INTRA OPERATIVE PHASE

(Skills Lab)

PERFORMING SURGICAL SKIN PREPARATION and DRAPING

(Adapted from Operating Room Technique by Berry and Kohn’s 13 th Edition and USLS Nursing Manual)

Surgical Skin Preparation – is cleaning the surgical site and applying antimicrobial agent.

RATIONALE:

1. To render the surgical site as free as possible from transient and resident microorganisms, dirt,
and skin oil with the least amount of tissue damage.
2. To cleanse and prepare the surgical site in a way that will reduce the possibility of post op
infection.

NURSING CONSIDERATIONS:

1. Body piercing should be removed for safety reasons before surgery.

2. Patients who have been involve in an accidents or injured during the commission of the crime
may bear physical marks or materials important to the investigation and should be handled
according to hospital’s policy.
3. Hair removal can injure skin. Remove hair from surgical site only when necessary, it is carried
out per doctor’s order as close to the scheduled time of surgery, may be done in the OR after
anesthesia has been administered. Clipper is preferred if in need of shaving instead of razor.
4. Before beginning of surgical skin prep, position the client according to the surgical procedure to
be performed.

EQUIPMENTS:

 Small table drape to create the sterile field

 Sterile gloves
 2 absorbent towels
 2 or 3 sterile kidney basins/small bowl for solutions (antiseptic scrub, antiseptic soap and sterile
water)
 Antiseptic solution
o Povidone Iodine 7.5 % and 10% solution (depends on the hospital policy)
 Sterile water (warm)
 Gauze sponges/ cherries
 Cotton tipped applicators (when necessary)
 Sterile pick up forceps
 Clippers w/ fine teeth (when necessary)

PLANNING AND IMPLEMENTATION

ACTION RATIONALE
1. Review the chart for surgery to be performed and To avoid errors regarding the site to
determine the exact area to be prepped. Ask the prepped and operated
client to verbally state the location for the surgery.
The correct site should be marked by the surgeon
before the client is brought to the OR.

2. Assess client’s level of consciousness and mobility. To determine client’s ability to cooperate
with the procedure

3. Confirm that the correct area is identified by the

surgery schedule as well.
4. Verify that the client has no allergy to iodine and To prevent from any allergic reactions
latex.

5. Wash hands. Don appropriate personal protective To reduce the transmission of

equipment microorganisms.

6. Be sure that jewelries, body piercing, nail polish, Removal of this will not interfere with the
contact lenses, prostheses and dentures were assessment, ensure safety and prevent
removed during preoperative preparation. post op infection.

7. Transfer client from stretcher to OR bed. Make sure To prevent extremities from sliding off the
wheels are securely locked and stable. Personnel table and prevent injury and accident.
should be at the head, foot and both sides of the
client.

8. Position the client for optimal access to the surgical To allow the surgeon access to the body
site according to hospital’s policy. part requiring surgery.

9. Several types of position:

 Supine (Dorsal) pos.
 Trendelenburg’s pos.
 Reverse T (Trendelenburg) pos.
 Lithotomy
 Modified Fowler’s pos.
 Prone pos.
 Kraske (Jackknife) pos.
 Lateral pos.
10. Cover with blanket
To maintain body temperature and provide
privacy. The temperature in the OR is often
lower than the client’s room.

11. Cover hair if required. To keep loose hair from entering the field.

12. Assemble equipment needed. To ensure smooth procedure.

13. Remove rings, and watch. Wash hands and apply To reduce the transmission of
sterile gloves. microorganism and to provide control of
infection.

14. Skin preparation for specific area depending on the

type of surgery to be performed.

Head and Neck:

The site extends from above the eyebrows, over the
top of the head and includes the ears and both
anterior and posterior areas of the neck.

Chest surgery:
The site extends from the neck to the bottom of the
rib cage and to the lateral midline. The shoulder
and arm of the operative sides should be included.

Abdominal surgery:
The preparation site extends from the axilla to the
pubis extending bilaterally to the lateral midline.
 Perineal surgery:
The area starts above the pubic bone anteriorly and
extends beyond anus posteriorly.

Cervical spine surgery:

Posteriorly from the top of ears to the waist. The
area extends in each side to the mid axillary line.

Lumbar spine surgery:

Posteriorly from the axilla down to the mid-gluteal
level of the buttocks. The area extends on each side
to the mid axillary line.

