Surgical Nursing-Operatining Theatre Management.pptx

Njombe Institute of Health and Allied
Sciences
Department of Nursing &Midwifery
Module: Care of a patient with Surgical Conditions
Operating Theatre Nursing.
Instructor: Makota, EP
Thursday, May 18, 2023 1
Makota Operating Theatre Nursing for
Ordinary Diploma in Nursing

Principles of Aseptic Techniques in
Operating Room
• Aseptic technique is most strictly applied in the
operating room because of the direct and often
extensive disruption of skin and underlying tissue.
• Aseptic technique encompasses practices performed
immediately before and during a surgical procedure to
reduce postoperative infection such as:
—Hand washing
—Surgical attire
—Surgical scrub, sterile gowning & gloving
—Patients surgical skin prep

—Using surgical barriers, including sterile
surgical drapes and personal protective
equipments
—Maintaining a sterile field
—Using safe operative technique
—Maintaining a safe environment in the
operating room

• All practitioners involved in the intraoperative
phase have a responsibility to provide and
maintain a safe environment. Adherence to
aseptic practice is part of this responsibility.
• The eight basic principles of aseptic technique
follow:
—All materials in contact with the surgical wound
and used within the sterile field must be sterile.
Sterile surfaces or articles may touch other sterile
surfaces or articles and remain sterile; contact
with unsterile objects at any point renders a
sterile area contaminated.

—Sterile drapes are used to create a sterile field.
Only the top surface of a draped table is
considered sterile. During draping of a table or
patient, the sterile drape is held well above
the surface to be covered and is positioned
from front to back.

—Items should be dispensed to a sterile field by
methods that preserve the sterility of the
items and the integrity of the sterile field.
After a sterile package is opened, the edges
are considered unsterile. Sterile supplies,
including solutions, are delivered to a sterile
field or handed to a scrubbed person in such a
way that the sterility of the object or fluid
remains intact.

—The movements of the surgical team are from
sterile to sterile areas and from unsterile to
unsterile areas. Scrubbed persons and sterile
items contact only sterile areas; circulating
nurses and unsterile items contact only
unsterile areas.
—Movement around a sterile field must not
cause contamination of the field. Sterile areas
must be kept in view during movement
around the area. At least a 1-foot distance
from the sterile field must be maintained to
prevent inadvertent contamination.

—Whenever a sterile barrier is breached, the
area must be considered contaminated. A tear
or puncture of the drape permitting access to
an unsterile surface underneath renders the
area unsterile. Such a drape must be replaced.
—Every sterile field should be constantly
monitored and maintained. Items of doubtful
sterility are considered unsterile. Sterile fields
should be prepared as close as possible to the
time of use.

—The parts of a surgical gown considered sterile
are the sleeves (except for the axillary area)
and the front from waist level to a few inches
below the neck opening. A "sterile" person
should keep his hands in sight and at waist
level or above

Scrub reaching for sterile supplies

• Items should be considered unsterile if there
is doubt about their sterility; if a sterile
appearing package is found in an area not
designated for sterile storage it is considered
unsterile and must be reprocessed and
resterilized or discarded.

• Only the top surface of a draped table is
considered sterile. Linen or sutures falling over
the edge of the table should be discarded. The
scrub nurse should not touch the part hanging
below the table level.
• Sterile team members should be within the
sterile area. Sterile team members should
stand back at a safe distance from the
operating table while draping the patient and
should pass each other back-to-back.

• Sterile areas should be protected from
moisture because a moist item may become
contaminated. Therefore sterile packages
should be laid on dry sterile areas, if any
portion of a sterile package becomes damp or
wet, the entire package should be either
resterilized or discarded.

Sterile persons pass each other back to back or front to front

Surgical Scrub Procedure
• Turn on water tap.
• Dispense a small amount of cleaning agent
into the palms of the hands
• Wash hands and arms including 2 inches
above the elbow and small amount of water
as necessary to work up a good leather. This
washing remove surface first and make the
hands socially clean.

