1. Welcome to Role of the Scrub Nurse

2. Agenda for this afternoon
*Terms and definitions
*OR Traffic and Surgical attire
*Case and room prep
*Role of the Scrub
*Counting
*Safety

3. Key Terms & Definitions
Asepsis: Absence of microorganisms that cause disease; freedom from infection; exclusion of microorganisms.
Contaminated: Soiled or infected by microorganisms
Cross Contaminated: Transmission of microorganisms from patient to patient and from inanimate objects to patients and vice versa.
Decontaminated: Cleaning and disinfecting or sterilizing processes carried out to make contaminated items safe to handle.
Fomite: Inanimate object that may be contaminated with infectious organisms and serves to transmit disease.
A role of the Scrub Nurse can be performed by an R.N. or a Surgical Technologist.
Asepsis – “without infection”
Aseptic Technique – are the methods and practices which exclude or restrict pathogenic organisms from the surgical patient.

4. Key Terms & Definitions continued
Sterile: Free of living microorganisms, including all spores.
Sterile Field: Area around the site of incision into tissue or site of introduction of an instrument into a body orifice that has been prepared for the use of sterile supplies and equipment. This area includes all furniture covered with sterile drapes and all personnel who are properly attired in sterile attire.
Sterile Technique: Methods by which contamination with microorganisms is prevented to maintain sterility throughout the surgical procedure.
Sterile Technique – practices used to prevent contamination (infection) to the patient and caregiver.

5. O.R. Traffic
Unrestricted Area – Any area outside the department; street clothes acceptable
Semi-restricted Area – Support areas within the department (PACU/recovery, store rooms). OR scrubs and caps required.
Restricted Area – OR suites, procedural rooms, central cores, and scrub sinks. Complete OR attire required, including cap, mask, face shield or eye protection
Transition zones just outside Semi- Restricted and Restricted Areas where uniforms, hats, booties and masks are stored.
All O.R. doors must remain closed; this maintains positive pressure gradient of air in the O.R.s. (aid in decreasing Post Op infections)15 air exchanges an hour
Shipping containers, boxes, etc. collect dust, debris, and insects, therefore, must never be taken into the O.R.s.

6. Surgical Attire 1st gloves worn in 1890
Gauze masks were advocated in 1897 when a “droplet theory of infection” was demonstrated
1st Cap and sterile gowns were worn in Germany in 1827
In 1910 the use of sterile instruments, gowns, gloves, masks and caps became standard practice in the larger university hospitals
The white morning coats changed to aprons, then to gowns. They later changed the color to a green for eye comfort.
The white aprons and gowns became soiled with blood and body fluids and it looked very disturbing. The green color hid the blood better than white

7. Surgical Attire
Check each of your facilities policy on surgical attire
You need a head cover to cover all your hair, side-burns, and neckline
Sterile gowns must be worn when setting up the sterile field or assisting at the surgical field
Sterile gloves must be worn for each case.
Shoe covers should be worn to protect your shoes and prevent tracking blood throughout the facility. They are recommended
BRING MASK, CAP AND EARRINGS FOR WRONG DEMOS!
Unscrubbed personnel are required to wear a two piece scrub suit with a warm up jacket (to prevent bacterial shedding from your arms). All lint free material. These are provided and laundered by your facility.
No t-shirts under your scrub tops, all clothing worn in the OR should be laundered at the hospital
Head covers should be made of non-woven linen and it should be laundered at the end of each day by the hospital. AORN is recommending covering cloth hats with a disposable head cover.
Shoe covers are not mandatory but if you wear them, they should be removed before leaving the OR suite. Shoes should have closed toes and low heels to prevent injury. You can wear shoes without covers if they are designated for the OR and don’t go outside the facility. YUCK!!
All surgical attire must be changed once soiled, infected case, MRSA.
Check with your facilities policies

8. Surgical Attire Continued
Masks decrease the spread of microbial droplets from the mouth and nose of the OR personnel to the patient. It also provides protection to the staff from aerosolized pathogenic organisms from the patient
eye protection, googles, or masks with eye shields
Jewelry must be contained within scrubs. No long earrings and studs must be contained under your cap. No rings, bracelets, or watches as they can harbor bacteria or harm a patient
Fingernails must be short and clean. Nail polish can be worn if not chipped or cracking, but not good practice. NO ARTIFICIAL NAILS. Fingernails can harbor gram negative organisms
Masks must cover the nose, the entire chin and across the cheeks. Change the masks between each patient or if soiled. Remove using the strings only, then wash hands. Do Not hang around the neck. (pg. 79) Wear them at the scrub sinks when a member of the surgical team is scrubbing.
Face shields can consist of a shield attached to a masks or goggle. Prescription glasses can be worn if side shields are applied and the glasses are cleaned in between patients.
OR attire has shown to decrease microbial shedding from 10,000/min to 3000/min (or 50,000 microorganisms/cubic foot to 500 microorganisms/cubic foot).
You must change into your OR attire in a designated area at work. Do Not wear your scrubs home, nor wear them into the OR suite from outside.