15. Position and focus OR light on the area to be To provide adequate lighting, proper
prepped. visualization and safe shaving (when
necessary).
16. If shaving if needed: To decrease the chance of skin irritation.
Holding the skin taut will decrease the
 Using warm water, hold the skin taut and gently chance of cutting the client.
shave with the clipper.
 Shave the area carefully by stroking in the Stroking in the direction of the hair growth
direction of hair growth. will reduce ingrown hairs when the hair
 Clean the clipper and remove accumulated hair grows back.
after use.
Cleaning the clipper will preserve the good
working condition of it.

17. Dry the client’s skin with a clean towel. To prevent spread of microorganisms.

18. Clear the shaving equipment from the preparation To prevent contamination of the area with
area. the used supplies.

19. A small sterile table is prepared by the circulating

nurse with the following sterile items:
 Sterile towels (to be placed on the sides)
 Sterile gloves
 2 or 3 basins/bowls
 Gauze sponges/cherries (the numbers varies
according to the size of the area to be prepped)
*these are not sponges counted from the
instrument table and should be discarded in a
separate trash and removed from the OR before
cutting of the skin
 Cotton tipped applicator (when necessary)

20. Carefully pour the antiseptic solutions and sterile To prevent splash and spillage.
water into the basins and soaked sterile
gauze/cherries.

21. Sterile gloves is donned by the person doing the To prevent contamination.
prep.

22. Apply sterile towels to sides. To prevent pooling under body parts.

23. With the use of the sterile gauze/ cherries, scrub To remove dirt and transient microbes
 the surgical site with an antiseptic cleaner. Using a from the skin.
circular motion, start at the incision site and
gradually enlarge the area towards the periphery.

24. Continue this process for 3 to 10 mins depending on To reduce the resident microbial count as
the hospital policy. Be sure to use a new gauze much as possible.
whenever returning to the incision site.

25. Clean any hidden areas in the surgical site (ear To decrease chance of transmission of
canals, under the finger nails, the umbilicus) using microorganisms.
the cotton tipped applicator.

26. Rinse the area with sterile gauze soaked in sterile To wash antiseptic soap before applying
water. Pat dry with a gauze or a sterile towel. antiseptic paint.

27. Apply antiseptic paint using the same stroke To prevent recontamination of the site.
direction.

EVALUATION:
1. The surgical skin preparation was performed without injury or trauma to the client.
2. The client verbalized understanding of the procedure and reason for it.
3. The client did not experience any allergic reaction or skin sensitivity secondary to the surgical
preparation.
4. The client did not experience any injury secondary to positioning.

DOCUMENTATION:
1. Report client’s response to surgical preparation.
2. Report any allergic reactions to the antiseptic use.
3. Report positioning of the client for surgery.

DRAPING
(Adapted from Operating Room Technique by Berry and Kohn’s 13th Edition and USLS Nursing Manual)

It is a procedure of covering the client and surrounding areas with a sterile barrier to create and
maintain adequate sterile field. Draping materials may be disposable or non-disposable.

Rationale:
To eliminate the passage of microorganisms between nonsterile and sterile areas.

Equipments:
All items must be sterile

 Towels
 Fenestrated sheets (laparotomy sheet, perineal sheet etc.)
 Table covers
 Drape sheet/long sheet (fan-folded)
 Leggings
 Stockinette

Nursing Considerations:
1. Draping depends on what the surgical operation is.
 2. The scrub nurse must be knowledgeable and ready to assist when draping.
3. Once a drape is placed it cannot be moved without contamination.
4. If a drape becomes contaminated, do not handle it further, discard it without contaminating
gloves or other items.
5. During the draping procedure, the circulator should stand by to direct the scrub nurse as
necessary and to watch carefully for breaks in sterile technique.

Planning and Implementation:

1. Make use of towels to create a window on the area to be excised. Hand up four towels and
towel clips (if the surgeon uses them). Some institutions may use four towels, others may use
two.
2. Secure with towel clips.
3. Hand over fan-folded drape/long sheet to the assistant, keep sheet high and holding it taut until
it is opened and spread on the chest up and over the anesthesia screen.
4. Another drape/long sheet is handed to the assistant and spread towards the foot part of the
client and lay it down slowly.
5. Place a laparotomy sheet (lap sheet) with the opening directly above the prepped area outlined
by the towels. Unfold the head part first, cover the entire chest of the patient towards the
anesthesia screen.
6. Unfold the sheet towards the feet of the client. Let it dangle off the table.

