LESSON 9: Perioperative Nursing 1 (LO-HLTH8155)

PUTTING IT ALL TOGETHER

REQUIRED TEXT:

Alexander’s Care of the Patient in Surgery, 17th Edition, Chapters 1-8

LESSON INTRODUCTION:

The following lesson is designed to combine the knowledge gained in the last
eight lessons and put it in a format to enable the student to gain an overall view of
the perioperative environment and the responsibilities of the novice perioperative
nurse. As a perioperative nurse you will continue to use skills that you have
already developed in your nursing career and the basic nursing skills will always
be the same in whichever area you choose to work in.

LEARNING OBJECTIVES:

Upon successful completion of this lesson the student will:

• Gain a basic understanding of the role and responsibilities of the circulating
registered nurse
• Gain a basic understanding of the role and responsibilities of the scrub
registered nurse or registered practical nurse
• Review specific key items of relevance to the role of the perioperative
nurse
• Identify the elements of the Surgical Safety Checklist and its importance in
the perioperative setting
• Review scrubbing, gowning and gloving procedures

The perioperative nurse can fulfill two very different roles in the perioperative
setting. The circulating nurse is the eyes and ears in the OR, the runner, assistant
to the anesthetist, assistant to the scrub nurse and the sterility police. This nurse
is considered unsterile. This position must be filled by a Registered Nurse. The
scrub nurse will be assisting the surgeon, surgical team and is considered sterile.
This position can be either a Registered Practical Nurse or a Registered Nurse.

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CIRCULATING NURSE:

Start of day:
• Check that necessary equipment is in the room, example: bair hugger,
ESU, fluid warmer, suction, instrumentation, prep solution (check
outdates), positioning equipment, video equipment, sponge counter
• Make sure all equipment is in proper working condition, replace any
questionable equipment
• Check the anesthesia cart for the following; a working laryngoscope handle
with the appropriate size blades available, lidocaine spray with working
nozzle, ECG stickers, BP cuff of the appropriate size, empty syringe to
inflate the ETT balloon after placement, tape or method of securing ET
tube in place, ET tubes of various and appropriate sizes, LMA, airways,
masks, working suction for oral secretions. If it is the circulator’s duty set up
anesthesia lines (IVs, art-lines, epidural and spinal trays, etc.)
• Spread instruments out on operating room tables in preparation of opening
the instruments for the procedure
• When opening instruments and supplies ensure sterility of items by
checking for perforations in wrappers, presence of the appropriate
sterilization indicators and filters on instrument pans, ensure everything is
dry
• Open small items and allow the scrub nurse to take them from you to avoid
flipping onto the sterile back table- flipping is not recommended by the
ORNAC Standards
• Refer to the surgeons’ preference card for any hints regarding the
procedure and set-up
• Dispense any medications and fluids to the sterile table, confirming visually
with the scrub person each bottle including what it is and the expiration
date
• Complete the initial count when the scrub person is ready

Next:
• Check the patient
• Confirm name, birth date, procedure to be performed, surgeon’s name
• Ensure all necessary armbands are in place
• Confirm the consent has been signed, checking date if your institution has
date restrictions for consent forms; check for blood administration consent
form as applicable
• Go through pre-op checklist with patient to confirm accuracy of information.
It is surprising how far a patient can get before they confess to having
eaten that day. You may phrase something in a different way that will
receive a different response than anyone previously.
• Confirm any allergies, include the type of reaction experienced. For latex
allergy ask what kind of reaction they have, what latex have they reacted
to, can they blow up balloons, etc. Pass this information on to the OR staff
in the room to allow appropriate precautions to be taken. A new set-up will

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 be required if a true latex exists and the case was set up with the scrub
wearing latex gloves.
• Try to make the patient feel at ease by smiling and not acting rushed. Ask
the patient what name they go by, it is not always the same as that written
on the admission card. This is a stressful time and they really appreciate it
when you take the time to answer any questions or make sure they are
warm enough. These are small gestures but greatly appreciated.