9. Pre-op Preparation Case preparation Choose cases with your preceptor
Review procedures for the day before you scrub
Review anatomy, procedure, instruments
Review preference cards- see following example.
Pick case (if applicable)
If you do the prep work the day before, it will help to decrease your anxiety. Try to talk through the procedure with your preceptor the day before. They can help give you helpful hints about the Dr.s preferences, etc.

10. Surgeon's Preference Cards
Samples of Preference cards
Follow department procedure for updating cards: ask if this is a permanent change or special need for this particular case
You will learn as a new scrub and circulator that the preference cards are always in a state of updating, being inaccurate, wrong supplies, etc.
You will soon learn the phrase “put that on my card!!” and despise it.
As an orienting scrub and circulator, it is helpful to learn the process to update preference cards and make it your practice to update them when you can. You will save yourself trouble when you are out on your own and help to save some anxiety for future interns to come

11. Room preparation
Team work is vital, sharing of work, the circulator may be getting positioning supplies and the scrub may be getting sterile supplies
Establish necessary room furniture i.e. beds, back tables, suction, cautery.
Damp dusting the flat surfaces and
overhead lights for first case
"Throwing the case around
the room" a term used to set
around supplies and sterile
instruments.
Room preparation
Scan the Operating Room Suite for visual signs of soiled materials or ‘splatter’ on equipment, walls, floors, and over-head lights, left over suture on the floor.
Room equipment; what is standard and what is specialty.

12. OR Room Correct OR table Back Table Mayo Stand, 1 or 2
Ring Stand, 1 or 2
Anesthesia machine
Positioning equipment
Kick bucket , 2
Counting bags
Prep stand
Additional equipment (i.e. IV Poles, SCD, Suction, Bovie, & Bair Hugger)
This list is of standard OR equipment that should be present in all rooms for any case that is performed in the OR. You should perform a visual check of your room at the start of the day to make sure that you have all of the right equipment in case someone has “robbed” your room after hours or on call.
You should also look ahead to the rest of the days cases and gather and organized any equipment needed for later in the day and store it outside of your room if space permits. Otherwise have OR assistants grab it during turnovers.

13. Roles of the Scrub RN Establishing the sterile field
Scrubbing, gowning, and gloving
Counting
Anticipating needs of Sterile Team
Sharps Management
Medication on the field
Draping
Drains
Specimens
Passing Instruments
Maintains neatness and
functionality of sterile field
There are many responsibilities of the scrub nurse.

14. Draping the Back Table
Patient is the center of the sterile field and the sterile tables will surround the patient.
Opening the back table cover by circulator or scrub nurse…
Review and Demo

15. Draping the Mayo Stand
The scrub steadies the stand with one of their feet as he places the drape over the end of the stand nearest him. The circulator assists by pulling the unsterile end of the cover over the stand
The scrub touches the sterile portion of the cover with sterile gloves. Note the scrub stands away from the stand as he places the cover on the Mayo stand. Both circulator and scrub are holding the stand in place with their feet.
This demo is with 2 people. It is likely that you are going to be doing this by yourself as a scrub. You can do it by yourself but then get your circulator to pull down the opening of the cover later.
Don’t forget to steady and hold the mayo stand with your foot b/c it will roll away as you try to put the cover on.
Demo

16. Opening Supplies Verify procedure and supplies to the preference card
Check package integrity, indicator tape, & expiry date
Opening packages aseptically onto sterile field. Never reach over the sterile field
Don’t drop heavy items to prevent tearing and strike through
Place sharps where they are clearly visible
Establishing the Sterile Field (Demo)
Review the preference card for necessary supplies & correct surgery
Isolate the "to open" items from the "hold" items
If your facility uses a clean case cart which becomes the dirty case cart, do not store clean items on the case cart once the case has begun.
Spread the packs and table covers on the appropriate tables. Place the major/large instrument pans on the surface you will use to open them. Place splash basins in the ring stands.
Opening packages aseptically onto sterile field. Peel packs need to be peeled apart and flipped onto the back table by the non-scrubbed personnel or picked straight up out of the package by the scrub staff. Do not allow the item to slide over the sealed (unsterile) edges.
If a blade falls where it can not be clearly seen by the incoming scrub person, then be sure to tell the scrub where it is.
scrub’s gown and gloves should always be placed on a separate table so that there is no risk of contaminating field with drips from arms.