• Use nail file to clean under nails while holding
fingers under the water flow. Discard file rinse
thoroughly, while the hands are upward
allowing water to drop from the flexed elbow.
• Take a sterile brush from the dispensing
container moisten it under running water, add
small amount of cleaning agent directly on the
brush.

• Holding the end of the fingers and thumb
evenly together scrub the finger nails on one
hand and repeat the procedure for other
hand.
• Discard the brush by dropping it into the sink
rinse from finger tips to elbow
• Collect the agent in the palm of one hand, and
thoroughly wash hands and arms. Pay
attention to the area between the fingers.

• Finishing washing at elbow
• Rinse again from finger tips to elbow turn off
water tap using elbow, keep hands and arms
over the sink, allowing water to run off. Do not
shake the water.
• Holds hands up in front only away from your
body and proceed to gowning area.

• Reach down the opened sterile package and
pick up the towel. Don’t drop water on the
package
• Use one end of the towel to dry the hand
starting with the fingers.
• Use the other end of the towel to dry the arm,
use a slower circular motion. Never return to
an area which has been dried.
• Repeat the procedure for the other hands,
then discard the towel.

Preparation of Surgical Procedure, Gowning,
Gloving and Dapping Procedures
Preparation of Surgical procedure:
Surgeon Preference Card:
A preference card is maintained for each
operation that each surgeons performs. A set
of card is kept in control file under the
surgeon name. The file is kept under the
instrumental room.

Gowning Procedure:
—Case is taken when lifting the gown from the
sterile package to prevent contamination by
accidental brushing a cross an sterile area, the
edge of the wrapper or trolley.
—The gown is held at the neck end and lifted
directly upwards. It is kept away from the
body during unfolding to prevent it from
coming contact with the unsterile attire, or
being nicked a cross the face mask.

—A gown is folded inside out, a label seen inside
the neck of sterile gown assists an
differentiating between the inside and outside
of the gown.
—The scrub person gowning must touch only
the inside of the gown because the outside of
the gown is regarded as sterile.
—The gown is donned by sliding the arms into
the arm holes, excessive shaking and handling
of the gown should be left within.

—The hands should lift within the sterile of the
gown, to facilitate the correct closed method
of gloving.
—The circulating nurse will ties the back tapes
of the gown.

Gloving Procedure:
Closed Method:
• The hands and fingers are kept within, the cuff
of the gown and the unexpected left hand is
used to pick up the right glove.
• The palm of the glove is placed against the
palm of the gloves should point to the right
elbow.

• The cuff or folded edge of the glove is grasped
in the left hand and inverted over the right
hand. The glove is pulled on at the same time,
unfolding the cuff of the glove and stretching
it over the stockinette cuff attached to the
sleeves. The sleeve is pulled slightly towards
the elbow to bring the stockinette cuff to the
wrist area.
• The same procedure is performed for the left
hand.

• Once the gloves are donned, they should be
checked to ensure that they are comfortable,
that the cuff are from and flat around the
wrist and that these is no possibility of
unraveling
Open Method:
When the gown is put on, the hands are put of
the cuffs.

• The hands are brought through the cuff. Using
the right hand the left glove is picked up by
the folded cuff and the hand inserted in the
glove.
Plunged Method:
• The most is used to maintain sterility in case
of the one who is not used to wear sterile
gloves by using closed or open.

Draping Procedure:
Draping is the procedure or covering of the
patient and surrounding area with a sterile
barrier to create and maintain adequate
sterile field during the operation.
—Draping of the Trolley: When draping a trolley
while you have donned sterile gown and
gloves start from near area toward far area
—Draping of Mayo Table:
—Abdominal Incision Draping:

Draping Techniques:
• The sterile draper are placed over the patient
allowing only the operative site to be
operated.
• For abdominal operation the patient is draped
from the incision site toward the foot of
operative table. The next draper is placed
from the incision site toward the head of the
operative table.

• The folded edge of the draper should be
positioned close to the operative site and the
unfolded edge positioned away from the
operative site.
• Once the drapers are in the place they may
not be repositioned.
• If draper is contaminated or fall below waist
level it must be discarded and new one
applied.

