MODULE VIII:

LMC OPERATING ROOM WORKFLOW

OBJECTIVES:
At the end of this module, the nurse participants will be able to:

1. Describe the general processes conducted in the LMC Operating room complex.
2. Promote and ensure safe surgery delivery to patients through strict adherence
and implementation of standard operating procedures and practices during the
pre –, intra – and post – operative phases of surgery.
3. Be knowledgeable on the various roles and responsibilities of nurses in the
conduct of procedures during the different phases of surgery and in performing
various processes related to the function of the operating room.
 PREOPERATIVE NURSING

The preoperative phase begins when the decision is made for surgical
intervention. The pre-op nurse is responsible for assessing the patient’s physical,
psychologic, and social states; preparing the patient for surgery; and implementing
nursing interventions. The pre-op phase ends when the patient is transported to the
operating room and care is transferred to the OR nurse.

The nurse should identify the patient’s support system – their significant other,
family, or friends that are present.

The key nursing intervention during the preoperative period is patient and family
education. Take every opportunity during the patient assessment and preparation for
surgery, to provide information that will increase the patient’s familiarity with the
procedure, which will decrease anxiety. Give instructions on activities that will promote
healing and prevent postoperative complications. Assess and address individual
learning needs, and involve patients in decision-making concerning their care – this
allows them to maintain some control over events. During the pre-op assessment, teach
the patient about postoperative pain control. Fear of pain is a common source of anxiety
and should be addressed before surgery, to decrease anxiety and add to the patient’s
sense of control.

A pre-op checklist is a way for the nurse to summarize patient data and ensure
the patient is ready for surgery. The patient should remove all personal clothing and put
on a hospital gown. Jewelry is removed, according to hospital policy. Patient’s personal
belongings, including eyeglasses, dentures or prostheses, are identified and secured.
Confirm the patient’s name & DOB on the ID band; confirm that consent forms are
completed & signed; x-rays, lab results, and EKG are on the chart; verify the availability
of an implant if needed, and the availability of blood.

To ensure patient safety, the Universal Protocol is a mandatory Joint

Commission quality standard that verifies correct patient identity, correct procedure, and
correct surgical site. At least two patient identifiers are used to verify patient identity,
such as asking the patient to state their full name and date of birth. The patient should
verbally confirm the surgical procedure and the surgeon should mark the surgical site
with the patient’s involvement. The pre-procedure verification and surgical site marking
are performed in the pre-op area, then the “timeout” is done in the OR immediately prior
to surgery.

Depending on the anesthesiologist’s preference, premedication may be given by

the pre-op nurse to decrease anxiety and provide sedation, to prevent or decrease
nausea and vomiting, to decrease gastric volume and acidity, to decrease secretion of
saliva and gastric juices, and to relieve pain and discomfort. Once premedication has
been given, ensure patient safety by keeping the patient in bed with side rails up.

There are certain legal and ethical issues that need to be addressed when a
patient is going to have surgery. Informed consent refers to the process in which the
patient is informed of the nature, consequences, harms, benefits, risks, and alternatives
to the proposed medical treatment. Before surgery, the physician asks the patient to
sign a statement consenting to the surgical procedure. The physician is legally
responsible for providing the patient with sufficient information to weigh the risks and
benefits of the surgery, which includes the disease process and diagnosis; nature of the
surgery with its benefits, risks, and prognosis if treatment is withheld; and alternative
treatment options. The informed consent must include the patient’s full legal name;
surgeon’s name; specific procedure(s) to be performed; signature of the patient, next of
kin, or legal guardian; witness (which is usually the nurse); and the date.

The nurse’s role is that of patient advocate. The nurse assesses the patient’s
decision-making capacity, confirms that the patient has received the necessary
information to give informed consent, and clarifies any misunderstandings. The nurse
should also support the patient’s decision, should the patient decide to withdraw
informed consent and refuse the surgical procedure.
 The pre-op nurse will document the patient care and teaching given during the
preoperative phase. Pertinent data will be communicated to the OR nurse, as care is
transferred over.