Once scrub nurse and the OR room is ready, the anesthesia person has spoken
with the patient, and the surgeon is available the patient is ready to be taken into
the OR:
• If the patient is able to, they have not received any medications that would
make them drowsy, no physical limitations and have on foot covers, the
patient can walk into the OR if institutional policy allows. Have a foot stool
available to help the patient get up onto the OR table.
• If unable to walk, maneuver the patient and stretcher into the room, place
the stretcher next to the OR table, lock both beds and have the patient
slide across. It is good practice to have personnel on each side of the OR
bed during this maneuver to prevent the patient from falling off the bed.
• Note the time the patient entered the room. If a white board is available in
the room write the time down for future charting reference. Other
information that may be written on the white board includes the patient’s
name, surgical procedure, any allergies, any other relevant information that
may be used during the procedure.
• Introduce the patient to any staff in the room as they enter, verbally state
any allergies and surgical side if applicable
• Explain everything that you do to the patient as it happens. When placing
monitors explain in general terms what they are for and that they are
routine.
• Routine monitors include the BP cuff, placed opposite the arm with the IV,
three lead ECG, white on right shoulder, black on left shoulder, red on left
side and pulse oximeter.
• Ask patient if they are warm enough, provide more warm blankets as
necessary
• The BRIEFING/SIGN- IN would now be performed. This is the first phase
of the surgical safety checklist. The OR team comprised of the surgeon, the
anesthesia person, the scrub nurse, the circulating nurse and the patient
are ALL involved in this phase of the checklist. After this phase has been
completed, the patient can then be sedated for their procedure ex: general,
local, MAC, moderate sedation with analgesia, spinal/epidural, regional IV
anesthesia.

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Helping Anesthesia if patient is receiving a general anesthetic:
• Stand to the right of the patient near the head, you will be holding a mask
for oxygen administration over the patient’s nose and mouth. Ask if it is OK
to place the mask prior to doing so as some patients are claustrophobic
and the mask can increase their anxiety. Advise that it is best to hold it on
the face but if it is a problem you can hold it at a slight distance. Encourage
deep, slow breathing as the anesthetist administers the anesthetic
medications.
• Be prepared to apply cricoid pressure, hold the jaw, manipulate the trachea
by applying pressure to the neck as required
• When the anesthetist has good visualization pass the lidocaine (if used),
then the ET tube. The anesthetist will not ask or look up for these at this
time as he/she has visualization of the vocal cords and glottis and wants to
maintain this view. Therefore, be quick to respond and anticipate his/her
needs. This is a critical time in the induction.
• Once the tube is in place gently grasp the tube ensuring that it does not
pull out or get pushed in further, only let go when the anesthetist gives you
direction to do so. Ensure the ETT balloon has been adequately inflated
• Do not walk away until the anesthetist has indicated they no longer need
your help. At this point the surgeon is often impatiently waiting to have their
gown tied up, but your first priority is the anesthetist and the patient.

Then:
• Put in the urinary catheter if one is required for the procedure
• Prepare the patient for the operation by helping the surgeon position them
as necessary ensuing pressure points are padded and that the body is in
good alignment
• Place the electrocautery dispersive pad in an appropriate place once
positioning is complete. Ensure good contact by checking that there are no
gaps. Put out any accompanying foot pedals as needed and determine
where the surgeon will be standing during the procedure and place within
reach of the surgeon’s foot. With the increasing use of hand-held cautery a
control foot pedal is almost a thing of the past.

Now:
• Prep the surgical site if institutional policy dictates that the circulator does
this duty
• Monitor the draping procedure ensuring sterility is maintained throughout
and that all areas of the patient and operative table are adequately covered
• Connect the suction tubing from the sterile field to the wall suction and the
diathermy cord to the ESU. Confirm the setting verbally with the surgeon.
• The TIME OUT in accordance with the surgical safety checklist would be
performed prior to the skin incision. Once the time out has been completed
the team may commence with the procedure. This phase of the surgical
safety checklist is completed by the surgeon, the anesthesia person, the

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 scrub nurse and the circulating nurse. The patient is not involved is this
phase.
• Set out the container to hold discarded sponges from the sterile field, in a
location convenient for the scrub nurse to visualize
• Tidy up any areas that no longer need to be sterile
• Prepare paperwork for specimens if there are any expected, ensure you
have an appropriate size specimen container available
• Start the charting. Do not enter the procedure until near the end and you
can be sure that is in fact what was done.
• Monitor the sterile field throughout the procedure to ensure sterility is
maintained, making any changes as needed, replacing items that become
contaminated
• Take specimen from sterile field when it is ready, ensure all necessary
labels and paperwork is complete. Wear gloves to avoid contact with the
formalin in the container.
• Perform counts as necessary, add items to the count as they are opened to
the sterile field, count off sponges in the appropriate numbers as they are
discarded. (if the package of sponges comes sterile wrapped with five
sponges, count five sponges when counting off)
• As the procedure finishes ensure that all necessary counts have been
completed, that dressings are available. If able clean the excess prep
solution from the patient (some surgeons will frown upon this practice)
• The DE- BRIEFING/SIGN- OUT in accordance with the surgical safety
checklist should be performed at this time, before the surgeon leaves the
room. The surgeon, the anesthesia person, the scrub nurse and the
circulating nurse are involved in this phase. The patient is not involved in
this phase.
• Once the dressing has been applied and drapes removed, cover the
patient with a warm blanket, bring in stretcher or bed and place adjacent to
the OR bed with wheels locked, rails down.
• Use a transfer device, such as a roller and four people to safely move the
patient from the OR table to the transfer stretcher or bed. Anesthesia will
lead this move and let you know when they are ready for the patient to be
moved.
• Stay with the patient as they wake up. Some patients wake up very strong
and agitated, so be prepared to hold their arms to avoid them harming their
eyes and face or to get out of the way quickly if they are moving
• Complete charting
• Assist anesthesia with transfer to PACU, ICU, SDS
• Give a report to the PACU, ICU nurse including patients preferred name,
procedure performed, any allergies, any other pertinent information

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*Return to the OR, wash your hands and begin preparing for the next procedure.

