Perioperative Nursing

- refers to the nursing care provided in the total surgical experience of the patient

- nursing care delivered to a patient before (pre), during (intra) and after (post) surgery.

PHASES OF PERIOPERATIVE NURSING CARE

– Preoperative Nursing Care– Intraoperative Nursing Care– Postoperative Nursing Care

PRE-OPERATIVE PHASE• From the time the decision is made for

surgical intervention until the transfer of the patient to the operating table

INTRA-OPERATIVE PHASE• From the time the patient is received in the

OR until admitted to the post anesthesia unit

POST-OPERATIVE PHASE• Begins from the time of admission to the

PACU and ends when healing is complete

The over-all goal of nursing care during the PRE-OPERATIVE phase is to prepare the patient mentally and physically.

The over-all goal of nursing care during the INTRA-OPERATIVE phase is to maintain client safety.

The over-all goals of nursing care during the POST-OPERATIVE phase are to promote healing and comfort, restore the highest possible wellness and prevent associated risk.

PREOPERATIVE NURSING CARE

OBTAINING INFORMED CONSENT• The surgeon is responsible for obtaining the consent

for surgery.• No sedation should be administered to the client

before the client signs the consent.• Minors may need a parent or legal guardian to sign

the consent form.• Older clients may need a legal guardian to sign the

consent form.• The nurse may witness the client’s signing of the

consent form, but the nurse must be sure that the client has understood the surgeon’s explanation of the surgery.

• The nurse needs to document the witnessing of the signing of the consent form, after the client acknowledges understanding the procedure.

Arellano Medical CenterLegarda, Manila

Consent for Surgery

I hereby authorize Dr. ________________ and the staff of the hospital to perform _____________, and as such additional operation(s) or procedure(s) as are considered necessary on the basis of their being a threat to life found during the course of the said operation.

The nature and purpose of the operation, the risk involved, and the possibility of complication have been explained to me, in my dialect or in a language which I understand. I acknowledge that no guarantee has been made as to the results that may be obtained.

_________________ __________________

Signature of Patient Signature of Witness

_________________

Date and time

(Continuation of the CONSENT form…)

This authorization must be signed by the next of kin of the patient in case the patient is a minor or physically or mentally incompetent.

Patient is a minor. _____ years

Patient is unable to sign because ___________________________________________

_______________________________________________________________________.

------------------------------------------------------------------------------------------------------------------

I, _________________________ being the next of kin of ________________________

(Name in Print and Signature) (Name of Patient)

hereby authorize Dr. _____________________ and the staff of the said hospital to perform the said surgery.

_______________________ _____________________________

Signature of Witness Signature of Next of Kin

_______________________ _____________________________

Date and Time Relationship to Patient

NUTRITION

• Review the physician’s orders regarding the NPO status before surgery

• Solid foods and liquids usually are withheld for 6 to 8 hours before general anesthesia and for 3 hours before surgery with local anesthesia to avoid aspiration

• Prepare to initiate an IV line and administer IV fluids as prescribed

• Prepare to administer total parenteral nutrition to clients who are malnourished, have protein or metabolic deficiencies or cannot ingest foods

ELIMINATION

• If the client is to have intestinal or abdominal surgery, an enema or laxative or both may be prescribed the night before surgery.

• The client should void immediately before surgery.• Prepare to insert a Foley catheter if ordered.• If Foley catheter is in place, it should be emptied

immediately before surgery, and the nurse should document the amount and characteristics of the urine.

SURGICAL SITE

• Prepare to clean the surgical site with a mild anti-septic soap the night before surgery as prescribed.

• Prepare to shave the operative site as prescribed.• Hair should be shaved only if it will interfere with

the surgical procedure and only if prescribed.

PREOPERATIVE CLIENT TEACHING• Inform the client about what to expect post-operatively.• Inform the client to notify the nurse if the client experiences

any pain post-operatively and that pain medication will be prescribed to be given as the client requests.

• Inform the client that requesting a narcotic after surgery will not make the client a drug addict.

• Demonstrate the use of a patient-controlled analgesia* pump if its use is prescribed.

• Instruct the client to use non-invasive pain relief techniques such as relaxation, distraction techniques, and guided imagery before the pain occurs and as soon as the pain is noticed.

• The nurse should instruct the client not to smoke for at least 24 hours before surgery.

• Instruct the client in deep breathing and coughing techniques, use of incentive spirometry, and the importance of performing the techniques post-operatively to prevent the development of pneumonia and atelectasis.

Deep Breathing and Coughing Exercises

– Instruct the client that a sitting position gives the best lung expansion.

– Instruct the client to breathe deeply 3 times, inhaling through the nostrils and exhaling slowly through pursed lips.

– Instruct the client that the third breath should be held for 3 seconds; then the client should cough deeply 3 times.

– The client should perform this exercise every 2 hours .

Administering Incentive Spirometry

– Instruct the client to assume a sitting or upright position.

– Instruct the client to place the mouth tightly around the mouthpiece.

– Instruct the client to inhale slowly to raise and maintain the flow rate indicator between the 600 and 900 marks.

– Instruct the client to hold the breath for 5 seconds, and then to exhale through pursed lips.

– Instruct the client to repeat this process 10 times every hour.

Incentive Spirometer

Instruct the client in leg and foot exercises to prevent venous stasis of blood and to facilitate venous blood return

Leg and Foot Exercises

Splinting of the Incision

– If the surgical incision is abdominal or thoracic, instruct the client to place a pillow, or one hand with the other hand on top, over the incisional area.

– During deep breathing and coughing, the client presses gently against the incisional area to splint or support it.

• Inform the client of any invasive devices that may be needed after surgery, such as nasogastric tube, drain, Foley catheter, epidural catheter, or intravenous or subclavian lines.

• Instruct the client not to pull any of the intravenous devices, for they will be removed as soon as possible.

PSYCHOSOCIAL PREPARATION

• Be alert to the client’s level of anxiety.• Answer any questions or concerns the client may

have regarding surgery.• Allow time for privacy for the client to prepare for

surgery psychologically.• Provide support and assistance as needed.

PREOPERATIVE CHECKLIST• Ensure that the client is wearing an identification

bracelet.• Assess for allergies.• Review the preoperative checklist to be sure that

each item is addressed before the client is transported to surgery.

• Ensure that informed consent forms were signed for the operative procedure, for any blood transfusions, for disposal of a limb, or for surgical sterilization procedures.

• Ensure that a history and physical examination were completed and documented in the client’s record.

• Ensure that consultation requests were completed and documented in the client’s record.

• Ensure that prescribed laboratory results are documented in the client’s record.

