operating Room Lec

Role of the Scrub Nurse (Sterile Team Member)

• Define the surgical nurse role and how to prepare for it; common titles include scrub nurse or sterile team member.
• Primary tasks when scrubbed in with the surgeon:
  • Help retract tissues to expose the surgical field.
  • Lavage the surgical field with sterile saline or sterile water, depending on procedure.
  • Keep exposed tissues from desiccating; may drip water on tissues to prevent drying.
  • Manage and organize the instrument table to support the surgeon efficiently.
• Personal reflections on the role: anticipation of surgeon needs, understanding procedures, fluidity with the surgeon, and managing hundreds of instruments during procedures (especially in orthopedics).
• The role is active and fast-paced; focus on patient safety and minimizing operative time where possible.

OR Attire and Hygiene

• Aseptic attire to minimize microbial shedding and maintain a sterile field:
  • Freshly laundered scrubs; avoid wearing scrubs home to work in many settings; change into scrubs at the facility.
  • Cap or bouffant/buffon cap to cover all hair; mask to cover mouth and nose; shoe covers as required by the clinic.
  • Avoid street clothes in the OR; launder scrubs between shifts or per clinic protocol; in some clinics scrubs are laundered on-site.
  • Wear a lab coat over scrubs when in prep or non-sterile areas to reduce contamination from shed hair and skin.
• Hair and cosmetics: no mascara or jewelry; avoid long fingernails and fake nails due to shedding risk and potential contamination.
• Personal hygiene: shower regularly; use deodorant; avoid strong perfumes/colognes in the sterile environment.
• Hair/partial coverage note: Bouffant/Buffon cap used to cover all hair; mask protects the sterile field.
• Footwear: comfortable, clean shoes; consider leaving dedicated surgical shoes at work and cleaning them regularly; shoe covers when required.
• Handling prep areas: clip patients in prep areas; clipping hair can shed hair onto scrub tops, so consider wearing a lab coat over scrubs during prep and removing it before entering the OR.
• Gowning and gown fit: scrubs should be snug rather than baggy; shirt tucked to prevent contact with the towel and to keep towels from hitting scrubs.
• Attire in practice: gown and gloves may be donned in the OR under the supervision of the circulating nurse; circulating nurse assists with gowning if needed.

Endogenous vs Exogenous Contamination

• Endogenous contamination: originates from the patient themselves; e.g., contents from the small intestine leaking during a foreign body removal could breach asepsis and cause infection.
• Exogenous contamination: originates outside the patient; e.g., an instrument that isn’t sterile or improper sterilization leading to infection.
• Cosmetic items can contribute to exogenous contamination (e.g., mascara flakes into the sterile field when leaning over a body cavity).

Hand Scrub vs Hand Rub

• Hand scrub:
  • Mechanical and chemical antisepsis; uses mechanical friction plus antiseptic agents to reduce microbial load.
  • Two main methods: timed and stroke method; commonly a minimum of $5 ext{ minutes}$, though initial or first scrub of the day may be $10 ext{ minutes}$ and subsequent scrubs around $5 ext{ minutes}$.
  • Coverage should include fingertips, hands, and arms up to the elbows; a common mental model is to treat the hand and arm as a “box” with four sides for each finger and the palm, base of fingers, and wrist up to the elbow.
  • Start by cleaning under the nails, then proceed to the rest of the hand and arm in a systematic pattern; never drop hands below the elbows to maintain the clean-to-dirty water flow.
  • Wet hands with water before starting; if you bump the sink or forget to remove rings, you may have to restart the timer.
  • Use FDA-approved antiseptic scrubs; should be broad-spectrum, fast-acting, non-irritating, with potential residual effect; follow manufacturer guidelines.
  • Sponge vs brush: modern practice favors a sponge side; avoid using the bristle portion of scrub brushes due to microabrasions that can hinder asepsis.
  • Typical products include FDA-approved scrubs; examples in the course reference Avagard as a common antiseptic scrub.
• Hand rub (alcohol-based, brushless):
  • Used for a rapid, waterless antisepsis when a full scrub is not required; often a three-step rub following manufacturer guidelines (e.g., Avagard is a common product).
  • Involves pumping the product into the palm, then a standardized rubbing technique to cover fingers, hands, forearms, and elbows for a defined contact time; no scrub sink is used.
• Key concepts:
  • Contact time is critical for effectiveness of antiseptics.
  • Product selection should follow FDA guidance and be broad-spectrum, fast-acting, non-irritating, and ideally with residual activity.