MAYO STAND SETUP

• Drape the Mayo stand with mayo tray
While sliding the cover on the mayo stand, place a foot on the base of the stand to
stabilize it
Cover surface with mayo cover, place one unfolded towel over the mayo cover to
protect from perforation by sharps.
A towel roll can be used to organize instruments on the mayo stand

PERFORMING A COMPLETE SURGICAL HAND SCRUB

(Adapted from Operating Room Technique by Berry and Kohn’s 13th Edition and USLS Nursing Manual)

Surgical Hand Scrub

It is the process of removing as many microorganisms as possible from the skin of the hands and arms
before donning sterile surgical attire.

It is likely to be required when you are working in the operating room, delivery room, burn units and
invasive diagnostic areas of the hospital.

Timed scrub – an effective method use to scrub the hands and arms vigorously for 3 to 5 minutes with a
reliable agent

Counted Brushstroke – it is another method used that is equally effective in decreasing the microbial
count on the skin.

Equipment:
 Antimicrobial soap
 Scrub brush
 Nail cleaner
 Sterile towels
 Deep sink with foot, knee or elbow control for dispensing soap and water.

NURSING CONSIDERATION:

1. A scrub person, wear all the appropriate attire for the restricted area before entering the OR.
(scrub suit, head cover, shoe cover/OR footwear, eye protection and mask)
 2. The gown and gloves must be opened before performing surgical hand hygiene.
3. Remove all jewelries including watch.

PLANNING AND IMPLEMENTATION

ACTION RATIONALE
1. Remove all jewelries. Jewelries harbors microorganisms.

2. The skin and nails should be clean and in good To avoid further skin irritation.
condition.

3. Fingernails should be short and not reach beyond the Artificial nails harbor microorganisms and
fingertips. No nail polish or artificial nails should be are inappropriate for a scrub personnel.
worn. To avoid puncturing the gloves.

Cooler water helps to minimize dry skin.

4. Turn water on by using foot or knee control and Hot water can increase chaffing by
adjust water to a comfortable temperature degreasing the skin.

5. Pre scrub wash: wash hands and arms under running A short pre-scrub wash removes gross
water and lather with antimicrobial agent up to 2 debris and superficial microorganisms
inches above elbow. and is an essential step before surgical
scrub.
 Keep hands elevated above elbows. Rinse
hands and arms thoroughly under running
water.
 Use the nail pick to clean under your finger
nails under a running water.

6. Obtain a brush and remove the sterile surgical The outside package is contaminated and
sponge from its wrapper and moisten the sponge should not be touched once scrubbing
under the running water. Apply antimicrobial agent. has begun.

7. Visualize each finger, hand and arm as having four To ensure removal of resident
sides. Wash all four sides effectively. Scrub the nails microorganisms on all surfaces of the
of one hand with 15 strokes, use a light firm pressure hands and arms.
using a back and forth motion with the abrasive side
of the brush. Scrub the palm, each side of the thumb To eliminate transient microorganisms
and fingers and dorsal side of the palm with 10 and reduce resident hand flora.
strokes.

Note: To prevent contamination of the

Once you scrub the area, do not go back scrubbed area.

8. Divide the arm mentally into thirds; scrub each third

10 strokes.

Note:
Some agency policy require scrub by time than counted
brush stroke.

9. Rinse brush and repeat the sequence for the other To avoid contamination of the other arm.
arm.

10. Once both hands and arms are completely scrubbed,

 discard the sponge in the trash can beside the scrub
sink/drop the brush in the scrub sink.
Hands remains the cleanest part of the
11. Holding your hands above the elbow, start rinsing on upper extremities.
the finger tips and continue to the hand, forearm,
and elbow moving in one forward direction. Do not
move arms back and forth in the water.

12. During and after scrubbing, keep the hands higher To prevent backflow of contaminated
than the elbows to allow water and suds to flow from water to the clean area.
the cleanest to the marginal area of the upper arm.

Note:
If you touch a non- sterile area while rinsing… REDO the
entire process with a new sponge

13. Once rinsing is complete, turn off the water with the
knee or foot control. (depends on the institution)

14. Keep hands higher than elbow and away from scrub To prevent backflow of contaminated
attire and non-sterile surfaces. water to the clean area.

15. Allow residual water to drip off down to the elbow

into the sink.

16. Do not shake of wave hands and arms to remove

excess water.