• Ensure that the electrocardiogram and chest radiography reports are documented in the client’s record.

• Ensure that a blood type, screen, type and crossmatch is performed and documented in the client’s record.

• Remove jewelry, makeup, dentures, hairpins, nail polish, glasses and prostheses.

• Document that valuables were given to the client’s family members or locked in the hospital safe.

• Document the last time that the client ate or drank.• Document that the client voided before surgery.• Document that the prescribed preoperative

medication was given .• Monitor and document the client’s vital signs.

Arellano Medical CenterLegarda, Manila

Preoperative Checklist

1. Was the consent for surgery signed properly? ________2. Was the preoperative site well prepared? ________3. Is the patient in proper OR attire? ________4. Were dentures, jewelry and nail polish removed? ________5. Are her/ his medicines/ OR supplies available and complete? ________6. Were the pre-meds administered as ordered? ________7. Has the patient voided before the pre-meds were given? ________8. Vital signs before giving pre-meds:BP _____ Temp. ___ PR ___ RR ___9. Vital signs after giving pre-meds: BP _____ Temp. ___ PR ___ RR ___10. Date and time of operation _____________

Name of patient: _________________________Sex: ___________ Age: __________

Checked/ Carried out by:

_______________________ NOD/ HN SgnatureClinical Area

___________

PREOPERATIVE MEDICATIONS

• Prepare to administer preoperative medications as prescribed or on call to the operating room immediately before surgery.

• Instruct the client about the desired effects of the preoperative medication.

• After administering the preoperative medications, keep the client in bed with the side rails up.

• Place the call bell next to the client; instruct the client not to get out of bed and to call for assistance if needed.

ARRIVAL IN THE OPERATING ROOM• When the client arrives in the operating room, the

operating room nurse will verify the identification bracelet with the client’s verbal response and will review the client’s chart.

• The operating room nurse will confirm the operative procedure and the operative site.

• The client’s chart will be checked for completeness, reviewed for informed consent forms, history and physical examination, and allergic reaction information.

• Physician’s orders will be verified and implemented.

• The intravenous line may be initiated at this time, if prescribed.

• The anesthesia team will administer the prescribed anesthesia.

- Done after patient has been anesthesized and positioned on the operating table; skin of the operating site and extensive area surrounding it is mechanically cleansed again with an antiseptic agent immediately prior to draping

SKIN PREPARATION

• Assess the client for sensitivity or allergies to scrub solution, skin integrity, level of mobility and existing appliances, catheters or other instrumentation.

• Review the chart for the surgery t be performed and review the exact area to be prepped.

• Assess the client’s level of consciousness and mobility.• Explain procedure to client and assess level of

understanding.• Be sure that hairpins, jewelry, nail polish, contact lenses,

prostheses and dentures were removed.• Assist client with the transfer from the wheelchair or bed to

the surgical table.• Position the client for optimal access to the surgical site

according to institutional protocol.• Cover with a blanket; used warmed covers, cover the hair if

required.• Assemble the equipment needed.• Remove rings and watch and wash hands and apply clean

gloves.

The surgical prep sites follow, 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. The face and eyebrows are not shaved.

– LATERAL NECK- Clean the external auditory canal with a cotton swab. Anteriorly, prepare the side of the face, from above the ear to the upper thorax to just below the clavicle. Posteriorly, prepare from the neck to the supine including the area above the scapula.

– 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 side should be included.

– ABDOMINAL SURGERY- The preparation site extends from the axilla to the pubis, extending bilaterally to the lateral midline. All visible pubic hair should be shaved.

– PERINEAL SURGERY- Shave all pubic hair and the inner thighs to the midthigh. The area starts above the pubic bone anteriorly and extends beyond the anus posteriorly.

– CERVICAL SPINE SURGERY- Posteriorly from the top of the ears to the waist. The area extends on each side to the midaxillary line.

– LUMBAR SPINE SURGERY- Posteriorly from the axilla down to the midgluteal level of the buttocks. The area extends on each side to the midaxillary line.

– RECTAL SURGERY- Shave the buttocks from the iliac crest down to the upper third of the thighs, including the anal region. The area extends to the midline on each side.

– FLANK SURGERY- Extends anteriorly from the axilla, down to the upper thigh, including the external genital area. Posteriorly the area extends from the midscapular to the midgluteal regions.

– HAND AND FOREARM SURGERY- The area includes the full circumference of the affected arm, from the axilla to the fingertips.

– LOWER EXTREMITY SURGERY- The area includes the entire leg, toes, and foot of the affected leg from the umbilicus anteriorly and the top of the buttocks posteriorly.

– LOWER LEG SURGERY- The area to be prepared includes the circumference of the entire region from midthigh to the distal toes of the affected leg.

• Arrange for adequate light on the area to be prepared.

• Using warm water, hold the skin taut and hold the razor at a 45-degree angle. Shave the area carefully by stroking in the direction of hair growth. Rinse the razor carefully to remove accumulated hair from the blade.

• Dry the client’s skin with a sterile towel.• Clear the shaving supplies from the preparation

area.• Apply sterile gloves and gown.

• Scrub the surgical site with an antibacterial cleaner. Using a rotary movement to clean the skin, begin in the center and gradually enlarge the area with each rotation.

• Continue this process for 3-10 minutes as prescribed by institutional policy,

• Clean any hidden areas in the surgical site ( the ear canals, under the fingernails, the umbilicus) using cotton swabs,

• Rinse the area with sterile water. Wait for the site to dry or pat dry with a sterile towel.

• Cover the area with sterile drapes, leaving the surgical site exposed.

• Evaluate and document.

PREPARATION OF THE HEAD FOR CRANIOTOMY

PREPARATION OF THE NECK FOR OTOLOGICAL SURGERY

PREPARATION OF THE NECK & THORAX FOR THYROIDECTOMY

SURGICAL PREPARATION OF UPPER EXTREMITIES AND TRUNK

FOR SURGERY

Preoperative Preparation

Objectives:

1. Enumerate the principle of sterile technique. 2. Observe correct sterile aseptic technique in the operating room. 3. Discuss the different positions of the patient for surgery. 4. Discuss the principles of surgical asepsis. 5. Apply principles of asepsis in handling sterile technique. 6. Describe the operating room attire. 7. Explain the purpose of wearing operating room attire. 8. Define surgical scrub. 9. Enumerate step by step the correct procedures of surgical scrubbing. 10. State the purpose of gowning and gloving. 11. Differentiate between an open glove technique and closed glove technique. 12. Observe and describe how an OR nurse does surgical scrub, gowning and gloving. 13. Put on and remove sterile gown and gloves following accepted principles.