SCRUB NURSE:

Start of Each Case:

• Help set out instruments and supplies
• Familiarize yourself with the case by looking at the surgeon’s preference
list, checking for any hints that could be helpful
• Help with the opening of supplies and instruments, including opening your
gown and gloves prior to scrubbing
• Perform a 5 minute surgical scrub as per Institutional policy. A 5 minute
scrub is performed for the first scrub of the day. Subsequent scrubs may be
shorter depending on Institution policies.
• Gown
• Glove
• Begin organizing and setting up the sterile back table, the mayo table and
any accessory tables that may be used (the giant sized omni retractor will
often have its own table; there may also be a draping table where draping
supplies can be placed ready for the start of the case)
• Label any fluids dispensed onto the sterile field, including labeling the
syringe which you draw the fluid up into
• Create a hands- free sharps passing tray/ neutral zone
• Count with the circulating nurse when ready. Depending on Institutional
policy the scrub may lead the initial count.
• Ensure you have all the necessary instrumentation and miscellaneous
items you need to get started
• Participate in the BRIEFING/SIGN- IN
• Gown and glove the surgeon and assistant when they enter the OR
• Prep the patient if this is the scrub nurses duty or assist the surgeon to
prep the patient
• Assist with draping the patient and creating a sterile field
• Once draping is complete pull your mayo stand into place, pass up light
handles and electrocautery cord, suction tubing; pull sterile table to
appropriate position
• Participate in the TIME OUT
• Use a foot stool to stand on if needed. Visualizing what is going on can
help with your ability to anticipate surgeon’s needs.
• Be attentive and focused throughout the procedure
• Pass off specimens confirming with circulator what they are and how they
are to be sent, dry or in formalin, as they are passed off
• Assist the surgeon and assistant with glove changes as needed
• Monitor sterile field throughout procedure taking necessary steps when
there is a break in technique

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 • Perform any necessary counts, confirm suture needles visually with
circulator as new packages are opened. The circulating nurse will lead any
subsequent counts.
• Participate in the DE- BRIEFING/SIGN- OUT
• Help apply dressings
• Remove drapes
• Clean patient if this is allowed
• Organize back table, separating sharps and discarding in the appropriate
sharps bin, separate small, delicate items, place sharp instruments in a
separate container, open all instruments with box locks, if pre-soak
cleaning solution is used at your facility apply it
• Help move patient to transfer stretcher or bed
• Place instruments and basin from back table onto case cart and cover with
plastic for transfer to decontamination unit

THE SURGICAL SAFETY CHECKLIST:

The World Health Organization (WHO) published its Surgical Safety

Checklist in June 2008. This checklist is divided into 3 phases.

1) Briefing/ sign in (before induction of anesthesia).

2) Time out or surgical pause (before skin incision).
3) De-briefing/ sign out (before patient leaves the OR).

The briefing/sign in occurs when the patient and team are in the OR,
before the start of surgery and while the patient is awake. The team and
patient participate in this phase. The time out occurs after the patient has
been anesthetized or sedated, after the prep has been completed, after the
patient has been draped and before the initial incision is made. The surgical
team participates in this phase. The de-briefing occurs after the surgical
procedure has been completed. The surgical team participates in this phase.

Before induction of anesthesia or sedation the briefing/sign in includes;

• Patient has confirmed his/her identity, site of surgery, procedure and
consent
• Each member of the team has introduced themselves
• Is the surgical site marked?
• Does the patient have any allergies?
• Risk for difficult airway and is equipment present
• Risk of blood loss and IV access established

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Before skin incision the time out includes;
• Confirm all team members are present and are introduced
• Confirm patient name, procedure and site of surgery
• Has antibiotic prophylaxis been given within 60 minutes?
• Any anticipated concerns addressed to surgeon, nursing and
anesthesia

Before patient leaves the OR the de-briefing/sign out includes;

• The nurse verbally confirms the procedure performed, correct surgical
counts performed, specimen labeling completed
• All team members addressed re: any concerns regarding procedure
and recovery management of patient

The Surgical Safety Checklist must be completed before all procedures. It

is a crucial component of perioperative nursing and cannot be neglected.
Please take the time to read this in the textbook and develop a basic
understanding of the 3 phases.