17. Opening Supplies
*Place the scrub’s gown and gloves on a separate table or mayo stand
*The back table is only sterile at table level
*There is nothing sterile below the edge of the table. Do not grab the table by the edge, place hands on top move it with your hands
*Do not bring anything back UP to table level
*Once drape is in place, do not move or shift it
*Solutions poured into containers on the sterile field should not be recapped to save for later. The edge of the container is considered unsterile….
If sterility is in question, consider the item/personnel unsterile. Sometimes the item can be flashed sterilized if there is not an appropriate replacement. The personnel can re-gown and glove
There is a golden rule that if someone considers you or an instrument or supply contaminated, then it is. As a new intern in the OR, you will make mistakes and accidentally contaminate yourself or something. If another team member observes it, and tells you then you do not argue with them and fix it. It is not a grey area. You are either sterile or you are not.

18. Opening Supplies Continued
IF there is any doubt, do not place the item in question on the field
Do not place hot instruments/instrument pans on the COOL back table.
When adding a sterile solution, have the scrub nurse hold, or place, the sterile receptacle near the table’s edge
Hot instruments will cause moisture, strikethrough or an ideal environment for bacterial growth

19. Establishing the Sterile Field
Sterile field should be prepared in the location in which it will be used.
Supplies should be opened for one patient at a time.
Sterile field should be prepared as close as possible to the time of use.
The edges of a sterile enclosure are not considered sterile.

20. Sterile Field Manners Observe good sterile technique
Always face the sterile field
Never leave the room unattended when you have an open sterile field
Never cover a sterile field (*)
Always place a scalpel where it can be clearly seen and use an instrument to attach the blade to the handle.
Always be aware of O.R. traffic; do not allow anyone unsterile to walk between two sterile fields
AORN: (pg. 320, 2009)Unacceptable to cover sterile field for unavoidable delays. Check with your facilities policy and procedures regarding this practice. A covered table is not under observation all the time and part of the cover is below the level of the table and must be brought back up to the table level to be removed. “Taping” an open room’s door cannot guarantee sterility of the field. The set up must be constantly monitored by a staff member, ex. As a preceptor, I am teaching the students the right way. We had a first case of the day delay and were to take a break. We went 1st and the scrub stayed behind, then we came back and then she took her break
Never point the blade towards a person when removing it.
Initial skin blade is contaminated; Do Not use it internally.
Never leave a scalpel on the surgical field. Move it back to the mayo stand as soon as possible.

21. Sterile Field Manners Continued
Needles need to be placed so they will not penetrate the drapes, and they are clearly visible
Arrange the instruments, pans and supplies on the back table and mayo stand per department routine or as your preceptor instructs
Never turn your back to the field
Never lean on sterile field
Secure all cords and ALWAYS holster your cautery pencil
Do not stand with your hands folded in your armpits
Remember, in an emergency you will do what is habit. Develop good habits.
Leaning can harm the pt. also your arms are only sterile above your elbow and you can expose you underarm to the field

22. Draping Incisional area is squared off with towels
Up or down sheets may or may not be used (U Drapes)
Primary drape placed, usually starting at incisional area, then unfolded to the sides, then to the head and feet.
Should not be moved once placed.
Basic types of drapes: fenestrated, limb, split, or lithotomy
Can add a sterile, plastic, adhesive drape to incision site (Ioban)
Drapes can be secured using suture, staples, towel clips
Draping (Video Surgical Draping 11 minutes)
Fenestrated will cover entire patient, table, and armboards.
During draping, gloved hands should be protected by cuffing the drape material over the gloved hands to reduce the potential for contamination.
Draping material should be held higher than the OR bed and placed from the surgical site to the periphery to minimize contamination of the surgical site.
Drape incision site 1st with paper or cloth towels, ¾ sheet, then main drape. Be careful if drape includes arm board covers, to fan or unfold them before putting over the armboard
New student contaminated self while trying to drape the armboards
Leggings for lithotomy, grab fold and toe. Or give fold to dr. and hold onto the toe b/c it will fall below waist level and be considered contaminated

23. Back table set-up: the 8 P’s
Proper Placement – drapes, suction, tourniquet, ESU, bed, back table.
Proper function – all equipment tested for proper function before use.
Place it Once – Instrument location should remain similar on back table, mayo.
Point of Contact – passing instruments securely to prevent fumbling, keep scalpel blade down in passing.
Place it once is good practice to try to learn when setting up the back table, it saves time and steps and the less you handle sterile items the better and less chance for contamination