Activities

• Orient students to the physical set-up of operating room, personnel, and policies.

• Practice surgical scrubbing in the skills laboratory.

• Position patient in the OR table according to surgeon’s preference.

• Perform surgical scrub, gowning and gloving while observing the principles of surgical asepsis.

Operating Room Attire

Purpose: To provide effective barriers that prevent the dissemination of microorganisms to the patient and to protect personnel from infected patients

• Scrub dress/ suit• Head cover• Mask• Sterile gown• Sterile gloves• Shoes• Surgical glasses/ Visor

Scrub Suit

Head Cover/Surgical Caps & Hoods

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Mask

Ways to Wear Masks

Wrong ways to wear a mask

                           

         

              

     

              

     

Surgical Gowns

Sterile Gloves

Surgical Shoe Covers

Surgical Glasses/ Visor

Positions for Surgery

Positions for Surgery• Supine/ Dorsal – usual position for induction of

general anesthesia and for entering the major body cavities

• Modified Trendelenburg – used for lower abdominal surgery and some lower extremity surgery

• Reverse Modified Trendelenburg – used for upper abdominal, neck and face surgery

• Lithotomy – used in operation requiring perineal approach

• Prone – used in surgery on the posterior part of the body

• Lateral – used for operation on the kidneys, lungs or hips

• Modified Fowler’s – sitting position; used mostly in neurosurgery

• Modified jacknife – for rectal surgery

Principles of Sterile Technique

Principles of Sterile Technique

Sterile fieldThe patient is the center of the sterile field, which includes the:

• areas of the patient• the operating table and • furniture covered with sterile drapes and the• personnel wearing the OR attire.

Strict adherence to sound principles of sterile technique and recommended practices is mandatory for the safety of the patient. This adherence reflects one’s surgical conscience.

Principles remain the same; it is the degree of adherence to them that varies.

The principles of sterile technique are applied in the following:1. Preparation for operation by sterilization of

necessary materials and supplies2. Preparation of the operating team to handle

sterile supplies and intimately contact wound3. Creation and maintenance of the sterile field, including the preparation and draping of the

patient, to prevent contamination of the surgical wound4. Maintenance of sterility and asepsis throughout the operative procedure5. Terminal sterilization and disinfection at the

conclusion of the operation

• The sterile technique is the basis of modern surgery.

A. Sterile persons have scrubbed and are gowned and gloved; Unsterile persons have not. Persons who are sterile touch only sterile articles. Persons who are not sterile touch only unsterile articles.

All supplies for the sterile team members reach them by means of the circulating nurse, through the medium of sterile forceps or wrappers on sterile packages.

B. Only sterile items are used within the sterile field.

Some items such as linen, sponges, or basins may be obtained from the stock supply of sterile packages. Others, such as instruments, may be sterilized immediately preceding the operation and removed directly from the sterilizer to the sterile table.

Every person who dispenses a sterile article must be sure of its sterility and of its remaining sterile until used. Proper packaging, sterilizing, and handling should provide such assurance.

If you are in doubt about the sterility of anything, consider it not sterile. Known or potentially contaminated items must not be transferred to the sterile field, for example:

1. If sterile package is found in the nonsterile workroom2. If uncertain about actual timing or operation of

sterilizer: Items processed in a suspect load are considered unsterile. 3. If unsterile person comes into close contact with a sterile table and vice-versa 4. If sterile table or unwrapped sterile items are not under constant observation; if a sterile table or sterile

articles are left unguarded and uncovered for more

than 30 minutes 5. If sterile package falls to the floor, it must then be discarded.

C. Gowns are considered sterile only from the waist to shoulder level in front, and the sleeves. When wearing a gown, consider only the area you can see down to the waist as the sterile area. The following practices must be observed:

1. Sterile persons keep hands in sight and at or above waist level.2. Hands are kept away from the face. Elbows are

kept close to sides. Hands are never folded under arms because of perspiration in the axillary region.

3. Changing table levels is avoided. If sterile person must stand on a platform to reach the operative field, the area of the gown below waist must not brush against sterile tables or draped areas.

4. Items dropped below waist level are considered unsterile and must be discarded. eg, when picking up a gown, if the top of the gown drops below waist level, it is discarded.

D. Tables are sterile only at table level.

1. Only the top of a sterile draped table is considered sterile. Edges and sides of drape extending below the table level are considered unsterile.

2. Anything falling over or extending over table edge, such as sutures are considered unsterile and are discarded. Scrub nurse does not touch the part hanging below table level.

3. In unfolding sterile drape, the part that drops below table surface is not brought back up to table level.

E. Persons who are sterile touch only sterile items or areas. Persons who are not sterile touch only unsterile items or areas.

1. Sterile team members maintain contact with sterile field by means of gowns and gloves.

2. Nonsterile circulating nurse does not directly come into contact with the sterile field.

3. Supplies for sterile team members reach them by means of the circulating nurse who opens wrapper on sterile packages.

F. Unsterile persons avoid reaching over a sterile field. Sterile persons avoid leaning over an unsterile area.

1. The scrub nurse sets basin or glasses to be filled at the edge of the sterile table. The circulating nurse stands near the edge of the table to fill them.

2. The circulating nurse stands at a distance from the sterile field to adjust the light over it.

3. The surgeon turns away from the sterile field to have perspiration mopped from his brow.

4. The sterile nurse drapes a nonsterile table toward self first to protect gown.

5. The circulating nurse, using sterile forceps, drapes a table away from her first.

G. Edges of anything that encloses sterile contents are considered unsterile. ex: the edges of wrappers on sterile packages, caps on solution bottles and test tube covers

1. Sterile persons lift contents from packages by reaching down and lifting them straight up, holding elbows high.

2. Steam reaches only the area within the gasket of a sterilizer. Instrument trays should not touch the edge of the sterilizer outside the gasket.

3. The circulating nurse peels the cover of a solution bottle or test tube, the edge of the cover never touches the lip.

4. If the instruments are boiled, the tray must not touch the edge of the sterilizer when lifting it out.

H. Sterile field is created as close as possible to time of use.

Degree of contamination is proportionate to length of time sterile items are uncovered and exposed to the environment.

1. Sterile tables are set up just prior to the operation.

2. It is difficult to uncover a table of sterile contents

without contamination. Covering sterile tables for

later use is not recommended.

I. Sterile areas are continuously kept in view.

Inadvertent contamination of sterile areas must be

readily visible.

1. Sterile persons face sterile areas.

2. When sterile packs are opened in a room, or a

sterile field is set up, someone must remain in the

room.