ORNAC STANDARDS:

*The standards support the following;

The time out/surgical pause is when all members of the operative team are
present in the room. It is performed before the incision has been made. It
includes the surgical team. All activity stops and the team verify the correct
type and site of surgery. It is the verbal re-affirmation of the correct patient,
correct surgery, correct surgeon, correct O.R., correct site and the
administration of antibiotics if applicable. The goal is to minimize or prevent
altogether the wrong type of surgery and/or the wrong site. It also involves
confirming that all documentation is in agreement including the chart,
consent, history and physical, consult, nursing assessment and surgical
schedule. The surgical time out and the process involved must be
documented.

SPONGE, SHARP and INSTRUMENT COUNTS:

Please refer to Alexander’s Chapter 2 and 7

Each institution will have policies in place that dictate the materials to be
counted, when the counts are to occur, the actions to be taken in the event
of an incorrect count and the correct documentation to be done for both
correct and incorrect counts.

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*ORNAC standards suggest;
A count of sponges, sharps, miscellaneous items and instruments shall be
performed for all procedures as determined by the health care facility. This
count is a team responsibility and must be completed before the patient
leaves the room. It is completed in the following order; sponges, sharps,
miscellaneous items and instruments.

Counts are done:

1. Prior to start of surgery and this count is directed by the scrub nurse
2. First layer of closure depending on the cavity involved
3. At skin closure-the closure counts are directed by the circulating nurse
4. An additional count of suture, reels, sponges, sharps and misc. items
shall be done when a cavity within a cavity is closed example: as in the
closing of the uterus after c-section delivery
5. Full instrument count if strong likelihood of an instrument being
retained in surgical site
6. A full count should be done at the time of permanent relief of the scrub
and/or circulating perioperative Registered Nurse.
7. Items should remain together until the initial count is done.
8. If an item is left in the patient, the surgeon assumes the responsibility
of retrieval/non-retrieval and the circulating perioperative Registered
Nurse will document this occurrence.

NOTE:
• Scrub and circulating nurse count aloud together, each item is visually
observed by both count personnel as the scrub nurse touches each
item and the circulating nurse documents the number prior to moving
onto the next
item
• If no scrub nurse the count is performed by the surgeon and the
circulating nurse
• Initial count lead by scrub nurse (confirm with hospital policy)

Closure counts lead by circulating nurse:

• Each nurse involved in the count will be accountable for the
correctness and completion of the count by signing the count record
• Do not interrupt the count !!! if there is any uncertainty related to the
correctness of the count start again at the last documented item
• Do not remove trash or linen bags from the room once the initial count
is done. They should remain until the case is complete and the patient
has left the room
• Institutional specific policies will outline steps to be taken with
incorrect counts, who to notify, if an x-ray is required etc.
• Use only radiopaque items in surgery

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 • Counts should proceed from the sterile field to the mayo stand to the
back table and then to the bagged sponges off the field
• Recommended sequence is sponges, sharps, miscellaneous items
and instruments
• Each item will be counted and documented as they are added
throughout the procedure
• With more than one set-up each set-up will be kept separate
throughout the procedure and will have a separate count sheet- items
shall not be exchanged between set-ups
• The circulating nurse will announce to the surgeon the outcome of the
final count and wait for a verbal response from the surgeon; repeating
the result of the count until the confirmation is given
• Closure count will be repeated in the case of re-opening of the
incision
• If the necessity of a complete count is questionable, a full count will
be done at the start. The closure count will be determined by the
surgery performed

Sponge Counts
• Should be separated from the others, radiopaque tag tugged and the
sponge opened. The tag must be seen by both the scrub and
circulating nurse
• Are packaged in standardized numbers; if a pack is opened that has a
number of sponges other than the standardized amount they will be
passed back to the circulating nurse, not added to the count, bagged,
labeled and isolated to be reported to the nurse manager for follow-up
with the manufacturer
• Counted prior to case, as closure begins, and at skin closure
• Types and sizes kept to a minimum; counted and documented as
separate groupings
• Can be counted off throughout the case as the standardized amount
of sponges are discarded by the scrub nurse; these sponges are
collected by the circulating nurse, counted by the scrub and circulator
they can then be bagged, labeled and set to the side (kept within the
OR)
• When removed from the surgical field and counted off done in groups
of 5 usually and the circulating nurse shall circle the number on the
count sheet to signify that they have been removed and initial
• Discarded sponges shall remain in the OR until the completion of
case
• Should never be cut during the procedure
• Radiopaque sponges not to be used as dressings

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 • If a towel is used within the patient during the procedure it must be
radiopaque. It is brought to the circulators attention and documented
to ensure its removal prior to closure.
• Small sponges such as peanuts, pushers, and gauze should be
attached to an instrument when used in a body cavity
• If used as packing it will be radiopaque, the type and number will be
documented and this count will be documented as incomplete with
number of sponges remaining in the patient

What happens in the case of a patient returning to the OR with

radiopaque packing in situ?- packing will be removed by the surgeon
and discarded from the sterile field bagged and documented, the type
and number of sponges must be included in the documentation.