24. 8 P’S
Position of Function – C-arm, laser position should be preplanned to prevent disruption
Point of Use – Items like basins, cautery should remain near the area of use.
Protected Parts – Pad the patient, use safety devices, don’t rest on the patient with arms, secure needles to prevent harm.
Perfect Picture – keep environment uncluttered, free of hazards.
C-arm usually comes in from the opposite side that is being operated on. It should be put in the room before the sterile items start to get opened
Keep you table and mayo tidy so you can find items in a hurry. Try to keep the same things in the same spot for each different case so you get in the habit

25. Anticipate Review the procedure before entering the case
Watch the field, pay attention
Practice listening to the surgeon, they mumble!
Ask questions to your preceptor or surgeon
Learn the routine sequences – Clamp, cut, tie or suture, scissors
Know your instruments
Ask for more supplies before they
run out
You are learning to scrub 1st in order to make you a better circulator. I learned to do both and I as a result am able to better anticipate when I am scrubbed in and when I circulate. I know what it’s like to run around b/c your scrub tech didn’t prepare as much as they should have and on the other hand, I know what it’s like to scrub and have to wait for your circulator to return from far away, or who knows where to retrieve something, meanwhile you are stuck there waiting while your surgeon, remember “impatient”’ is starting to get frustrated and irritated when you could’ve asked for it long before you needed it and had it ready to go.

26. Hand out. Have students go through and find the 20 things wrong with this picture

27. Scrubbing, Gowning , Gloving
The purpose of the surgical hand scrub is:
The surgical hand scrub may be timed or anatomical
New to the practice is the alcohol based, waterless hand scrub; follow hospital policy and manufacturers directions
To remove dirt and skin oils
To remove transient microorganisms
To reduce the number of resident organisms
To prevent the growth of microorganisms for as long as possible
(Scrubbing, Gowning and Gloving video 20 min)
Demonstration with practice session for return demonstration – Scrubbing, gowning and gloving.
Before scrubbing, (take care of personal needs) adjust clothing, blow your nose, scratch your nose, adjust your mask for comfort and proper fit, and take a deep breath. Apply goggles, face shield or side shields for eye protection. Scrub, gown and glove appropriately.
Hand health before and after scrubbing.
Mechanical (Friction) & Chemical (Antimicrobial Antiseptic Solution) this combination provides the best method to free hands of microorganisms

28. Types of Surgical Hand Cleansers “Surgical Scrub”
Surgical hand scrubs should be broad spectrum, fast acting, effective, non irritating, prolonged action
Common types of scrubs
Chlorhexidine Gluconate (CHG)
Iodophors (Iodine)
*Recommend Chlorhexidine Gluconate
*Scrub brush or waterless technique
*Waterless technique
-do mechanical wash 1st
-then use 1 pump, dip nails, then go up arm, 2nd pump dip nails and go up other arm, 3rd pump, just do hands
-rub hands to create friction and let completely dry
Iodine preps are more damaging to the skin, stain your skin.
Demo the avagard prep
For the waterless technique, 3 pumps are necessary. You will see some members do 1 pump only, maybe 2. Drs will come it with their hands wet with this prep and ask for a towel. You will see team members waving their hands and arms around. This is not good practice. Why?

29. Demonstration of Gowning, Gloving
Closed gown gloving
Open gown gloving
Gowning and gloving someone else
Re-gloving during a case
Removing gown and glove at end of case
Gowning and gloving should be done off a sterile table/mayo stand away from the back table to decrease the risk of dripping or reaching over the sterile field.
Hands must always be kept in sight and at the table level at all times, once gloved.
Sterile gowns are only sterile in the front from the chest level to the level of the sterile field. Avoid changing levels. Sleeves are sterile from 2” above the elbow to the start of the cuff (cuff is unsterile because it collects moisture and has slid across your skin). Cover the cuff completely with sterile gloves. You are unsterile at the neckline, shoulders, back and under the arms due to perspiration and inability to observe sterility. Reusable gowns should only be laundered approximately 75 times to maintain barrier quality.
Double gloving is recommended (2010 AORN). If you choose to wear double gloves, the inside glove should be ½ a size larger than the outside glove. Two of the same size gloves can cause compression on the medial nerve = carpal tunnel syndrome. Re-gloving of the scrub personnel will include the open glove method or assisted gloving.