J. Sterile persons keep well within the sterile area.

Allow a wide margin of safety when passing unsterile areas and follow these rules:

1. Sterile persons stand back at a safe distance from

the operating table when draping the patient.

2. Sterile persons pass each other back to back.

3. Sterile person turns back to nonsterile person or

area when passing.

4. Sterile person faces sterile area to pass it.

5. Sterile person asks nonsterile individual to step aside rather than risk contamination.

6. Sterile persons stay within and around a sterile field. They do not walk around or go outside the room.

7. Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons.

K. Sterile persons keep contact with sterile areas to a minimum.

1. Sterile persons do not lean on sterile tables and on the draped patient.

2. Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate, they do so without proximity to nonsterile areas.

L. Unsterile persons avoid sterile areas.A wide margin of safety must be maintained when passing sterile areas.

1. Unsterile persons maintain at least one foot distance from any area of the sterile field.

2. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it.

3. Unsterile persons never walk between two sterile areas, eg, between sterile instrument tables.

4. Circulating nurse restricts to a minimum activity near sterile field.

M. Destruction of the integrity of microbial barriers results in contamination.The integrity of a sterile package or sterile drape is destroyed by perforation, puncture or strike-through (soaking of moisture through unsterile layers to sterile layers or vice versa- may transport bacteria to sterile area). To ensure sterility:

1. Sterile packages are laid on dry surfaces.2. If sterile packages become damp or wet, it is re-

sterilized or discarded. A package is considered nonsterile if any of it comes in contact with moisture.

3. Drapes are placed on a dry field.4. If solution soaks through sterile drape to nonsterile

area, the wet area is covered with impervious sterile drape or towels.

5. Packages wrapped in muslin or paper are permitted to cool after removal from the sterilizer to avoid steam condensation and resultant contamination.

6. Sterile areas are stored in clean dry areas.7. Sterile packages are handled with clean dry hands.8. Undue pressure on sterile pack is avoided to prevent

forcing sterile air out and pulling unsterile air into the pack.

N. Microorganisms must be kept to an irreducible minimum.

Perfect asepsis in the operative field is the ideal. Although all the microorganisms cannot be

eliminated, this does not obviate the necessity for sterile technique. It is generally agreed that:

1. Skin cannot be sterilized.Skin is a potential source of contamination in every operation.

All possible means are used to prevent entrance of microorganisms into wound. Preventive measures include:

a. Transient and resident flora are removed from skin around operative site of patient and the hands and arms of sterile team members by mechanical washing and chemical antiseptics. (shaved and scrubbed)

b. Gowning and gloving of operating team is accomplished without contamination of sterile exterior of gowns and gloves. (without touching with their bare hands)

c. Sterile gloved hands do not directly touch skin and then deeper tissues.

d. If glove is pricked or punctured by a needle or instrument, glove is changed immediately. Needle or instrument is discarded from sterile field.

e. In draping, all the skin area is covered except the site of incision.

f. All operators scrub their hands and arms.g. Operators scrub between cases to remove

bacteria that may have emerged from the pores with perspiration under the gloves.

h. The knife used for the skin incision is placed in a specimen basin which thereafter is considered contaminated.

2. Some areas cannot be scrubbed.

When the operative field includes the mouth, nose, throat or anus, the number of microorganisms is great. Various parts of the body, such as the GIT and the vagina, usually are resistant to infection from flora that normally inhabit these parts.

The following steps may be taken to reduce the number of microorganisms present in these areas and to prevent scattering them:

a. Surgeon makes an effort to use a sponge only once, then discards it.

b. The GIT , especially the colon, is contaminated. Measures are taken to prevent spreading this contamination.

- gastric route when possible

- cautery when cutting across a lumen

- colostomy is walled off from the operative site when possible

- antibiotics given preoperatively

- septic routine clean-up after procedure on the colon

3. Infected areas are grossly contaminated.

The team avoids spreading the contamination.

4. Air is contaminated by dust and droplets.

Examples of control measures:

- Masks are worn over the nose and mouth.(fit snugly)

- Talking is kept to minimum.

- Sneezing and coughing are avoided.

- Doors from corridors into the OR are kept closed.

- Floors are wet-mopped, not dry-swept as dust may

float in the air for a long time.

- OR attire is not worn outside the surgery suite.

- Wash hands before and after the care of each client.

SUMMARY

Principles of Sterile Techniques

1. Sterile surface touching sterile surface means sterile.

2. Sterile surface touching un-sterile surface becomes contaminated.

3. When there is doubt about the sterility of any item, it must be considered not sterile.

4. Reaching across or above sterile with bare hands or arms or other non-sterile item must be avoided.

5. Sterile materials must kept dry; moisture transmits microorganism and contaminated.

6. Coughing, sneezing or unnecessary talking near or over a sterile field must be avoided.

7. When wearing sterile gloves, hands must be kept in sight, away from un-sterile objects and above waist level.

8. The wrapper of a sterile pack must be opened, away from the body, the distal flap first, the lateral flaps next, and the proximal flap toward the body last, thus it unnecessary to reach over the sterile field.

9. The sterile zone is confined to the tabletop or to above waist level. Anything that hangs, falls, or touches below these levels is considered contaminated.

10.Any area of 1 inch or so surrounding the outer edge of the sterile field must be considered un-sterile.

11.The sterile field must be kept in sight at all times. Do not turn your back on it or leave. If you do, you cannot be sure that it is still sterile.

12.The floor must be recognized as the most grossly contaminated area. Clean or sterile items that fall on the floor should be discarded or decontaminated.

Parts of the Surgical Instrument

JAWS

RATCHETTIP

BOXLOCK FINGER RINGS

SHANK

Functions of the Instrument Parts

• Finger Ringers: Provide place for the user to place his fingers and grip the instrument securely

• Ratchet: Allows the instrument to be locked in place• Shank: Connects the boxlock to the finger rings• Boxlock: Hinge joint; controls the jaws of the

instrument• Jaws: Along with the tip is the working part of the

instrument; may be smooth or serrated or cross-hatched for grasping tissue or suture; can be straight or curved

• Tips: Can be pointed or round; have teeth or no teeth

Important Tips:

To identify and differentiate instruments:- Look at the tip.- Does it have teeth and what do the teeth look like?- Is the jaw smooth or serrated?- If the jaw is serrated, do the serrations run

horizontally or longitudinally?- Do the serrations run the entire length or halfway

through the jaw?