Sharp Counts
• Counted after the sponges have been counted
• Include suture needles, scalpels and electrosurgical blades,
hypodermic needles and safety pins
• Atraumatic needles counted in unopened packages at initial count;
verify needle count when package is opened
• All needles on set should be mounted on a needle driver, sealed in
their package or secured in a needle counter or book
• If broken all pieces of the item will be accounted for
• Passed to the surgeon in a hands free method/neutral zone method;
one passed up should get one passed back (needle exchange basis)
• If the surgical procedure does not allow an exchange basis the scrub
nurse should be aware of the number and location of the needles on
the field and retrieve them as soon as possible
• If dropped out of sterile field will be clearly displayed within the OR
• If a glove is punctured with a needle, the glove, needle and needle
driver shall be removed from the sterile field. Any cleaning or care
concerns in regards to the puncture should be addressed prior to re-
gloving
• Always use a sharps pad

Miscellaneous Items
• might include but not limited to suction, cautery tips, syringes, springs,
washers, small endoscopic parts, clip cartridges, vessel loops,
screws, scratch pads

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Instrument Counts
• Counted immediately prior to procedure by the scrub and circulating
nurse as appropriate
• Sets should be standardized with the minimum number and type of
instruments
• The count is determined by the type of surgery performed and
institutional policies
• Counted instruments remain in the OR until the completion of the
procedure and the exit of the patient from the OR

SURGICAL HAND and SKIN CLEANSING:

Surgical hand cleansing or surgical scrub is the process of removing as many

microorganisms as possible from the skin of the hands and arms by mechanical
washing and chemical antisepsis. It is completed prior to participation in a surgical
procedure. The hand and arm scrub are done just before gowning and gloving for
each surgery.

Scrub sinks should be adjacent to the OR for safety and convenience. Sinks have
knee/foot or sensor operated controls. They shall be deep, wide and low enough
to prevent splashes on the surgical attire. Single use disposable products are
typically a brush/sponge/nail cleaner combination impregnated with antiseptic
agents. Another option would be the brushless/waterless surgical hand rub.

Preparation for Surgical Hand Cleansing

The perioperative nurse shall:

1) Inspect their hands to ensure the nails are short, cuticles in good condition and
no cuts or skin problems exist. Long nails have the potential to puncture gloves.
Artificial nails harbor microorganisms such as bacteria and fungi and are
inappropriate for scrub personnel. Check individual institutions policies for nail
polish.

2) Remove all jewelry including rings, watches and bracelets from the hands and
forearms. Check individual institutions policies for earrings.

3) Cover all hair with a head cover.

4) Don a disposable mask snugly and comfortably over the mouth and nose.
Masks should be changed between surgical cases.

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5) Eyewear if applicable should be put on and adjusted at this time to ensure clear
vision and to avoid lens fogging.

Surgical Hand and Arm Scrub with a Brush

Check the institutions policies for the scrub. It may be a timed 2- 5 minute scrub or
a counted brushstroke method.

• Remember a prolonged scrub is as ineffective as too short a scrub.

• Subsequent scrubs should follow the same procedure as the first scrub of
the day, but may be shorter in duration. When gloves are removed
following the procedure the hands should be washed.

1) Start the water at the sink. Most often the temperature will be preset. Open the
brush/sponge package and remove the brush to one hand and the nail cleaner to
the other. Discard the package. Clean under the nails of both hands under
running water. Discard the nail cleaner. Holding the brush perpendicular to the
nails next scrub the nails. Rinse each hand and arm under the water thoroughly
taking care to hold the hands higher than the elbows. Avoid splashing water onto
your scrub attire.

*Personnel who scrub should think of their fingers, hands and arms as having 4
sides or surfaces. Both the timed scrub or counted brushstroke scrub follow an
anatomic pattern of scrubbing; the 4 surfaces of each finger, beginning with the
thumb and moving from one finger to the next, down the outer edge of the fifth
finger, over the back surface of the hand, then the palm surface of the hand, or
vice versa, from the small finger to the thumb, over the wrists and up the arm in
1/3’s, ending 2” above the elbow. Because the hands are in the most direct
contact with the sterile field all steps of the scrub begin with cleansing the
fingernails, then the hands and lastly the arms to the elbows.

2) Wet the brush/sponge and create a lather then proceed to clean the fingers,
hands and arms. Generally whichever fingers you start with proceed to the same
hand and arm then switch sides. DO NOT return to the already cleaned hand and
arm. During and after scrubbing keep the hands higher than the elbows to allow
water and suds to flow from the cleanest area- the hands- to the area of the upper
arms.