A. OBTAINING CONSENT

The attending physician/surgeon shall ensure that informed consent from

the patient/watcher has been obtained after a thorough explanation.
 The surgeon shall sign the physician’s declaration (see Annex A)
 The patient signs the consent to operation, consent to anesthesia, pre
– anesthesia profile (complete name & signature) (see Annex A, B & C)
 The nurse signs the consent as a witness (complete name, signature,
date & time) (see Annex A, B & C)
 For other invasive/special medical procedures, obtain also a consent
(consent to medical procedure) (see Annex D)

B. SCHEDULING OF SURGICAL OPERATION

1. Receive the electronic OR notice at least 6 hours prior to the

scheduled procedure (for elective cases).
o Complete patient details in the OR notice:
 Full name (with middle name)
 Address
 Age
 Gender
 Marital status
 Birth date
 Hospital number
 Admission number
  Surgical procedure (laterality)
 Surgeon, Surgeon Assist, Anesthesiologist

2. Check if the form is properly and completely filled in.

3. Verify in the Schedule of Operations Logbook if there is any conflict of

schedule.
Note: If there’s a conflict, notify the GNU nurse on duty, to update the
surgeon & anesthesiologist for a possible reschedule. For emergency
operations, notify the surgeon, anesthesiologist of any on deck
operation for possible adjustment to accommodate the emergency
case.

4. If there is no conflict, acknowledge the notice of operation form by

signing on the upper right corner. Write also the date and time the
Notice form has been received.

5. Record the case in the Schedule of Operation Logbook.

6. Write the operation in the Schedule of Operation board on the day

of surgery.

C. PRE – OPERATIVE PREPARATIONS

1. Skin prep
 Instruct patient to have a full bath on the day of surgery to reduce
microorganisms in the skin (antibacterial soap), mouth care (gargle
with antiseptic).
 Inform patient of the possibility of being shaved (if ordered by the
surgeon).
2. GI prep
 Check NPO status (6 – 8 hours)
Note: for patients under local anaesthesia, no need to undergo NPO
unless ordered by the surgeon
 Do cleansing enema, as required
 Administer oral laxatives, as ordered

3. Preparing the patient for anesthesia

 Instruct patient to avoid alcohol & cigarette smoking for at least 24
hours prior to surgery.
 Review medications, ask if patient is on blood thinners (if yes, refer to
AMD)

4. Site - marking
 Marking should be on the intended site of the incision or as near as
possible to the intended site
 Mark must not be ambiguous
 Marking must be visible after the patient is prepped and draped
 The Surgeon will mark the site using an indelible, hypoallergenic, latex-
free, skin marker
 Exemptions to site marking:
 Simultaneous bilateral surgery (bilateral MRM)
 Single organ cases (appendectomy)
 Cases involving the mucosa (hemorrhoidectomy, tonsillectomy,
tympanoplasty, etc)
 PREMATURE INFANTS (marking may cause permanent tattoo)
 DENTAL SURGERY
 ENDOSCOPY
  Interventional cases for which the catheter/instrument site is not
predetermined (cardiac catheterization, epidural/spinal
analgesia/anesthesia)
 Obvious wounds or lesions
 LIFE THREATENING EMERGENCIES

5. Other pre – operative preparations

 Cardio – Pulmonary Clearance
 high-risk patients – with co – morbidities; 40 years old & above
 c/o Internist (Internal Medicine)
 Correct any fluid and electrolytes imbalances (refer abnormal labs)
 Restore adequate blood volume with blood transfusion (as ordered)
 Treat chronic Disease – Heart Disease, Renal insufficiency, Diabetes
mellitus
 Treat any infectious process

D. PRE – OPERATIVE NURSING VISIT

The pre – operative nursing visit is done to determine any factors that could
significantly increase a patient’s risk for intra – operative complications. This
procedure also offers a chance to collect data to better manage patients in the
surgery process and to educate patients on how to cooperate with their medical
care and surgical team.