Blades

Use: For cutting the skin; for small puncture incisions; for cutting tissue and blood vessels

#10 #11 #12 #15

Scalpel handleaka knife handle/ blade handle

Use: holding scalpel blade

Needles

Use: For suturing; may be cutting or curved

Shape:

• Straight - The needle is straight and usually has a cutting surface.

• Half-curve or Ski - the needle is straight and curves near the point.

• Curved - The needle is formed in an arc of 1/4, 3/8, 1/2, or 5/8 of a circle

Needle Holder

*Jaw may have a groove

Use: For holding needle

Surgical Needle Holder

• Needle Holders are used to suture deep areas where hands cannot reach comfortably or where high precision and clear visibility is required. The holders may be with or without a catch. All needle holders have a firm grip.

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Towel Clipaka towel clamp

Use: For securing towels and drapes; grasping tissue; holding or reducing small bone fractures

Towel Clips

Thumb forceps

Use: grasping tissue

Tissue forceps aka pick-ups; rat-tooth forceps

Use: For grasping tissue; closing wound

Adson forceps(plain) aka Adson dressing forceps

Use: grasping tissue

Adson Tissue Forceps(with teeth)

Use: grasping skin layer during wound closure

DeBakey Tissue Forceps

Use: grasping fine tissue

Russian Forceps

Use: grasping tissue; aortic aneurysm plaque

Sponge Forceps

Use: For holding sponges or grasping tissue

Babcock

Use: grasping delicate tissue (eg, fallopian tube, bowel, vas deferens)

Allis

Use: grasping organ or tissue that is being removed

Kocheraka Ochsner

Use: grasping heavy tissue, eg, fascia

Mixteraka right angle

Use: clamping tissue; grasping a ligature around a curve blood vessel for hemostatic purposes

Mosquito Forcepsaka Halstead Hemostatic Clamp; stat

*can be straight or curved; 5” longUse: used for more delicate tissues; fine and small hemostats used to control the bleeding of finer vessels

Kelly Hemostatic Clamp

*5.5’’ – 7” long*Heavy blades*May be straight or curved*looks like Pean clamp but is serrated only halfway

Use: clamping large blood vessels or tissues

Pean aka Mayo-Pean clamp

*5.5” – 9” long* Can be straight or curved* Looks like Kelly but jaws are fully serrated

Use: clamping large blood vessels or tissues

Crile Hemostatic Clampaka Hemostat

*5.5” , 6.5”, 7.5” long* Can be straight or curved

Use: clamping large blood vessels or tissues

Mayo Scissorscurved - dissecting scissorsstraight – cutting scissors

*Heavy bladesUse: staight Mayo – cutting sutures, dressings and drainscurved Mayo – cutting or dissecting heavy tissue or muscle

Metzenbaum Scissorsaka Metz

Use: cutting or dissecting delicate tissueNOT used for cutting sutures, drains, heavy tissue

MAYO METZ

Bandage Scissors

Use: cutting dressings and bandages

Iris Scissors

Use: cutting and dissecting fine tissue

Army – Navy Retractor

*double-ended*usually used in pairs

Use: exposing superficial wound

Richardson Retractor

Use: exposing wound

Richardson-Eastman Retractor

Use: exposing wound

Deaver Retractor

Use: deep retraction

Malleable Retractoraka Ribbon

Use: exposing wound

Harrington Retractoraka sweetheart; valentine

Use: exposing deep wound

Balfour Retractoraka self-retaining retractor; abdominal self-retracting

Use: deep abdominal retraction

Bladder Blade for Balfour Retractor

Goelet Retractor

*double-ended*usually used in pairs

Use: retracting superficial tissue

Senn Retractor

double-ended*usually used in pairs

Use: retracting superficial tissue

Hysterometer

Use:

Tenaculum

Use: Grasping cervix

Thomas Curetteaka Dull Curette

Use: scraping endocervical and endometrial linings

Sims Curetteaka Sharp Curette

Use: scraping endocervical

and endometrial linings

Simpson Obstetrical Forceps

Use: delivering baby

Simpson-Luikart Obstetrical Forceps

Use: delivering baby

Naegele Obstetrical Forceps

Use: delivering baby

OTHERS• Vaginal Speculum• Bladder Retractor• Dilator• Sponge Forceps• Russian Forceps• Kocher/ Ochsner• Babcock• Allis• Scissors

Surgical scrub

• used to remove debris from nails, hands, and forearms

• reduce the numbers of transient and colonizing microorganisms on the skin and

• inhibit rapid rebound growth of microorganisms• decrease the client's risk for an infection should a

sterile glove tear or break

The skin on the nurse's hands and arms should be intact (free of lesions) and the nails should be kept short, clean, and healthy.

Surgical Scrub ProcedureA. Time Method

B. Counted Brush Stroke Method

*depends on the institution

Time Method

Fingers, hands and arms are scrubbed by alloting a prescribed amount of time to each anatomical area and each step of the procedure.

A. Complete Scrub: 5-7 minutes; donea. in the morning before the first gowning and glovingb. following a clean case, if gloves have been removed inadvertently, before the gownc. following a clean case, if gloves have had a hole between themd. following a clean case, if hands have been contaminated in any other wayd. before an emergency case at anytime

B. Short Scrub – 3 minutes• done following a clean case, if the hands and arms

have not been contaminated• done to remove the bacteria that have emerged

from the pores and multiplied while the gloves were on

Brush Stroke Method(for return demo)*

• A prescribed number of brush strokes, applied lengthwise of the brush or sponge, is used for each surface of the fingers, hands and arms. Scrub the nails of one hand 30 strokes, all sides of each finger 20 strokes, the arms 20 strokes for each third of the arm up to 2 inches above the elbow.

• Before each operation, all members of the surgical team – that is, those who will touch the sterile surgical field, surgical instruments or the wound – should scrub their hands and arms to the elbows.

• Scrubbing cannot completely sterilize the skin, but will decrease the bacterial load and risk of wound contamination from the hands.

Surgical scrub items

When scrubbing

• Remove all jewelry and trim the nails. • Use soap, a brush (on the nails and finger tips) and

running water to clean thoroughly around and underneath the nails.

• Scrub your hands and arms up to the elbows. • After scrubbing, hold up your arms to allow water to

drip off your elbows.

• Clean clothing must be worn.• Hair must be completely covered.• Mask should be in place. • Jewelry and earrings should be removed.

Always ensure

• The water temperature is comfortable.• The flow of water is gentle to avoid excessive

splashing.• Hands are always held higher than the elbow.

Wear your cap and mask.

Turn on faucet with knee or foot control.

Get antiseptic soap/ solution. Prewash hands and forearms.Apply a liberal amount of soap/antiseptic onto hands and rub hands and arms up to 2 inches above the elbows.