3) When the scrub is completed holding hands and arms in front of your body with
elbows slightly flexed step back from the sink and enter the OR without touching
anything.

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*If a brushless/waterless hand scrub is completed please refer to manufacturer’s
instructions. Make certain the product is completely dry before donning the sterile
gown and gloves.

Drying the Hands

Moisture remaining from the scrub will be dried with a sterile towel before donning
the sterile gown and gloves. The gown, gloves and towel shall be opened on a flat
surface before the surgical scrub is started. A small sterile field will be created by
the gown wrapper when opened on a flat surface. Use a separate table to place
this on. NOTE: the gown, gloves and towel should not be opened on the sterile
back table because of the increased chance of contamination of the field.

1) The folded towel is grasped firmly near the open corner and lifted straight up
and away from the sterile pack. Be mindful not to drip water onto the pack as this
will contaminate the gown and gloves.

2) Step back from the table making sure not to come in contact with anything.
Bend slightly forward at the waist keeping the hands and elbows above the waist
and away from the body. The towel is allowed to unfold downward to its full length
and width.

3) The top 1/2 of the towel is held securely with one hand and the opposite fingers
and hand are blotted dry- do not rub back and forth- before moving to the arms. A
rotating motion is used to dry up the arm.

4) The lower dry end of the towel is then grasped with the dried hand and the
procedure is completed on the second hand and arm.

5) Discard the towel with the hand holding it without touching your surgical attire.
Do not drop the hands below the waist and do not wad the towel up and toss it.
The towel should be discarded in the laundry or garbage.

GOWNING:

Before scrub personnel can touch sterile equipment or the sterile field they must
put on sterile gowns and surgical gloves. This aids in the prevention of
microorganisms on their hands and clothing being transferred to the patient’s
wound during the surgical procedure. Gowns may be disposable or reusable
depending on the procedure or institutional policies.

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There are two methods of gowning:

1) Self- gowning
2) Assisted gowning

Self -Gowning Procedure

Self- gowning and gloving should be done from a separate sterile surface away
from the sterile instruments. DO NOT open sterile gowns and gloves on the sterile
back table.

The scrub nurse should do the following:

1) Reach down to the sterile pack and pick the folded gown up at the neckline
with both hands and lift it directly upward and away from the wrapper.

2) Step back away from the table into an unobstructed area to allow for a wide
margin of safety while gowning.

3) Hold the gown away from the body and allow it to unfold with the inside toward
the wearer. Keep your hands on the inside of the gown while it completely
unfolds.

4) Slip both hands into the open armholes keeping the hands at shoulder level
and away from the body.

5) Push the hands and forearms into the sleeves of the gown advancing the
hands only to the proximal edge of the cuff.

The circulating nurse should do the following:

1) Pull the gown over the scrub nurse’s shoulders touching only the inner
shoulder and side seams. The gown is pulled on leaving the cuffs extended over
the hands. DO NOT push the hands through the cuffs.

2) The gown is then tied by the circulating nurse at the neckline and the inner
waist being mindful to touch only the inner aspect of the gown.

3) Once the gown has been tied in the back by the circulating nurse the scrub
nurse may don their sterile gloves. If the closed gloving technique will be used the
hands are kept inside the sleeves of the gown.

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The scrub and circulating nurse should do the following together:

1) To finish gowning with a disposable gown the scrub nurse, after gloving is
completed, hands the tab attached to the back of the gown to the circulating
nurse.

2) The scrub nurse then makes a 3/4 turn to the left while the circulating nurse
extends the back tie to its full length. This effectively wraps the back panel of the
gown around the scrub nurse and covers the previously tied inner waist ties.

3) The scrub nurse retrieves the back tie by carefully pulling it out of the tab held
by the circulating nurse and ties it with the other tie that had been secured to the
front of the gown.

*If the gown is reusable the scrub nurse will wrap the sterile glove wrapper around
the back tie ensuring the tie is hidden and secure within the wrapper. The scrub
nurse then hands the glove wrapper to the circulating nurse and completes the
procedure described above.

Assisted Gowning Procedure:

1) The sterile scrub nurse grasps the gown as previously discussed and allows
the gown to open. The gown is turned so that the inner side faces the person to
be gowned.

2) The scrub nurse then forms a cuff with the shoulder and neck area to protect
their gloves and gown.

3) Sterile scrub nurse holds the gown with open armholes towards the person to
be gowned

4)Once the hands and forearms are in the sleeves the sterile scrub nurse lets the
gown go and the circulating nurse will assist with pulling the gown the rest of the
way on and complete the tying up process.