1. Assigning the pre – op visit:

- pre-op visit shall be performed by the OR nurses (preferably two
OR nurses) on elective surgical procedures.
- the department head or head nurse or a senior nurse shall
assign OR nurses who shall conduct the pre-op visit.
- the pre-op visit shall be conducted during the 2-10 shift
preferably by senior nurses.
2. Checking and verifying data:
- the assigned OR nurse shall check the Schedule of Operation
Logbook or the printed OR schedule confirmation slip of the
scheduled cases for the following day.
- the OR nurse shall sort and come up with a list of patients to be
visited on that day.

3. Documentation
- A pre – op visit checklist is used by the OR nurses as a clinical
risk assessment tool to assess the health of a patient and
determine if the patient is safe to undergo anesthesia and
surgery.
- the OR nurse/s shall provide education with emphasis on the
measures to be taken before the day of the surgery such as
body and oral hygiene; removing dentures, underwear and
fingernail polish, if applicable; voiding before transport, and
maintaining NPO status.
- the OR nurse/s and the ward nurse shall collaborate as a team
and both affix their signature in the pre-op details of the
Operating oom checklist.
- the OR nurse/s shall fill up necessary details in the pre-op
logbook and affix his/her signature and have the GNU nurse
countersign as proof of the visit.
- the OR nurse/s shall attach the filled – up pre – op assessment
visit checklist to the patient’s chart

E. DAY OF SURGERY
1. Instruct morning bath, oral care.
2. Do skin shaving, if indicated by surgeon.
3. Remove dentures, underwear, jewelleries, nail polish.
 4. Verify if any special order has been carried out – Enema, IV line insertion,
NGT insertion, NPO status maintained.
5. Take baseline vital signs prior to patient transport to OR and before giving
any pre – op medication.
6. Let patient void before any pre – op medication is given.
7. Administer pre – op medications prior to OR transport (as ordered)
Note:
 Upon anesthesia induction – to be given in the OR during anesthesia
induction; for antibiotics, skin test is to be done in the GNU
 30 minutes/1 hour prior to OR transport – medication is to be given
prior to OR transfer
 Oral meds - with sips of water only

8. Attach latest labs & diagnostic procedure results to chart (if done as OPD).
This is available at Medsys.

9. Endorse Xray, MRI, CT scan films (if done as OPD). This is available at
Medsys.

INTRAOPERATIVE NURSING

Nursing responsibilities during the intraoperative phase include continuing the

assessment of the patient’s physiologic and psychologic status, promoting safety and
privacy, preventing wound infection, and promoting healing. The surgical team must
work together to deliver safe and effective care to the patient in the intraoperative
phase. The team is divided into categories based on responsibilities, and consists of the
primary surgeon and assistants, the scrub tech/nurse, circulating nurse, and
anesthesiologist. The surgeon, assistant, and scrub tech work in the sterile field, while
the circulating nurse, anesthesiologist, and other personnel function outside the sterile
field.
Surgical Environment

The surgical environment is designed to provide a safe therapeutic environment

for the patient. Traffic in and out of the operating suite is kept to a minimum to decrease
potential contamination from air turbulence and bacterial shedding. Floors, walls, and
ceilings are made of materials that are easy to clean with antimicrobial agents.

Asepsis

Aseptic technique involves following practices that prevent contamination from

pathogens and must be followed by all members of the OR team to reduce the risk of
surgical site infections. The Association of periOperative Registered Nurses (AORN)
has “Perioperative Standards and Recommended Practices” for asepsis that include the
following:

 Scrubbed persons should function within a sterile field.

 Sterile drapes should be used to establish a sterile field.

 Items used within a sterile field should be sterile.

 All items introduced onto a sterile field should be opened, dispensed, and
transferred by methods that maintain sterility and integrity.

 A sterile field should be maintained and monitored constantly.