17. Enter OR suite by backing into the room.

18. Approach sterile set up and grasp towel taking care To dry hands without contaminating the
not to drip water on the sterile field or you may use sterile field.
the bottom part of the sterile gown. Dry hands
thoroughly from finger tips up to elbow.
(check agency policy)

19. Bending slightly at the waist while keeping both

hands and arms above the waist outstretched, grasp
one end of the sterile towel or bottom part of the
gown to dry one hand thoroughly, moving from
fingers to elbow in a rotating motion

20. Use the opposite end of the towel to dry the other To avoid transfer of microorganisms from
hand. elbow to opposite hand.

21. Drop the towel into the hamper or into circulating

nurse’s hands.
22. Keep your hands above waist level at all times To prevent contamination, keep hands in
your line of vision.

VARIATION:
Surgical Hand Rubbing Technique (Brushless antiseptic hand scrub):

1. After pre-scrub, wash, dry hands and forearms thoroughly with a sterile towel.
2. Dispense approximately 5 ml (3 doses) ABHR (alcohol based hand rub) into palm of one
hand, dip fingertips of the opposite hand into the solution and work it under the nails.
Spread the remaining hand prep evenly over both hands and up just above the elbow
covering all surfaces.
3. Using the same amount, repeat above procedure to the other side.

EVALUATION:
1. Able to complete the surgical hand scrub correctly.
2. Hands are free of microorganisms.

DONNING A STERILE GOWN AND GLOVE (Closed-Gloving Technique)

(Adapted from Operating Room Technique by Berry and Kohn’s 13th Edition and USLS Nursing Manual)

RATIONALE:
1. A sterile gown and gloves are worn to exclude skin as a possible contaminant and to create a
barrier between the sterile and the non-sterile areas.
2. The gown protects the client and the wearer from cross-contamination.
3. To allow the nurse to move freely in the environment with sterile drapes and instruments.

NURSING CONSIDERATIONS:
1. Gown packages preferably are opened on a separate table from other packages to avoid any
chance of contamination from dripping water.
2. The scrub person gowns and gloves from a surface separate from the main sterile field using the
closed-gloving technique and then gowns and gloves the surgeon and the rest of the sterile
team using the open-assisted gloving.
3. Splashing water on scrub suits during surgical scrub should be avoided because moisture may
contaminate the sterile gown.

EQUIPMENT
 Sterile pack containing a sterile gown
 sterile gloves

ACTION RATIONALE

1. Establish a sterile field. To contain sterile items within the sterile area.
 Open a sterile pack containing a sterile
gown.
 Drop the gloves in their inner sterile
wrap on the sterile field.
2. Perform surgical hand scrub.

3. Put on sterile gown. To keep the outside part of the gown sterile and
to prevent contamination.
 Reach down to the sterile field and
grasp the gown at the crease near the
neck.
 Step back and allow the gown to open in
front of you, do not allow it to touch
anything unsterile.
 Holding the folded gown, carefully To prevent any part of the gown from touching a
locate the neckline and the armholes. non-sterile object and to provide complete
 With the gown raised at the shoulder coverage of undergarments.
level, while holding the inside front of
the gown just at the armholes, let the
 gown unfold.
 Extend both arms into the armholes
simultaneously as the gown and sleeves
unfold.
 The circulating nurse stands up behind
you and grasp the inside of the gown,
bring it over your shoulders and secure
the ties at the back.

CLOSED-GLOVING TECHNIQUE :

 This is preferred for establishing the initial

sterile field by the scrub person.
 This process prevents bare skin to be exposed
because the bare hands do not extend
through the cuffs of the gown.
 During this process the scrub nurse keeps the
hands inside the cuffs of the sterile gown.

1. With hands still inside the gown sleeves,

open the sterile glove wrapper on the sterile
field.

2. With your non-dominant sleeved hand, grasp

the cuff of the glove for your dominant hand.

3. Lay the glove on the extended dominant

palm, thumb side down with the glove
opening pointed towards the fingers.

4. Use the non-dominant hand to grasp the cuff

of the glove through the gown cuff and
wriggle the fingers in.

5. With the dominant hand working through its

sleeves, grasp the upper side of the glove’s
cuff and stretch it over the cuff of the gown.

6. Pull the sleeve up to draw the cuff over the

wrist as you extend the fingers of your
dominant hand inside the glove’s fingers.

7. With the gloved dominant hand , repeat the

procedure for the non-dominant hand.

8. Be sure that the entire cuff of each sleeve is

contained within the sterile glove.