30. Scrubbed Personnel Traffic Patterns
Passing other scrubbed team members is sometimes necessary so it’s important to remember the principles of sterile vs. unsterile.
For 2 scrubbed personnel, it’s front to front or back to back
For 1 scrubbed and 1 non scrubbed, the scrubbed personnel should kept their front close to their sterile table/field and the non scrubbed personnel can pass behind them

31. Meds and Solutions on the Field
Confirm all medications from Preference Cards,
with the Surgeon, prior to case
Always read the label
Verify the medication, strength &
expiry date with circulator and scrub nurse
Confirm patient allergies
Label all receptacles on the field before administering the medication/solution to field
Always verbally identify the medication to the surgeon before you pass it to the surgeon to be administered
Check for temperature of solution before using as irrigation
Administer one medication to the field at a time.
Labeled solution receptacle on the sterile field should be placed near the table’s edge or held by the scrubbed person. The entire contents of the container should be poured slowly to avoid splashing. Any remaining fluids should be discarded. Label should contain name,strength, mixed, when applicable, and expiry date if a short shelf life (ie: Botox 1 hour and Tisseel 4hours).
Stoppers are removed from the vials for the purpose of pouring medications using a plier like device. Sterile transfer devices can also be used (vial spike or decanters).
AORN recommends using decanters. Our OR did an EBP experiment using the stopper remover and decanting and culture swabbed the top of the vials. Neither bottles grew any micro organisms. Check with what your facility uses
-Always use two persons , a circulator and scrub nurse, one of which MUST be licensed.
Keep original containers for reference until the end of case.
Discard any unlabeled medication/solution immediately.
Give “hand-off” report of every med/solution and its amounts used, for every change of personnel.
All meds and solutions must be documented in the Intraoperative Record.

32. 5 R’s of Administering Medications/Solutions
Right Patient
Right Medication
Right Dose
Right Route
Right Time
Always use two Identifiers before administering
Medication (i.e. Pt. name, MRN, DOB…)
Same rules pertain in the OR as did on the floor, There might be 7 Rs now….

33. Sponges, Sharps, Needles and Instruments
Counts
Sponges, Sharps, Needles and Instruments

34. Before Procedure Begins
Count sponges, sharps and instruments and misc items in their categories before moving on to another category. (i.e., all Lap sponges, then all Raytecs (4x8 sponges), then all suture needles then all blades)
Count with two people viewing each item; one of which must be a licensed personnel (RN). Count out loud together
Only x-ray detectable sponges and items to be used during procedure
Never remove counted items from the room,
Keep all garbage in room until end of case
Sponge, Instruments and Sharps Counts (Video Surgical Counts 9 minutes)
Before procedure begins:
Before beginning, know your facility’s Policy and Procedures surrounding Counts; standard work.
Count before the procedure to establish a baseline.
Separate each sponge as you count.
When additional counted items are added to the field, they should be counted at that time and recorded.
Linen and trash containers should not be removed from the room until counts are complete and resolved
All counts must be documented on the Intraoperative Nursing documentation with the names of the individuals involved.
Document in a timely manner, when it actually occurs. With computer charting all 2-3 counts could be entered at beginning of case. In case of a missed item, does not look good in court!

35. During a Procedure
Count before closure of a cavity within a cavity, uterus, bladder
Before wound closure begins, 1st layer, fascia
At skin closure or the end of the procedure, final count
At permanent relief of either scrub and/or circulator
Sponges are to be discarded into a kick bucket and the Circulator will separate the sponges for easier counting with the Scrub Nurse. These sponges will be counted off in the same number as they come in the original pack, then placed in a sponge counter (check facility P&P)
Advice, as newly oriented staff. When you are relieved for a break or lunch, as a scrub or circulator, always do a count of your needles and smaller items if you are in a case that involves more than a couple of sutures. I have had experience with staff where a needle count is incorrect at the end of a vaginal case and I go in to investigate and there was staff relieved for a break or lunch and they didn’t do a needle count before leaving. The pt. ended up needing a Xray.
That really bothers me and makes me mad!!

36. Nearing the end
Start at the surgical site, move to the mayo and back table then to items off the field
Sponges must have
a radiopaque strip &
must not be used for
dressing sponges
Notify surgeon of
final count
Anything placed in the body should have a radiopaque marker in it.
Laps, raytecs, peanuts, tonsil sponges, towels, patties, etc.

37. Incorrect Counts Notify Surgeon so he/she can search the wound.
Search the sterile field, floor, trash, linen and room
Recount thoroughly all bagged items and countable items from the field.
X-ray done prior to patient
leaving the room
Complete Event Report.
If there is an incorrect number, from the original pack (i.e.: 4 laps instead of 5 laps) at the start of a procedure, remove the item in its entirety and place it in a bag with the original label and report it to a supervisor. These items must be removed from the room immediately.
Omissions of count are during trauma and a post-op x-ray is mandatory. Check the P&P at your facility. Some cases with smaller incisions will include an initial count (incase the procedure “opens”) but may not require a final count (i.e. lap chole, diagnostic Lap)
Story about missing raytec , scrub had placed into med cup and put it in the medication waste bin, laying suture on mayo then covered mayo with clean towel near end of case to tidy it up…
Retained foreign objects. They do happen. University of Washington ribbon retractor
Retained lap sponge, retained plastic piece of grasper
It does happen,