Pre-scrub Preparation and Antisepsis Protocols

• Preparation before scrubbing:
  • Remove all rings, watches, jewelry, pins, name tags; secure or remove items to prevent contamination.
  • Some practitioners tie rings to their scrubs or keep watches on scrubs to prevent losing them;
  • Ensure nails are clean and free of polish; trimming nails below fingertip length.
• Scrub sinks and water control:
  • Modern scrub sinks are foot- or sensor-operated; use water flow to wet hands and forearms.
  • Begin with nails and underneath; maintain hands above elbows throughout the process.
  • Do not touch anything after you start the timer; if you contaminate, restart the timer.
• Scrub technique (box method):
  • Begin at the fingertips and go around each area to ensure full coverage; address web spaces, back of hands, palms, base of fingers, wrists, forearms, and up to the elbow.
  • Example sequence: start with nails, then interdigit web spaces, palms, dorsal surfaces, thumbs, then base of fingers to wrists, then forearms to elbows.
  • For each region, ensure adequate friction and coverage for the designated contact time.
• Antiseptic contact time: follow product guidelines to ensure effectiveness; the duration is part of the protocol and differs by product.

Drying and Gowning

• Drying after scrubbing or rubbing:
  • Use a sterile towel provided with the gown; keep the shirt tucked in to prevent the towel from contacting the scrub top.
  • Use one corner of the towel to pat dry each hand (do not rub to avoid increased shedding); switch to a clean corner to dry the other hand.
  • Do not let the towel touch the scrubs; ensure fingers do not drop below the waist during drying.
  • Place the used towel on the ground when finished drying.
• Gowning:
  • After drying, pick up the gown from the table (do not contaminate by grabbing from the wrong area).
  • Locate the neckline and armholes; gown should be donned with the hands staying above the waist.
  • The circulating nurse will assist by helping to place the gown over the shoulders.
  • The gowning process is performed while maintaining sterility; this step is practiced in lab.

Gloving: Closed, Open, and Assisted

• Three methods of gloving:
  • Closed gloving: gown and glove donning while remaining sterile with a gown (for surgeons).
  • Open gloving: sterile hands without a gown; used in situations where hands need to remain sterile but gowning isn’t yet completed.
  • Assisted gloving: a sterile team member who is already gowned and gloved helps others don their gown and gloves.
• Assisted gloving example: a sterile team member who has downed gown and gloves helps another team member don theirs; this is common and can speed procedures.
• If gown or gloves become contaminated during a procedure:
  • The circulating nurse unties and pulls the contaminated gloves/gown off in a manner that maintains sterility; options include using a sterile sleeve or regowning and regloving.
• Practical tip: some practitioners may “gown and glove” the surgeon to reduce anesthetic time and optimize patient safety.

Intraoperative Considerations: Comfort, Safety, and Well-Being

• Duration variability: procedures can take longer than anticipated; for example, elbow replacement may take around $4 ext{ hours}$ but can extend to $8.5 ext{ hours}$; scrub techs may be standing the entire time without bathroom breaks.
• Physical and logistical precautions:
  • Do not rely on phrases like, "oh, it’s just a spay"; there can always be unexpected events prolonging surgery.
  • Eat before surgery; quick, portable snacks (e.g., yogurt and granola bars) are common for long cases.
  • Avoid fake nails and long nails; ensure fingernails are groomed.
  • No strong perfumes or colognes in the OR; consider deodorant and regular showers.
  • Hydration and energy management are important in a long case.
• Conditioning and posture:
  • Scrubbed-in staff should avoid locking knees; shift weight to maintain balance and circulation.
  • If feeling hot or dizzy, step back from the sterile field; do not lean into the field.
  • Circulating nurse may apply a small amount of alcohol to the back of the neck to help when feeling faint.
  • If uncomfortable or unwell, speak up promptly to protect the patient and sterile field; no shame in stepping out.
• Environment and footwear:
  • Comfortable and clean shoes are essential; consider leaving dedicated surgical shoes at the workplace.
  • If hot, maintain a position that prevents loss of sterility and protects the patient.
• Additional preparation considerations:
  • Jewelry removal, including rings and watches; avoid nail polish because chipped polish can contaminate packs or instruments.
  • Prep-related hair shedding can contaminate sterile items; clipping patients in prep areas and then removing the lab coat before entering OR helps reduce shedding.
• Practical ethics and teamwork:
  • The patient’s safety and sterile field integrity are top priorities; speaking up when unwell is a professional duty.
  • Team members should support each other to minimize anesthesia time and optimize patient outcomes.

Practical Takeaways and Lab Preparation

• Use the PowerPoint as a reference during lab practice; it provides pictures and step-by-step visuals to reinforce technique.
• Expect to demonstrate and practice:
  • Hand scrubbing and hand rubbing techniques, including under-nail prep and the box method.
  • Drying technique with circumferential patting using a sterile towel without touching scrubs.
  • Gown and glove donning, including open, closed, and assisted gloving.
  • Handling of contaminated gowns/gloves and regowning procedures if needed.
• The scrub nurse role emphasizes anticipation and fluid communication with the surgeon, especially in specialties with abundant instrumentation (e.g., orthopedics).
• The session reinforces the importance of asepsis, proper attire, and personal hygiene to protect patients and maintain sterility in the operating room.
• Final note: this content is intended to supplement hands-on lab practice and serve as a standby reference for at-home study with partners.