• Rub palms against each other.• Rub one palm of one hand to the back of the other

hand. Do the same to the other hand’s back.• Forearms are done by stroking wrist in a circular

motion going upwards up to 2 inches beyond the elbow.

• Do not return to the area you have already soaped.• Rinse hands and arms so the water flows off at the

elbows.

Open prepackaged scrub brush if available.

Clean fingernails under running water. Drop file into sink/ proper container when finished.

With brush in your dominant hand using a circular motion, scrub nails and all skin areas of nondominant and then dominant hand and arm using time or counted brush stroke method (depending on hospital policy).

Wet sponge of scrub brush to release antimicrobial soap (Apply soap, if needed).

Counted Brush Stroke Method

With brush in your dominant hand using a circular motion, scrub nails and all skin areas of nondominant hand and arm. • nails – 30 strokes• sides (4) of fingers (include web spaces) – 20 strokes• back of hand – 20 strokes• palm of hand – 20 strokes• distal 3rd of the forearm – 20 strokes• middle 3rd of the forearm – 20 strokes• proximal 3rd of the forearm – 20 strokes to 2 inches above the elbow

Rinse brush thoroughly, reapply soap. Repeat above procedure with dominant hand and arm.Discard brush into proper container/ Drop brush onto the sink (depending on hospital policy).

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Rinse from fingertips to elbows and away from the body, letting water drip from elbows.

Keep hands higher than elbows and away from the body. Proceed to the operating room with your back to the door.

Drying Hands after Surgical Scrub

1. Pick up the towel from the gown pack and hold away from you at all times.

2. Step backward and let towel open.

3. Dry left hand to mid-lower arm; then transfer dry end of towel to other hand.

4. Dry right hand to mid-lower arm. Do not return to an area you have already dried.

5. Fold towel into thirds. Dry elbow areas. 6. Discard towel in linen hamper.

Gowning

Purposes:• To exclude skin as a possible contaminant and to

create a barrier between sterile and unsterile areas• To permit the wearer to come within the sterile field• To carry out sterile techniques during an operative

procedure

General Considerations• The scrub nurse gowns and gloves self, then gowns

and gloves the surgeon and assistants.• The sterile gown is folded inside out.

Putting on a surgical gown

1.Grasp the sterile gown at the neckline with both hands. Step back from the table.

2. Holding the folded gown at the neckline with the inside toward you, keep your hands on the inside of the gown as you let the gown unfold in front of you at arm’s length. Do not allow it to touch anything.

3. Hold the unfolded gown at shoulder level and simultaneously push both hands and arms into the sleeves.

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4. The circulating nurse assists by reaching inside the gown to the sleeve seams and pulls the gown over your shoulders. Then she secures the ties at the neckline and waist (swinging motion).

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Gowning another Person

• A team member in sterile gown and gloves (scrub nurse/ scrub technician) may assist another team member in gowning.

1. Give the towel to the surgeon, being careful not to touch the hand.

2. Unfold the gown, holding it at the neckband.

3. Keep the hands on the outside part of the gown under the protective cuff and shoulder area. Offer the inside of the gown to the surgeon. The surgeon slips into the sleeves.

Gloving

The sterile gloves are put on immediately after gowning.

Purposes:• To exclude skin as a possible contaminant • To create a barrier between sterile and unsterile

areas• To permit the wearer to handle sterile supplies or

tissues of the operative wound

Three gloving techniques exist:1. Closed – preferred when initially putting on

sterile gown and gloves2. Open – used when sterile gloves are replaced

or a sterile gown is not required3. Assisted – used when one team member

wearing sterile gown and gloves helps another team member put on his sterile gloves

A. Closed Glove Technique

1. Using the right hand, and keeping it within the cuff of the sleeve, pick up the left glove by grasping the folded cuff. Place left glove palm-side down along the forearm of left hand, (thumb to thumb) with thumb and fingers pointind toward the elbow. The glove cuff should be over the gown cuff.

2. Securely hold the glove cuff of the hand being gloved. With the other gown-protected hand, stretch the glove cuff over the end of the gown sleeve and hand.

3. Pull the glove on over your extended fingers until it completely covers the gown cuff. Adjust your hand and fingers in the glove.

4. Using your gloved hand, pick up the second glove from the sterile wrapper.

5. Repeat the above procedure with the other hand to put on the second glove.

6. Pull the second glove over your extended fingers until it completely covers the gown cuff. Adjust your hand and fingers in the glove.

B. Open Glove Technique

1. Lift the right glove from the wrapper by the edge of the everted glove cuff, using your left thumb and finger.

2. Slide the glove over your right hand, holding the glove cuff. Adjust your hands and fingers inside the glove.

3. Using your gloved right hand, pick up the second glove by placing your gloved fingers under the everted glove cuff. Slide your ungloved hand into the glove.

4. Adjust your hand and fingers in the glove.

5. Adjust both gloves to cover the sterile gown cuff. To adjust the gloves, place your gloved fingers under the everted glove cuff and pull the glove upward.

C. Assisted-Gloving Technique(Gloving another Person)

1. Wearing sterile gown and gloves, pick up the right glove with fingers under the everted cuff glove cuff. Hold the glove so its thumb and palm are facing the person you are gloving. Then stretch the glove cuff to allow hand access and maintain sterility.

2. Apply resistance as the person you’re gloving pushes his hand into the glove.

3. Release the glove cuff when the glove is securely in place.

4. Repeat the procedure with the other hand.

Draping - is the procedure of covering the patient and surrounding area with a sterile barrier to create and maintain an adequate sterile field during operation

Points to remember:

• Drapes serve as barrier to prevent the passage of microorganism between sterile and non-sterile areas.

• The sterile field includes the patient, furniture, and other equipment that is covered with sterile drapes.

• Sterile drapes are positioned over patient in such a way that only a minimum area of skin around the incisions site is exposed.

• Frequently draped furniture includes instrument or “back” tables, mayo stands, and the ring stands.

Techniques to Remember in Draping:• Allow sufficient time to permit careful application.• Allow sufficient space to observe sterile technique.• Handle the drape as little as possible.• If a drape becomes contaminated, do not handle it

further. Discard it without contaminating gloves or other articles.

• If in doubt as to its sterility, consider it contaminated.• If end of the sheet falls below waist level, discard it.• Never reach across the operating table to drape the

opposite side; go around the table.• Take the towels and towel clips to the side of the

table from which the surgeon is going to apply them before handling them to him.

• Carry the folded drapes to the operating table; watch the front of the sterile gown; it may bulge and touch the non-sterile table or blanket of the patient. Stand back from the non-sterile table.