• An anesthetic Screen is used to separate the
sterile surgical area from non sterile
anesthetic area, it is covered by extending the
sterile draper over the screen.

Abdominal Incision
• Tissue Layer of the abdominal Incision:
1…………….Skin
2…………….Subcutaneous fats
3.……………..White anterior fascia
4………………Muscle
5………………Posterior rectus sheath
6……………….Peritoneum.

• Opening the abdomen:
―The skin and subcutaneous tissue is incised
and blood vessels are ligated.
―Fascia, covers the muscles anteriorly and
posteriorly. The anterior fascia is incised and
each muscle layer is separated and/or divided
by blunt dissection and retracted outwards.
The bleeding vessels are ligated.

—The peritoneum is the thin serous lining
anterior of the abdominal cavity (parietal) and
surrounding the organs (visceral). It is lies
beneath the posterior fascia, both posterior
fascia and peritoneum may be cut at the same
time, thus exposing the contents of abdominal
cavity.

• Instruments used for Abdominal Incision:
―General set
―Laparatomy set:
o Gall bladder forceps curved on flat (Kelly
fraser) 25
o Long scissor curved on flat (Mc indoe)
o Hernia director (Key)
o Hernia bustomy curved
o Aneurysm needle large (Moynihan)

o Artery forceps straight 20cm (Spenser Wells)
25
o Deep retractor curved narrow blade (Deaver)
o Retractor self retaining abdominal
(Gassel/Denis Browne)
o Deep retractors, right angled narrow blade
(Kelly).

• Characteristics of Well Planned Incision:
—Easy and speed of entrace into the abdominal
cavity
—Maximum exposure
—Ease and speed of extension of incision if
necessary.
—Ease and speed of closure
—Minimum post operative discomfort
—Maximum post-operative wound strength.

Thursday, May 18, 2023
39
Types of Abdominal
Incision

1. Paramedical Incision: The paramedian is a
longitudinal incision made approximately 4cm
(about 2 fingers depth) from the midline of the
abdomen. This incision can be upper or lower
abdomen and to the right or left of the midline.
―Right Upper Paramedian: used for Biliary
surgery or pancreas.

―Left Upper Paramedial: used for
Surgery of the spleen
Gastrectomy
Repair of hiatus hernia
—Right Lower Paramedial: used for
Appendectomy
Small bowel resection
Surgery of Right adnexae.

―Left Lower Paramedial: used for
Sigmoid colon resection
Millin’s resection (prostatectomy)
Hysterectomy (Abdominally)
Surgery of the left adnexae.

2. Midline Incision: The midline incision is a
longitudinal incision in the Centre of the
abdomen. It can be above umbilicus or below
(Subumbilicus)
—Upper Midline Incision: Begins at the
epigastrium at the level of xiphoid process and
carried vertically down to the level of
umbilicus, used for emergency like Bleeding
gastric ulcers.

―Lower Midline Incision: Begins near the
umbilicus and extends vertically downwards in
the suprapubic region. It provides quickly
entry and good exposure of to pelvic organs
including Bladder, Prostate, Uterus, Fallopian
tubes, ovaries and Sigmoid colon.

Disadvantages:
Upper Midline incision:
• It is considered strong incision
• Wound dehiscence is high.
Lower Midline Incision:
• Give weaker scar
• Incisional hernia may follow its closure

3. Mc Burney’s Incision or Grid Iron Incision:
This is an oblique incision made over Mc
Burney’s point which lies on the third from
anteriorly, superior iliac spine along an
imaginary line drawn from the anterior iliac
spine to the umbilicus (Mc Burney point is in the
right lower quadrant).
—Indication: Appendectomy.

4. Kocher’s Incision or Subcostal Incision: This is
an oblique subcostal incision in the right or left
side.
―Right Kocher’s Incision: Cholecystectomy and
Biliary Tract Surgery.
―Left Kocher’s Incision: Surgery of the spleen
(splenectomy).

5. Pfannenstiele’s Incision (Transverse
Suprapubic): This is a curved transverse incision
across lower abdomen within hairline of the
pelvis rectus fascia is severed transversely and
the muscle separated. The peritoneum is incised
vertically in the midline.
—Pelvic surgery: Abdominal hysterectomy,
Surgery of the fallopian tubes and ovaries,
Prostatectomy, Cystectomy, Caesarian section.