38. General Information incorrect number count
Never remove counted items from the room
Count all parts of a disassembled instrument
Count suture needles as identified on package
Raytec’ s are not to be used
as dressings/packing
Remove from the field/room
any newly opened packages
of sponges that have an
incorrect number count
General Information on Counts.
Count suture needles as identified on package (scrub to verify with the circulating nurse when package is opened. (i.e. a package with 8 needles is counted as 8 before the package is opened. Then when the package is opened, the scrub is to verify that the package does indeed contain 8 needles.) If you find a pkg, the short pack should be removed from the room. Please enclose the package insert with the items so the company can track a lot number is necessary
Some sutures come enclosed in a pkg. with alcohol or a solution to keep it wet, ie. Chromic gut suture. The scrub must open the pkg. to show that there is a needle in it. Some scrubs won’t want to open the pkg. to show b/c they say the fluid will run out of the pkg. They can open the pkg. then fold over the opening and place the pkg. standing up so the fluid will not run out
You will encounter many staff with many different practices, remember you are learning the right way to do things and if you encounter another staff member doing something different from how you are learning things, use your preceptor for assistance.

39. Counting Sharps and Instruments
Account for all parts of a broken item, needle, instrument, vessel loops, sponge
Establish a zone where sharps are passed hands free
Keep needles in a needle container
Omit counts in an emergent case and documented as such. Fill out an Incident Report form, perform an x-ray, and document the result on the patient chart.

40. SHARPS SAFETY IN THE OPERATING ROOM Handling Sharps:
Safety, safety, safety, for yourself, the team and the patient

41. OSHA’S COMPLIANCE DIRECTIVE
*Directs field inspectors to cite employers for failure to eliminate or minimize occupational exposure to blood.
*Stated recommendations for safe practices include: “No hands passing” of sharps, blunt suture needles where applicable, and use of other safety devices like safety scalpels, magnets, and safety needles.
Protect yourself and protect your team!!

42. Don’t be the next statistic!!
Needle sticks with hypo or suture, m
OR usually accounts for the most significant amount of total injuries

43. Utilize Safety Devices Do not disable safety devices!!
They are here to protect YOU!
On the sterile field used needles should be kept in a disposable, puncture resistant needle container
No recapping if possible (if needed, use the one-handed scoop method). No bending, no disassembling safety devices, or removing the needle from the syringe (may result in a fine per incident 10,000.00). If OSHA finds a disabled safety device in your facilities sharps container
Place sharps items, sharp side down, taking care to protect the integrity of the sterile field

44. Utilize a “No Pass Zone”
You can place the scalpel in a kidney basin and put it on your mayo and then the Dr. can pick it up themselves out of it. Then they can put it back in when they are done. For incisions, they are only using it once, then they will use a different blade later on. For laparoscopic cases there are multiple incisions, keep the blade on the mayo until all ports are placed and then you can move the blade to your back table
When receiving and returning
Sharps

45. Remember…
Practice Safe Sharps!!!

46. Intra-op Instrument Care
Keep set up neat and
organized
Keep instruments clean of
debris and blood, wipe with
sterile water
Remove broken or dull instruments from the field and tag for repair/replacement.
Never dump heavy instruments onto delicate ones
Keep tips visible for ready identification.
Keep sharps visible and safe, use needle pad or magnet
Keep the cautery pencil in its holster when not in use
CARE AND HANDLING OF INSTRUMENTS
With proper care and handling, instruments will last for many years. Surgical instruments represent a significant portion of an Operating Room Budget. Cost for a single clamp can range from a few dollars to a thousand or more. Abuse, misuse, inadequate cleaning or processing, or mishandling can damage the instrument. The surgeon can not do his job if tips do not meet, or the needle turns in the needle holder. Scissors which are dull, not only do not cut the tissue, but can damage the tissue. Patient safety is jeopardized if the instruments contain debris from improper cleaning and reprocessing.
Keep them clean and wipe them with a sponge. Instruments with debris on them do not slide easily through tissue, they can catch and cause damage to other tissue

47. Incisions
1 - Subcostal - Biliary procedures, gallbladder and pancreas ( Lt. Subcostal for the spleen)
2 - Midline – most common for exploratory lap
3 - McBurney – RLQ for
appendectomies
7 - Transverse – General access
8 - Oblique – Open Inguinal
Hernias
9 - Pfannenstiel – for C-sections
Common incisions: 1,2,3,7,8,9
1 = subcostal
2 = Can be both upper midline or lower midline
3 = muscles separated rather than cut
7 = can also occur laterally
Type of incision affects the type of instruments.