• Hold drapes high enough to avoid touching them on the blanket but avoid touching the light.

• Do not let your gloved hand touch the skin of the patient.

• Hold the linen high until it is directly over the proper area, then lay it down where it is to remain.

• If drape is incorrectly placed, the circulating nurse discards it from the table without contaminating other drapes or site .

• If unfolding the sheet on the operative site, toward the foot or the end of the table, protect the gloved hand by enclosing it in the turned back cuff of the sheet.

• A towel clip that has been fastened through a drape has its points contaminated- remove it only if absolutely necessary, then discard it.

• Place the drapes on a dry area.

Draping

• Place the first drape sheet from the foot to the knees. The scrub will select the sheet and hand one end to the surgeon across the operating table, supporting the folds, keeping it high, and holding it taut until it is opened, then drop it (open fingers and release sheet).

• The second drape sheet is handled in the same manner. This sheet is placed below the incision site with the edge of the sheet just below the incision site. This draping sheet provides extra thickness of material under the area from the Mayo tray to the incision where instruments and sponges are placed. It also closes some of the opening in the laparotomy sheet, if necessary.

• The third step in draping is placing the four sterile towels around the line of incision.

• The scrub unfolds first towel, passes the towel drape to the surgeon with the strip side facing the scrub. The surgeon places the towel within the scrubbed area on the near side of the line of incision, leaving only enough exposed skin for the incision.

• The second towel is placed in the same way, except the towel is placed on the lower side (toward feet) of the line of incision.

• The third towel is passed the same way, except the towel is placed on the upper side (toward head) the line of incision.

• The last towel is passed to the surgeon the facing the surgeon and is placed on the far side of the line of incision. The adhesive area holds the towel drapes in place.

• The towels may be held in place by towel clips.

• The scrub will select the surgical drape (lap sheet). This lap sheet has a fenestration (opening) in the drape for the incision.

• The scrub nurse carries the folded laparotomy sheet to the table. Standing back from the table, with one hand, the scrub lays sheet on the client and places the opening directly over the prepared skin area, outlined by the drape towels.

• The lap sheet will have an arrow or some other indication to identify the head or foot portion of the drape.

• Drop the folds over the sides of the table, then open it downward over the patient's feet and upward over the anesthetist screen. The hands approaching the unsterile area are protected in a cuff of the drape and the sheet may be stabilized with other hands.

Opening a Sterile Pack

• A sterile team member (scrub nurse or technician) should open a sterile pack from near side to far side.

• An unsterile team member (circulating nurse) should open a sterile pack from far side to near side. Remember, an unsterile team member must never reach over a sterile field.

A circulating nurse opening the cover of a pack of sterile drapes. She keeps her fingers under the cover to avoid contact with the sterile parts.

As this scrub nurse/ technician places the sterile drape cover on an OR stand, he keeps his fingers under the drape’s cuff to protect his sterile/ gloved hands and avoid contamination.

Scrub duties

• Perform surgical hand scrub. • Gown and glove using closed glove technique. • Re-gown and glove when breaks in technique occur. • Assist the 1st scrub in setting up case (back table,

mayo stand and O.R. basins).  • Arrange instruments and supplies (back table, mayo

stand and O.R.). • Count needles, instruments and sponges.• Check instruments for proper functions.• Prepare irrigating solution. • Draw medications properly. • Gown and glove surgeon and assistant. • Assist with draping.

Scrub duties

Scrub duties• Prepare electric cautery, suction and light handles for

proper use. • Prepare necessary sutures. • Pass instruments to surgeon and assistant. • Retract, sponge, and suction during case as

necessary. • Proper identification and handling of specimen. • Prepare instruments for decontamination at

completion of case. • Dispose of sharps properly. • Discard soiled drapes and trash properly.• Transport soiled drapes and trash properly. • Anticipate the surgeon and assistant needs. • Anticipate the operative procedure needs.• Help apply wound dressing.

Circulating Responsibilities

Circulating Responsibilities

• Clean operating room prior to case. • Gather all supplies, instruments and equipment

necessary for case. • Arrange O.R. furniture properly. • Open and flip sterile supplies for the surgical

procedure.• Assist with IV therapy. • Assist the anesthesiologist. • Assist with the skin preparation.• Tie gowns of the scrub nurse and surgeon.

Circulating Responsibilities

• Provide scrub personnel with sitting stools and foot stools as necessary.

• Turn and help adjust lights as necessary. • Supply the scrub nurse with necessary supplies. • Receive and label specimen properly. • Log and deliver specimen to pathology properly. • Help apply wound dressing. • Pull case for following procedure.

SPONGE AND INSTRUMENT COUNTS

It is essential to keep track of the materials being used in the operating room and during any complicated procedure in order to avoid inadvertent disposal or the potentially disastrous loss of sponges and instruments in the wound.

It is standard practice to count supplies (instruments, needles, screws and sponges): • Before beginning a case• Before final closure • On completing the procedure

• The aim is to ensure that materials are not left behind or lost. Pay special attention to small items and sponges.

• Create and make copies of a standard list of equipment for use as a checklist to check equipment as it is set up for the case and then as counts are completed during the case. Include space for suture material and other consumables added during the case.

• When trays are created with the instruments for a specific case, such as a Caesarean section, also make a checklist of the instruments included in that tray for future reference.

Cleaning a wound and applying a sterile dressinga. Prepare the client and assemble the equipment.b. Remove binders and tape.c. Remove and dispose of soiled dressing appropriately.d. Set up the sterile supplies.e. Clean the wound if indicated.f. Apply the ordered ointment/ cream, if any.g. Apply dressing to the drain site and the incision.

Irrigating a Wound • Wound irrigation - the process of washing debris,

drainage, or exudate out of the wound to promote healing.

• Fluid used to irrigate a wound - normal saline, Betadine, hydrogen peroxide, acetic acid, and specially prepared antibiotic solutions. If cytotoxic solutions are used, then the area must be flushed/irrigated afterwards with normal saline.

• Wounds that require irrigation vary -simple open lacerations; tunneled pressure ulcers; or complex, open abdominal wounds extending down to the abdominal fascia.

• Wound irrigation is a sterile procedure because the skin's integrity, the body's primary defense against infection, has been breached.

• The nurse must take care not to contaminate the wound, but must also take care not to become contaminated with wound drainage.

Irrigating a Wound

1. Confirm the health care provider's order for wound irrigation and note the type and strength of the ordered irrigation solution.

2. Assess the client's pain level and medicate if needed with analgesic 30 minutes before procedure if the medication is to be given PO or IM.

