies to the sterile field,
 Pass knife blades and suture to scrub.
 Pass additional sterile supplies to scrub as
needed.
 Pour sterile solutions: water, N/S, and
antibacterial solutions.
 Pass dressing sponges to scrub.
►Saving all discarded sponges during surgery.
 Participates in the surgical count.
►Takes part in sponge and instrument counts
and their documentation.
►count sponge with scrub.
►Record on sponge count board.
►Verify sponge count with scrub.

 Assist in moving patient to litter and secure with straps.
 Patient positioning
 Assisting anesthetist
►with moving & positioning patient.
►in securing drapes.
 Check with anesthetist before touching patient.
 Place the restraining strap properly.
 Assist surgeon with prep–expose area.
 Place linen protectors to absorb excess moisture.

 Removes surgeon's gloves after prep.
 Move liner containing soiled prep sponges to outer circle of room.
 Attach suction tubing to machine.
 Remain alert to needs of the scrub.
 Assist scrub with arrangement of draped furniture.
 Position kick buckets for easy access.
 Replace kick bucket liner.
 Prepare adhesive strips for dressing.
 Remove and check drapes for instruments and supplies before discarding into
hamper.
 Clean the room and prepare for next case.

During the positioning procedure, it is the
Circulator responsibility to:
►Restrict access to the OR
►Close all doors
►Limit traffic within the OR
►Minimize exposure
►Provide auditory privacy
►Prohibit prejudicial behavior

Coordinated Roles of the Scrub and the Circulator
The coordinated role is essential
►to move the schedule of surgical procedures efficiently and
►to serve the best interests of the patient.
complete preparation of the environment.
Consists
►Sponge, Sharp, and Instrument Count

General Responsibilities of Nurses in the OR
 Nurses have exciting and diverse role involving some or all of the following:
►Preparation role
►Prevention role
►Assistance role
►Monitoring role
►Organizing role
►Managerial role
►Record keeping role
►Statistical reports
►Supervision role
►Training role
►Safety ensuring role
►Controlling role
►Stock mgt role etc.
Nurses may be assigned to
►the scrub,
►the circulator,
►the recovery room,
►the workroom,
►the instrument room,
►the anesthesia section, or
►any other area within the surgical
suite.

General Responsibilities of Nurses in OR..….
function in various roles, including those of
►manager/director,
►clinical practitioner, e.g.,
 scrub,
 circulator,
 clinical nurse specialist,
 registered nurse first assistant [RNFA],
►educator, and
►researcher.

 monitoring the patient’s vital parameters with anesthesia provider,
 organizing patient transportation from OR to RR,
 carry-out and/or supervise all post-op activities to prepare OR for the next operation.
 receiving pts from preparation room, taking to OR &
 ensure pts are ready for surgery.
 care, preparation, and maintenance of sterile and unsterile supplies.
 preparation of the material and equipment,
 implementing hygiene, sterilization, asepsis & disinfection protocols & procedures at
all times, before, during & after operations.

In addition to understanding and performing tasks related to assignment as
the scrub or the circulator for an operation,
OR Nurses are required to:
►understand and participate in tasks concerned with
 preparing the patient for surgery (surgical "prep"),
 assembling packs for use during surgery,
 assembling instrument sets, and
 sterilizing supplies and equipment.
►practice personal hygiene measures to prevent spread of pathogenic
organisms;
►demonstrate a high standard of personal ethics, as well as practicing
such medical ethics as upholding the patient's right to privacy.

Ensure safety of patients and staff
Supervise and train the assistants and cleaners in OR
Control all equipment and material stock used in the OR
►to ensure efficient and rational use of material resources
Record keeping
Contribute to monthly reports according to guidelines (statistical reports,
etc.)

Assistance role
►Assist the surgeon during the operation
►Assist the anesthetist;
Prevention of Complications
►Prevention of Later Post op Complications
►Prevention of Respiratory Complications.
Assisting the Client With Post op Exercises
►Splinting an Incision
►Turning, Coughing, and Deep Breathing (TCDB)
►Huffing
►Use of the Incentive Spirometer
►Leg Exercises
►Suture and Staple Removal

Additional responsibilities that promote personal and professional
growth and contribute to the profession include, but are not limited to,
the following:
►Participation in professional organization activities
►Participation in research activities that support the profession of
perioperative Nurses.
►Exploration and validation of current and future practice
►Participation in continuing education programs to enhance
personal knowledge and to promote the profession of
perioperative Nurses.
►Functioning as a role model for nursing students and
perioperative Nurse colleagues.
►Mentoring, precepting, and instructing other perioperative Nurses.