OPEN-GLOVING TECHNIQUE :
(In a sterile field)

 This method is the same as the closed-gloving

technique. The only difference is that the
hands of the scrubbed person extends all the
way through the cuffs and sleeves of the
sterile gown.
 The hands are totally exposed outside the
cuffs.
 Not preferred for the person establishing the
sterile field but is used when changing a
contaminated gloves during surgical
 procedures.
 Uses skin to skin, glove to glove technique.

1. With your left hand, grasp the inner edge of

the cuff of the glove for your right hand and
lift from the wrapper. Take care not to touch
the outer portion of the gloves.

2. Align the fingers of the right hand and insert

the right hand into the glove, leaving the cuff
turned well down over the hand. Wriggle the
fingers into the gloves.

3. Do not adjust the cuff of the gloves, this will

be done as the last step.

4. Hold the left glove by the inside of the cuff,

align the fingers into the glove and pull all the
way, unfolding the cuff of the gloves and
enclosing the cuff of the gown sleeves at the
wrist.

5. With the sterile gloved fingers of the right Sterile surfaces touches only sterile surfaces.
hand, pull the cuff of the left glove up and over
the cuff of the sleeve. Avoid touching the bare
wrist.

EVALUATION:
1. The client is not exposed to microorganisms from the nurses’ uniform and the client does not
experience nosocomial infection.
2. Sterility of the gown and gloves was maintained while the scrub nurse applied them.

ASSISSTING GOWNING AND GLOVING OF TEAM MEMBER

(Adapted from Operating Room Technique by Berry and Kohn’s 13th Edition)

A scrub nurse usually assist the surgeon or another team member in gowning and gloving

PLANNING AND IMPLEMENTATION

ACTION RATIONALE

1. Open the sterile towel and offer the one end To avoid contaminating the scrub person’s
to the freshly scrubbed member of the team, gloves.
being careful not to touch the hand.

2. Lift the gown and unfold it carefully with the To prevent the outside part of the sterile gown
outside part towards you and the inside part touch the unsterile scrub suit of the person being
towards the person being served. Hold it served.
open at the shoulders and neckline by cuffing
over the hands.

3. Keeping your hands cuffed on the outer side

of the gown, he or she slips the arms into the
sleeves taking care not to let the sleeves
touch with unsterile area.
 4. Release the gown when it is secured by the
person being served. He or she keeps arms
outstretched while the circulating nurse pulls
the gown to the shoulder pulling the sleeves
and exposing the hands for open-assisted
gloving.

OPEN-ASSISTED GLOVING

1. Offer the right hand first.

2. Pick up the right gloves, grasp it firmly with

the fingers of both hands, invert the very
edge of glove with the palm of the glove
facing towards the person being served.

3. Stretched open the glove and offer it to the

surgeon. Exert upward pressure as the
surgeon slides the hand into glove. Avoid
touching the hand of the surgeon by holding
your thumbs out.

4. Do not allow the hand to drop below the Anything below the sterile field is considered
level of the sterile field. unsterile.

5. Repeat the same procedure for the left hand.

REMOVING (DOFFING) CONTAMINATED GOWN AND GLOVES

(Adapted from Operating Room Technique by Berry and Kohn’s 13th Edition

A contaminated gown and gloves must be removed and discarded in a proper way after every surgical
procedure.

NURSING CONSIDERATIONS:
1. The gown is always removed first followed by the gloves.
2. The gown is pulled off inside and out by the wearer and rolled off away from the body.
3. The gloves are remove using a glove to glove and then skin to skin technique.

PLANNING AND IMPLEMENTATION

ACTION RATIONALE
1. The circulating nurse unties the
contaminated gown at back.

Avoid touching the skin at the neck with

2. The scrub nurse grasp the front of the gown contaminated gloves to prevent contamination.
at the shoulders below the neckline

3. The gown is pulled off inside and out by the

wearer and rolled off away from the body.

4. Discard the contaminated gown in the linen

hamper.

5. The cuffs of the gloves usually turn down as

the gown is pulled off the arms.

6. Grasp the cuff of left gloves with the gloved

fingers of the right hand and pull it
 completely off.

7. Slip the ungloved fingers of the left hand

under the cuff of the right glove and lip it off
inside and out.

8. Both gloves will be inside out. To contain the contamination.

9. Discard the gloves in a trash receptacle.

10. Wash hands thoroughly. Gloves are never 100% impenetrable.

11. After exiting the sterile area remove the mask

and discard it into the proper waste
receptacle.