48. Drains Drains may be placed deep or superficial.
Drains may or may not be tied/sutured in place.
Reservoir may be used.
Reservoir, gravity or vacuum, may be used. If not, the end of the drain should be well padded with drain sponges to absorb wound drainage
Hemovac, Jackson Pratt or JP drain. Bulb resevoir. Differnent sizes, in FR size, flat or round.
Placed laparoscopically through a trocar site
Constavac has a battery, used on total joints
Penrose drains, not used as much

49. Dressings Deliver dressings after counts are done and wound is closed.
Types include, 4x4’s, Telfa, ABD, Benzoin, Kerlix, Ace wrap etc.
May be placed over a drain site.
Apply appropriate adhesive.
Dressings: Dressings are delivered to the sterile field after the counts are done and wound is closed enough that they can not be placed into the wound and they will not be counted by mistake. Keep them clean.
- Flat as in a Telfa, 4x4, ABD, tape, Tegaderm
Wrapped as in a Kerlix or Kling with an ace bandage
Cast or splinted with Softroll and plaster or fiberglass and/or Ace bandage
Make sure sterile dressing is secured in place before the sterile drapes are removed.
If cleaning around the incision site, leave a small parameter of prep solution around incision site as it has longer kill rations up to 48 hours (Chloraprep) post application. Less irritating than rubbing incision site too. Chloraprep does not come off easily so it’s best to leave it on. Orange tint vs. blue tint
If dermabond or histocryl used, sometimes no dressing at all.
Dressing sponges fenestrated to go around drains.
Do not attach drains to pt. gowns, secure them to the pt.

50. Specimens
Can consist of blood, soft tissue, bone, body fluid, and foreign bodies
Document & Label the specimen (pt. name, type of specimen, source/location, required tests, and special handling needs)
MD must provide the description and RN repeat it back, very important
Need a diagnosis on the Pathology card
Check your facility Policy & Procedure Manual for proper protocol.
Use caution when handling specimens with Formalin; wear gloves.
Mislabeled specimens can result in misdiagnosis and inappropriate treatment for that patient.

51. Specimen treatments
Fixed: place specimen in a container of preservative, label with patient information and send to Pathology.
Frozen Section: placed on a saline moist Telfa and put in an empty container, send to Pathologist as soon as possible. A frozen section pathology report is usually called into the O.R. by the pathologist. The wound is usually not closed until that report is called into the room.
Fresh Section: placed on a saline moist Telfa and put in an empty container, send to Pathologist as soon as possible. A fresh specimen will require special
treatment, but does not need an
immediate report back to the O.R.
by the pathologist.
Specimens (Performs nursing actions that demonstrate accountability)
Keep in a specimen basin, or on Telfa (until collected in specimen container), maintain specimen ID, Rt. / Lt. Status, and time specimen was removed from the body.
Sometimes the specimen will be marked by the surgeon with a suture tag or marking pen, to identify a specific margin or orientation. Include this information on your pathology form.
Hand off as soon as feasible, with permission of surgeon
Clearly repeat the specimen labeling to circulating nurse
All specimens to be contained to prevent leakage during transport, and the outside of the container should be clean and labeled.
Never hand off a specimen in a counted sponge

52. Preventing Surgical Fires
Momentary Lapse of Caution
You will learn more about fire safety during your Safety lecture. These are a few quick points to cover.
Repetition in content helps you to remember and retain the information better
Approx. 100 surgical fires occur annually
To prevent use single use dispensing applicators, avoid pooling, and allow prep to dry 3-5 minutes before applying drapes (incorporate this into “Time Out”).

53. 4 Types of Fires (On or In Patient)
Endotracheal Tube/Laryngeal Mask Airway (Airway)
Oral Cavity/Oropharyngeal (Airway)
Surgical Site/Hair/Skin/Sponges
Drapes
*SURGICAL TEAM MUST PUT IT OUT!!!

54. Saline on Sterile Field on ALL Cases

55. Small Surgical Fires: Smother or Remove DO NOT FAN IT!!
Demo

56. P.A.S.S. PULL the activation pin
AIM the nozzle at the base of the fire
SQUEEZE the handle to release the extinguishing agent
SWEEP the stream over the base of the fire

57. If evacuation is necessary: R.A.C.E.
REMOVE the source, RESCUE the patient
ACTIVATE; call emergency number/code and activate the alarm
CONTAIN flames and smoke; pull doors closed
EVACUATE & EXTINGUISH the fire and prepare to evacuate