GLOVING:

The sterile gloves are put on immediately after gowning. Sterile gloves can be
donned by the scrub nurse in one of two ways;

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 1) Closed gloving technique
2) Open gloving technique

Or can be done by another sterile scrub person;

1) Assisted open gloving technique

• The closed gloving method is preferred for establishing the initial sterile
field by the scrub nurse. Properly executed the closed gloving method
affords assurance against contamination when donning the gloves
because no bare skin is exposed in the process because the bare hands
do not extend through the cuffs of the gown.

• The open gloving method is used when changing a glove during a surgical
procedure or when donning gloves for procedures not requiring a gown.

• Assisted open gloving technique is used by the scrub person to help other
sterile team members don gowns and gloves before entering the sterile
field ex: the surgeon.

Closed Gloving Technique

During the closed gloving process the scrub nurse keeps the hands inside the
cuffs of the sterile gown. At first this may seem tricky but with practice the
technique will become refined and quick. When using this technique, the gloves
are handled through the fabric of the gown sleeves. The hands are not extended
through the cuffs when the gown is put on. Instead the hands are pushed through
the cuff openings as the gloves are being pulled into place. Because the cuffs of
the gown collect moisture, become damp and are considered unsterile the closed
gloving technique may only be used for initial gloving. For subsequent gloving an
alternative method must be used- assisted or open technique.

1) If the gloves are still in the folded inner paper wrapper they need to be opened.
Using the cuff – covered hands place the wrapper in front of you like a book.
Open the two sides. With the two cuff- covered hands grasp the lower inner
corners of the bottom fold. Lift both corners open and fold under at the same time.
When this method is used the wrapper will remain open and not close while you
are gloving.

2) The glove is lifted up by grasping it through the fabric of the sleeve of the gown.
The glove is placed palm down along the forearm of the matching hand with the
thumb and fingers pointing toward the elbow. Glove cuff lies over gown cuff.

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3) The glove cuff is held securely by the hand on which it is placed and with the
other hand the cuff is stretched over the opening of the sleeve to cover the gown
cuff entirely.

4) As the cuff is drawn back onto the wrist the fingers are directed into the glove
and the glove is adjusted to the hand.

5) Gloved hand is used to position the remaining glove on the opposite sleeve in
the same fashion. Be sure that the entire cuff of each sleeve is contained within
the sterile glove.

Open Gloving Technique

This gloving technique can be used by individuals not wearing a gown. This is not
preferred for those personnel establishing the sterile field. Open gloving should
have been discussed already in your nursing programs and practiced as a nursing
student therefore it will not be discussed further. Please read your textbook
chapter 4 for a refresher on this method.

Assisted Gloving Technique

A gowned and gloved individual may assist another individual with gloving. This
could be the sterile scrub nurse who is already gowned and gloved assisting the
surgeon.

1) The sterile scrub nurse would grasp the glove under the everted cuff. Make
sure the palm of the glove is turned toward the ungloved individual’s hand.

2) Using fingers stretch the cuff to open the glove. The ungloved individual can
then insert their hand into the glove.

3)Repeat the procedure for the other hand.

Note on Double Gloving

Some institutions and situations promote double gloving. Evidence has shown this
to be an effective means of reducing contamination and injury should there be a

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breach in the first layer of protection, example: needle stick. If double gloving, the
larger glove should be donned first.

REMOVING SOILED GOWN, GLOVES and MASK:

To protect the forearms, hands and clothing from contacting bacteria from the
outer side of the gown and gloves the following procedure is used:

1) The gown is always removed first. The sterile/contaminated member steps

away from the sterile field and the circulating nurse unties the gown at the neck
and waist.

2) The sterile/contaminated nurse grasps the gown at the shoulders below the
neckline and pulls the gown off inside out. As the gown is being pulled off it is
being rolled off and away from the body. Discard in the laundry or garbage.

3) The gloves are removed by grasping the cuff of the one gloved hand and
pulling it off inside out. The ungloved fingers of that hand are then slipped under
the cuff of the other hand and that glove is removed inside out. Discard gloves in
the trash.

4) Wash hands thoroughly.

THE OR ENVIRONMENT:

Unrestricted areas
• Personnel may wear street clothes
• Traffic not limited

Semi-restricted areas
• Processing and storage areas for instruments and supplies, as well as,
corridors leading to restricted areas
• Personnel must wear surgical attire and patients wear gowns and hair
covers

Restricted areas
• OR rooms, clean core, scrub sink
• Surgical attire and masks required

Environmental parameters
• Temperature of OR should be maintained between 20*C and 23*C to
reduce metabolic demands of the patient

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 • Relative humidity at 30% - 60% to reduce bacterial growth and suppress
static electricity
• Should have at least 20 room air exchanges per hour, 4 fresh air
exchanges (this might vary with institutional policies but these amounts
would be the minimum)
• Positive pressure inside the OR is created to prevent potentially
contaminated air from entering through adjacent areas; requires doors
closed at all times except entry and exit of patient and personnel

COMPETENCIES for PERIOPERATIVE NURSING:

• Practices professionally
• Provides physical care; circulating role and scrub role
• Provides supportive care; patient and family/designate, team members
• Provides a safe environment
• Responds to urgent/emergency situations
• Manages resources

*According to the Canadian Nurses’ Association, a Standard is a desired and

achievable level of performance against which we can measure actual
performance.