6. Inguinal Incision: This is an oblique incision in
the inguinal region. It extends from the pubic
tubecles, one finger breadth above and parallel
to the inguinal crease up to the anterior iliac
crest. The incision does not enter the abdomen,
but it is used for exploration of the inguinal
canal.
―Used for Inguinal Herniorrhaphy, and excision
of hydrocele of the spermatic.

7. Mid-Abdominal Transverse Incision: It starts
on either right or left side slightly above or
below the umbilicus. It may be carried laterally
to the lumbar region between the ribs and crest
of the ilium.
—Uses: Choledocho-jejunostomy and Transverse
Colostomy.

8. Thoraco-Abdominal Incision: With the
patient in either left or right lateral position the
incision begins at a point midway between
xiphoid process and umbilicus and extends
across abdomen to 7th or 8th costal interspace
and along the interspace into the thorax. It
allows excellent exposure of operation of :
―Upper end of stomach e.g. hiatus hernia
―Lower end of esophagus e.g. Oesophageal
varices

9. Elliptical or Fish-Mouth Incision: The incision
is carried and is used to advantage in the
approximation of the skin area to form a neat
scar,it and used for:
—Mastectomy
—Amputation of the leg or arm.
—Umbilical hernia.
10. Sternal Incision: This is an incision through
the sternum for open heart surgery or lung
surgery.

Haemostasis in Surgery.
• Haemostais is the arrest of flow of blood or
haemorrhage. The mechanism is coagulation or
formation of blood clot. The clotting block takes
place by enzyme reaction in several stage.
Importance of Haemostasis:
Prevent blood loss
Provide as bloodless a field for accurate
dissection
Prevent haematoma.

Ways of Achieving Haemostasis:
• Digital Pressure: Using swab and apply direct
pressure to the intended site.
• Artery Forceps and Ligature (Haemostat):
incised artery or vein is clamped with a
haemostat and ligature is tied at the base of
the forceps to achieve haemostasis

• Ligature: A ligature commonly called “TIE” is a
stand of material that is tied around a blood
vessels to occlude the lumen and prevent
bleeding.
• Metal Ligating Clips: These are used to
facilitate haemostasis by a vessel during
surgery. They are used on the are vessels or
those vessels in anatomic location difficult
ligature or ligate by other means.

• Hot Packs: Packs dipped in the hot water and well
wrong out are used as compressor to control
capillary bleeding during operations such as
Mastectomy or Abdominal Hysterectomy. The
heat action vessels in constriction of the blood
vessels.
• Surgical Diathermy: A controlled electrosurgical
current passed the patient body between the
electrode to destroy body cells and scar bleeding
vessels (Coagulation and Cutting). Therefore
Diathermy Machine has 2 parts (Functions)
namely, Coagulation and Cutting.

• Electrocautery: Cautery means of applying a
caustic substance and caustic substance
means substance of capable burning organic
tissues i.e. Silver Nitrate (Lunar Caustic)
• Cryosurgery: Performed with the aid of
special instruments for local freezing diseased
tissue without harm to normal adjacent
structure.

• Other Haemostatic Methods:
Oxidized cellulose Coxycell.
Absorbable Gelatin Sponges
Topical Thrombin
Bone Wax
Laser
Adrenaline
Postural Haemostasis
Tourniquets

Sponge, Needles and Instruments
Counting.
Counting Procedure:
A counting procedure is a method a counting for
items put on the sterile table. The count and
recording usually includes:
―Swabs and packs
―All types of needles
―Instruments and parts of instruments
―Miscellanous e.g. surgical blades

Sponge Counting
Safety Precautions:
• Ray Tex swab should be used on the sterile
field and tables. These swabs have barium
sulphate thread through the swab this thread
can be visible by x-ray
• Swabs used by the anaesthetist should have
different colour

• No loose swab will be allowed in operating
theatre.
• No swabs or packs will be removed from the
OT during a surgical procedure.
• Small swabs should not be used inside a cavity
unless they are mounted on a sponge holder.