58. Post op Responsibilities
Dispose of sharps appropriately.
Dispose of biohazardous linen, sponges, properly.
Dispose of biohazardous material (blood and fluids) appropriately.
Open all instruments and place in water, heavy instruments on bottom, sharp and delicate instruments protected.
Once sharp and non-disposable items are cleared, roll up back table cover and throw away.
Be alert to patient needs.
Assist with patient transfer.
Check your hospital’s policy and procedures.
When closing has begun or is completed:
For some major surgeries, vascular, thoracic, heart. The scrub nurse will remain sterile until patient has left the room, per procedure.
Remove drapes aseptically after dressings applied; check for clips or instruments left in/on the drapes.
Follow hospital protocol for disposal of waste material (blood, body fluids) or “flushes”/chemicals.
Place “clean” trash and linen in appropriate containers.
Remove all clean instruments/supplies from, what is now the dirty case cart and place all used instruments onto the dirty case cart (according to hospital procedure).
Dispose of sharps appropriately and into sharps containers. Any dismantled sharp can result in a fine during a DOH inspection ($7000 per incident).
Be alert to patient needs. They can, and do, hear. They are aware. They may be moving. Be ready to help.
Don't handle patient’s clean linen with your dirty gloves
Return extra equipment and supplies.

59. Room Turnover Wipe surfaces Wash splashes from walls and equipment
Wet mop floors
Replace anesthesia supplies
Wipe & replace the room furniture
Restock room per department procedure
Room Turnover
Once the "contaminated items" are removed from the room, cleaning and turn over of the room begins. The room must be made ready for the next patient. If there is no case following in the room, it must be terminally cleaned and left ready to receive a patient (pg. 94).
All used horizontal surfaces are wiped down with antimicrobial solution
All visible splashes and debris are removed from walls and equipment
All visible debris and solution is wet mopped with an antimicrobial solution
All Anesthesia supplies are cleaned up and replaced
The room is arranged in the usual and customary arrangement, with extra equipment and supplies removed from the room and put away
Remove all documentation/labels/x-rays from previous patient
Restocking of room per department procedure
Is the room ready to receive a patient? Would you be comfortable bringing an emergency case into this room?

60. PNDS Domain Outcome Nursing Intervention/Action Safety
O2. The patient is free from signs & symptoms of injury caused by extraneous objects.
I11. Prepares, applies, attaches, uses, and removes devices and takes action to minimize risks.
I93. Ensures that the patient is free from injury related to retained sponges, instruments, & sharps.
O3. The patient is free from signs & symptoms of electrical injury.
I72. Prevents skin & tissue trauma secondary to active electrode handling.
Health System
O10. The patient is free from signs & symptoms of infection.
I70. Initiates the actions necessary related to risks associated with disease-causing microorganisms by creating and maintaining a sterile field, preventing contamination of open wounds, and isolating the operative site from the surrounding non-sterile physical environment.
I81. Restricts access to patient care area to authorized individuals only.
Perioperative Nursing Data Set: The guiding premise of the language development effort was to assist perioperative nurses in documenting the care they gave, while providing a foundation for examining and evaluating the quality and effectiveness of that care. To develop nursing diagnostic, nursing intervention, and patient outcomes statements. The PNDS is the only ANA-recognized standardized vocabulary of its kind that meets the specific needs of the perioperative nurse clinician.
Extraneous Objects: equipment, instrumentation, sponges, sharps and staff leaning on pt.
Outcome Indicators: Skin condition, Neuromuscular (movement with no numbness & tingling), Cardiovascular (warm & pink, pulses present)
Nursing Diagnoses: Risk for injury, Risk for impaired skin integrity, Risk for peripheral neuromuscular dysfunction

61. Additional PNDS for the Scrub Nurse
Domain
Outcome
Nursing Intervention/Action
Safety
O2. The patient is free from signs & symptoms of injury caused by extraneous objects.
I84. Collects, identifies, labels, processes, stores, preserves, and transports specimens.
O3. The patient is free from signs & symptoms of laser injury.
I73. Provides safety equipment and protective measures during a procedure using laser sources.
O9. The patient receives appropriate medication(s), safely administered during the perioperative period.
I8. The correct prescribed medication or solution is administered to the right patient, at the right time, in the right dose, via the right route.
I123. Identifies allergies, sensitivities to medications.
Health System
O10. The patient is free from signs & symptoms of infection.
Designates the appropriate wound classification category for each surgical wound site according to the CDC and Prevention.

62. Newly graduated Scrub Nurses, circa. 1900’s
[i], ii References:
Berry & Kohn's Operating Room Technique._11th edition, by N. Phillips
Alexander’s Care of the Patient in Surgery 14th edition by Jane C. Rothrock
2011 Standards, Recommended Practices & Guidelines, AORN
Source materials from: "Perioperative Nursing Course", Edison Community College, Instructor Eileen Collins, RN
Outline of "Role of the Scrub" by Carolyn Bell, RN for NW Perioperative Nursing Consortium
Revised by Tracey Jones, RN September 2011 for NW Perioperative Nursing Consortium