3. Explain the procedure to the client.4. Place a waterproof pad on the bed. Assist the client

onto the pad. Then assist the client into a position that will allow the irrigant to flow through the wound and into the basin from the cleanest to dirtiest area of the wound.

5. Wash hands and apply the disposable gloves; remove and discard the old dressing.

6. Assess the wound's appearance and note quality, quantity, color, and odor of drainage.

7. Remove and discard the disposable gloves and wash hands.

8. Prepare the sterile irrigation tray and dressing supplies. Pour the room-temperature irrigation solution into the solution container.

9. Apply sterile gloves (and goggles if needed).10.Position the sterile basin below the wound so the

irrigant will flow from the cleanest area to the dirtiest area and into the basin.

11.Fill the piston or bulb syringe with irrigant and gently flush the wound. Hold the syringe approximately 1 inch above the wound bed to irrigate. Refill the syringe and continue to flush the wound until the solution returns clear and no exudate is noted or until the prescribed amount of fluid has been used.

12.Dry the edges of the wound with sterile gauze.13.Assess the wound's appearance and drainage.14.Apply a sterile dressing. Remove sterile gloves and

dispose of properly. Wash hands.15.Document all assessment findings and actions

taken.

Obtaining a Wound

Drainage Specimen for Culturing • Bacterial wound contamination is one of the most

common causes of altered wound healing. • A surgical wound can become infected with

microorganisms preoperatively, intraoperatively, or postoperatively.

• Infection slows healing by prolonging the inflammatory phase of healing, competing for nutrients, and producing chemicals and enzymes that are damaging to the tissues. Identifying when a wound is contaminated and the infectious agent is an important step in wound healing.

• During the preoperative period, the wound may become exposed to pathogens because of the manner in which the wound was infected, such as in traumatic injuries. Nicks or abrasions created during preoperative shaving may also be a source of pathogens.

• The risk for intraoperative exposure to pathogens increases when the respiratory, gastrointestinal, genitourinary, and oropharyngeal tracts are opened.

• Nonsurgical wounds from trauma, pressure ulcers, or disease can become infected as well. If the amount of bacteria in the wound is sufficient or the client's immune defenses are compromised, clinical infection may result and become apparent 2 to 11 days postoperatively.

Obtaining a Wound Drainage Specimen for Culturing

1. Wash hands, apply disposable gloves, and remove old dressing. Place old dressing in moisture-proof container and remove and discard gloves. Wash hands again.

2. Open the dressing supplies using sterile technique and apply gloves.

3. Assess the wound's appearance; note quality, quantity, color, and odor of discharge.

4. Irrigate the wound with normal saline prior to culturing the wound; do not irrigate with antiseptic.

5. Using a sterile gauze pad, absorb the excess saline, then discard the pad.

6. Remove the culture tube from the packaging. Remove the culture swab from the culture tube and gently roll the swab over the granulation tissue. Avoid eschar and wound edges.

7. Replace the swab into the culture tube, being careful not to touch the swab to the outside of the tube. Recap the tube. Crush the ampule of medium located in the bottom or cap of the tube .

8. Remove gloves, wash hands, and apply sterile gloves. Dress the wound with sterile dressing.

9. Label the specimen, place in biohazard transport bag, and arrange to transport the specimen to the laboratory according to institutional policy.

10.Remove gloves and wash hands.11.Document all assessment findings and actions

taken. Document that a specimen was obtained.

Removing Skin Sutures and Staples

• Sutures and staples are a surgical means of closing a wound by sewing, wiring, or stapling the edges of the wound together.

• Most wounds are sutured in layers to maintain alignment of the tissues and reduce scarring.

• Sutures are generally removed 7 to 10 days after surgery, depending on where the wound is located and how well it is healing. Suture removal requires a health care provider's orders.

• Timing is important because sutures left in too long can increase the risk of infection and irritation from a foreign substance.

• Sutures placed deep within the tissue layers are made of absorbable materials.

• Surface sutures are made of wire, nylon, or cotton. • Continuous sutures are made with one thread, tied at

the beginning and end of the suture line. Interrupted sutures are tied individually.

• Staples are used for large incision areas where the risk of dehiscence is greater, such as in sterneotomies, in clients with increased adipose tissue, abdominal areas, and wounds that fail to heal or adhere.

Removing Skin Sutures and Staples1. Wash hands.2. Assess the wound to determine whether the edges

of the wound are well-approximated and healing has occurred.

3. Ascertain whether the client has had sutures removed before. If not, explain the procedure.

4. Close the door and curtains around the client's bed.5. Raise the bed to a comfortable level.6. Position the client for comfort with easy access and

visibility of the suture line.7. Drape the client so that only the suture area is

exposed.8. Open the suture removal kit, and assemble any

supplies needed within easy access on a clean surface.

9. Apply clean gloves to remove the old dressing and place it in a disposable bag.

10.Remove gloves and rewash hands.11.If dressings are to be used, assemble equipment and

supplies on sterile field.12.Measure the heart rate, rhythm, and volume; the

respiratory rate and rhythm; and the blood pressure bilaterally.

• Apply sterile gloves according to institutional policy.• Clean the incision with saline-soaked gauze pads,

antiseptic swabs, or per institutional policy.13.When removing an interrupted suture, hold forceps in

your nondominant hand and grasp the suture near the knot.

14. Place the curved edge of the scissors under the suture or near the knot.

15. Cut the suture close to the skin where the suture emerges from the skin (not in the middle). Pull the long end and remove it in one piece.

16. If the client has a continuous suture, cut both the first and second suture before removing them.

17. Some policies require the removal of every other suture, with the remaining sutures removed at a later time. Assess the suture line to ensure that the edges remain approximated.

18. Discard the sutures onto the gauze squares as they are removed and then place the gauze squares in the disposable bag when all the sutures have been removed.

19.Assess the suture line to ensure that the edges remain approximated and that all sutures have been removed.

20.Apply adhesive strips or butterfly tape adhesive strips across the suture line to secure the edges. The amount of reinforcement varies depending on the adherence of the suture line and the length of the suture line. Adhesive skin closures may be placed 1 inch apart or closer together.

• Tincture of benzoin may be used.21.Dispose of the soiled equipment.22.Remove gloves and wash hands.

23.Repeat Actions 2 to 12.• Use a staple extractor to remove every other staple.

Place the lower tip of staple remover under the staple and squeeze the handles together. The ends of the staple will extract from the skin. Move the staple away from the skin surface and release the staple into a disposal container. Assess the wound for adherence. Move on to the next staple if the skin has adhered well.

• Repeat Actions 20 to 22.