• Number of Counts of Swabs:
— First Count: This is done by the person who
prepare the bundles for sterilization
—Second Count: The circulating and scrub nurses
count together when packages are opened before
the operation begins and as each additional
package is opened during the operation.
—Third Count: This is done by the circulating nurse
and the scrub nurse before the wound closure
—Fourth Count: The final count is done before the
skin suture are completed.

• The Count Procedure:
―As the scrub nurse finger each item he or she
and circulating nurse number each one loud
until all items are count.
―The circulating nurse immediately records the
count on the Chinegraph Board or on a sheet
of paper.
―Holding the thumb over the folded edge of
the sponge separately from the pack and
number it while placing it in a pile on the
table.

—Count additional packages for away from the
counted items, already on the table in case it
is necessary to repeat the count or discard the
bundle
—The circulating nurse should use sponge
forceps or gloves to unfold each discarded
sponges and shake tapes (packs) to be sure no
sponges are on them.

Method of Guarding Sponge:
• Keep sponges packs separated and far away from
each other.
• Keeps sponge far away from needle and clips as
they might be dragged into the moved by them.
• Never mix packs (tapes) and sponges in the
solution basin at the same time. There is a danger
of dragging a small sponge unknowingly.
• Do not give a pathologist a specimen on a swab
to take it away from the room. Put it on a towel
instead.

• Discard all soiled swabs into the Vicle Bucket
for tearing to clean on the field.
• Be economic with the use of swab. There is
greater chance of error if many swabs are
used.
In the case of Incorrect Count:
• The entire count is repeated.
• The circulating nurse looks into the waste
receptacles under the furniture, on the floor
in the linen hamper and throughout the room.

• The scrub nurse looks over the drapes and
under the articles on the tables.
• The surgeons recheck the field and wound.
• If the sponge is not found the surgeon may
order X-ray to be taken at one.
• If count is wrong the circulating nurse should
write the report of the incident.

Needle Count:
• The needles put racks or a suture back are
counted uniformly into sets in multiple of two
or three of each types and size
• The procedure for counting is the same as for
sponge count.
• Give needles to surgeon on exchanging basis.
Instrument Count:
• The procedure is the same as for sponge
• Standardized set makes count easier.

Reference
• Alexander, M. F., Fawcett, J. N. & Runciman, P. J. (2002).
Nursing Practice: (2nded). London, Churchill Livingstone.
• Bewes, P. (2003). Surgery. A manual for rural health workers.
(2nded.). Nairobi. AMREF.
• Black, J. M., Hawks, J.H. & Keen, A.M (2001). Medical surgical
Nursing. (6thed.). Philadelphia: W.B Saunders Company
• Bloom, R. & Stephen, (1994). Toohey’s Medicine: A textbook for
students in the Health Care Professions. (15thed). London,
Churchill Livingstone
• Brigden J. Raymond. (1998). Operating Theatres Technique.
(5thed.). London, Churchill Livingstone
• Brunner and Suddath. S. (2000). Medical Surgical Nursing (9th
ed.), New York, Lippincott
• Brunner, L. S. & Suddath, S. D. (2010). Medical Surgical Nursing.
(12th ed.). Philadelphia. Lippincott

• Aseptic technique. Retrieved on 29/10/2012 from
http://www.google.co.tz/url?sa=aseptic%2520technique%2
55B1%255D/
• Introduction to the operating room. Retrieved on
29/10/2012,
http://freeinfosociety.com/media/pdf/4418.pdf
• Johnstone, P. L. (2000) surgical technologies implicated in
role conflict: Inducing stress amongst operating theatre
scrub and circulating nurses. ACORN Journal,
• Operating Theatre Nursing. Retrieved on 29/10/2012 from
http://ukbookworld.com/bookdetails/
anybook/%223164849%22/warren-operating-theatre-
nursing-lippincott-nursingseries
• Operation theatre attire. Retrieved on 29/10/2012 from
http://www.authorstream.com/Presentation/monikajoseph
-1084012/

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