INSTRUMENTS:
The list of instruments and their uses may seem endless and daunting. I would
suggest familiarizing yourself with the most commonly used ones. If, you choose
to work in a specialty area of perioperative nursing then you can focus on the
instruments pertinent to that field. Below is a list of some instruments that are
common to many surgical procedures, especially general surgery. When you are
completing your placement portion of the course or if the college you registered
with provides lab opportunities, you will then see these instruments in use and
you will be able to handle them and gain a better understanding of them.

Common Instruments
• Various scalpel handles; #10, #11, #15
• Various types of tissue forceps; Adson, DeBakey and dressing
• Metzenbaum scissors
• Mayo scissors; straight and curved
• Suture scissors
• Needle holders
• Towel clips
• Mosquito clamp
• Crile, snap, hemostat clamps
• Kelly clamps
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 • Lower/Right angle clamp
• Allis clamp
• Babcock clamp
• Kocher clamp
• Sponge stick forcep
• Various hand held retractors; army navy, Richardson, Deaver, Harrington,
S-retractors, Rakes
• Various self-retaining retractors; Bookwalter, O’Sullivan-O’Connor, Balfour,
Omni, Weitlaner
• Various suctions; frazier, poole, yankeur
• Various disposable stapling devices; EEA, GIA, Ligaclip, ligature

LESSON SUMMARY:

Lesson 9 gives the student a brief summary of the role and responsibility of the
novice perioperative nurse. The surgical safety checklist is reviewed as well as
the practice of performing the surgical counts. This lesson also revisits the
techniques for scrubbing, gowning and gloving. Students are encouraged to
practice these skills at home or if able in the workplace. Please consider the
websites listed at the end of this lesson for added review. The student is
responsible for the content of Chapters 1-8 Alexander’s text and the previous
lessons of this module.

LEARNING ACTIVITIES:

The following activities are designed to enhance your level of comfort with the
lesson’s material and to prepare you for the final exam. They are not to be
submitted for marking.

1)Match the following terms with the correct definition;

a. metzenbaum 1. Clamp
b. kocher 2. Steam sterilizer
c. monofilament nylon 3. Cutting instrument
d. lithotomy 4. Position
e. gravity displacement 5. Suture

2)Describe the various areas in the O.R;

a) Unrestricted area
b) Semi-restricted area
c) Restricted area

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3)How many room air exchanges per hour are recommended in the OR suite?
a) 15
b) 12
c) 20

4)How many outside air exchanges per hour should there be in the OR suite?
a) 5
b) 3
c) 6

5)The acronym LASER stands for

L____________ A____________ S_____________ E______________
R____________

6)Determine which nurse performs the following duties:

a) spreads instruments on the OR table 1) circulating nurse

b) charts/documents 2) scrub nurse
c) checks patient into the OR
d) gowns and gloves the surgeon
e) removes sterile drapes
f) implements pre-op catheterization
g) assists surgeon with glove changes
h) helps apply sterile dressing
i) dispenses fluids to the sterile table
j) confirms signed consent

Answers:

1)
a. 3
b. 1
c. 5
d. 4
e. 2

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2)
a) Unrestricted areas
Personnel may wear street clothes
Traffic not limited

b) Semi-restricted areas
Processing and storage areas for instruments and supplies, as well as,
corridors leading to restricted areas
Personnel must wear surgical attire and patients wear gowns and hair
covers

c) Restricted areas
OR rooms, clean core, scrub sink
Surgical attire and masks required

3) c)

4)c)

5) LASER: light amplification by stimulated emission of radiation

6) 1) circulating nurse: a) b) c) f) i) j)
2) scrub nurse: d) e) g) h)

Visit the following websites to become more familiar with the material covered in
the course.

https://www.youtube.com/watch?v=40EFUho0xP0

https://www.youtube.com/watch?v=gnPXRe46SXU

https://www.youtube.com/watch?v=wgqIkhkXYMQ

https://www.youtube.com/watch?v=pcfnzbhPHGo

https://www.youtube.com/watch?v=FfUezHrR24M

Can’t ctrl-click on this underlined link? Just copy and paste the complete address into the
location bar of your browser and click “enter”.

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You may proceed to the final exam. Good Luck!

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