Patient assessment before, during, and after surgery
Patient and family teaching
Patient and family support and reassurance
Patient advocacy
Performing as scrub or circulator during surgery
Control of the environment
Efficient provision of resources
Coordination of activities related to patient care
Communication, collaboration, and consultation with other healthcare team
members.
Maintenance of asepsis
Ongoing monitoring of the patient’s physiological and psychological status
Supervision of ancillary personnel

Surgical Count
consists Sponge, Sharp, and Instrument Count
Done before and after use.
Need accountability which is a professional responsibility.
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.

Sponge, Sharp, and Instrument Count
foreign body unintentionally left in the pt’s body:
►can be source of wound infection or disruption.
►may lead to
 abscess formation and
 development of fistula b/n organs
►Foreign body reaction may be immediate or delayed for years
►Sometimes difficult and costly to diagnose
►Removal of the object usually requires major surgery
A contaminated sponge or needle that is unaccounted for at the close of
procedure could also in advertently come in contact with the personnel
who clean the room.

Sponge, Sharp, and Instrument Count
Blood or any other body fluids are sources of pathogens such as HIV, HBV or
HCV.
Inventory control
►is monitored by accounting for the instrument set in its entirety.
Counting ensures that expensive instruments such as towel clips and
scissors are not accidentally thrown away or discarded with the drapes.
Injury to laundry and housekeeping/env’tal services personnel by the
contaminated sharp edges of surgical instruments, blades, and needles is a
potential risk.
Surgical instruments also can cause major damage to equipment in the
laundry service.
A count must be undertaken for all procedures in which the likelihood exists
that swabs, instruments and/or sharps could be retained.

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.
is made three times in a surgical procedure.
►First Count
►Second Count
►Third Count

Counting Procedure
A.First Count
is performed by the person who assembles and wraps items for
sterilization.
In commercially prepackaged sterile items, the count is performed
by the manufacturer.

Counting Procedure…………
B. Second Count
►done by the scrub and the circulator together
►done before the surgical procedure begins and during the surgical procedure
as each additional package is opened and added to the sterile field.
►is 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:
►counting all items as the scrub touches each item.
►numbering each counted item aloud
►immediately recording the count for each type of item on the count record.
►counting additional packages away from counted items already on the table
►Counting should not be interrupted.
►should be repeated if there is uncertainty because of interruption, fumbling, or
any other reason.

C. Third Count
►performed before the surgeon starts the closure of a body
cavity or a deep/large incision:
►takes place in three areas
 Field Count
 Table Count
 Floor Count

Field Count
►done by the scrub assisted by either the surgeon or the assistant.
►additional items are accounted at this time.
Table Count
►the scrub & the circulator together count all items on the Mayo stand &
instrument table.
►surgeon & assistant may be closing the wound, while this count is in
process.
Floor Count
►is counting of items recovered from the floor or passed off the sterile
field to the kick buckets.
►done by circulator
►should be verified by the scrub.

Qualities of the OR Nurse
Stamina
►is having good physical condition and the energy to complete
daily work in a safe and efficient manner.
►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/his daily work in a safe and efficient
manner.

Qualities ……
Emotional stability
►is the ability to cope with own tension and with that of teammates.
►The OR work is stressful.
►The nature of the work can cause team members to be tense or to
display aggressive behavior while working.
►In the OR you must be able to cope with your own tension and with
that of your 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
OR supervisor, all team members must appreciate the responsibility
that rests on the surgeon and not become personally offended by
occasional outbursts.

Qualities ……
Respect
►respect for the patient’s rights for privacy, for other team members,
and for own self is very important in the OR.
►The OR relies on chain of command for efficient and safe patient
care.
►Those who experience problems in responding to authority should
not work.

Qualities ……
Stable health
►If one person is ill, the workload of other team members is increased because they
must perform the work of the absentee.
►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 OR is a stressful situation and because stress can contribute to ill
health, you must be careful to guard against illness and injury.
►Of particular importance are prevention of injury to the back and maintenance
of healthy skin and respiratory tract (common areas of illness).

Qualities ……
Good Humor
►is having 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.
►In a difficult and demanding env’t such as the OR, it is important to have a
proper perspective on the day’s events and to share in good spirit.

Qualities ……
Team spirit
►is the ability to work with team members toward a common goal.
►is very important in surgery.
►The patient expects and should receive the undivided attention of all
who care for him/her.
►To accomplish this, you should recognize the importance of not only
your own job, but also those of the other team members.
►You should either put personnel problems aside or bring them to the
attention of the supervisor, who might able to resolve them.

Co-operation and Economical Use of
Hospital Supplies, Equipment and Time
 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 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 individual can accomplish the goal without the cooperation of the rest of the team.

A. Economical use of supplies and hospital
Equipment
 Most of the hospital equipment is being imported from abroad and it is costy and, therefore
economical and proper usage 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.
 The OR 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.

A. 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:
►Pour just enough antiseptic solution,
►Follow the procedures for draping,
►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,
►Supplies should be opened only as needed, not routinely “just in case” they
may be needed,
►Turnoff lights when they are not needed.

B. Time Economy
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.

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