 All personnel moving within or around a sterile field should do so in a manner

that maintains the sterile field. (Sterile persons remain close to the sterile field
and never turn their backs to it.)

 Policies and procedures for maintaining a sterile field should be developed,

reviewed periodically, and readily available in the practice setting.
Surgical Attire

Individuals working in the OR are a major source of microbial contamination to

the environment due to the large quantities of bacteria in the respiratory tract and on the
skin, hair, and clothes. Surgical attire is required to reduce the patient’s risk of surgical
site infection (SSI) from microorganisms and also to protect personnel from exposure to
hazardous substances and infectious microorganisms.

Everyone in the OR will need to wear a surgical cap, mask, and shoe/boot
covers. Dressing in OR attire progresses from head to toe—surgical hat first (to prevent
the shedding of microbes from the head/hair to the scrubs), then surgical scrub suit,
face mask and safety eyewear, and shoe/boot covers. Non-sterile team members
should wear a long-sleeve scrub jacket. Those in the sterile field will also perform a
surgical scrub of hands and arms before entering the OR to put on a sterile gown and
gloves.

Patient Skin Preparation

Patient skin preparation involves the patient showering thoroughly with an

antiseptic wash prior to surgery. The intraoperative circulating nurse will be involved in
hair removal from the surgical site (when necessary) and cleaning the incision site with
skin antiseptic, using the manufacturer’s recommendation for contact and drying time.
Skin preparation begins with mechanical scrubbing at the incision site, moving out in a
circular fashion, away from the site. The sponge is considered contaminated when it
reaches the outer edge and is then discarded. A new sponge is used each time the area
is scrubbed.

“Time-Out”
Once the patient is prepped and draped in the OR, the circulating nurse usually
initiates the “time-out” that takes place between the entire surgical team. The time-out is
a verbal agreement that includes, at a minimum, the following: correct patient identity,
correct site, and correct procedure to be performed. If implants or radiologic exams are
involved, these should be verified at this time also. Document the completion of the
time-out, indicating that everything has been verified and agreed upon.

A. RECEIVING THE PATIENT IN THE OPERATING ROOM

The endorsing nurse (from the GNU/ER/ICU) & the receiving OR nurse shall
ensure proper patient handover.

1. Identify the patient:

- If the patient is conscious, ask his/her name, birth date (patient identifiers)
- Check the identification band/bracelet
- Countercheck the received patient’s chart from the GNU nurse
2. The receiving OR nurse (circulating nurse) shall utilize the LMC operating
room checklist when receiving patients in the OR.
3. Transfer the patient to the operating room via a stretcher. Ensure that
stretcher’s side rails are up.
4. Place the patient comfortably on the operating table. As much as possible,
two persons shall carry the patient from the stretcher to the operating room
table.
5. Apply knee and hand straps gently but firmly, and stay with the patient.
6. Connect the patient to a patient monitor and take the baseline vital signs,
including FHT if the patient is pregnant.
7. Assist during the induction of anesthesia.
8. Perform special procedures as ordered by the physician such as insertion of
foley catheter, nasogastric tube, etc. as necessary.
9. Document all procedures, medications given and interventions done to the
patient.

Note: The WHO surgical safety checklist (see Annex F) shall be utilized prior to the
induction of anesthesia, before skin incision and before the patient leaves the
 operating room to ensure correct patient identification, correct procedure and
correct site. (Time Out procedure.)

B. DURING THE OPERATION

The scrub nurse shall have the following duties:

 Assists in the preparation of the operating room.

 Gathers sterile instruments to the surgical team and assists as needed to
enhance the continuity of the procedure.
 Constant surveillance of the surgical field to maintain sterility.
 Anticipates the needs of the surgeon and asking for items before they are
needed.
 Counts sharps, instruments and sponges together with the circulating nurse and
assures the correctness and completeness of the count of each.
 Secures the specimen.
 Helps with the application of the sterile dressing at the end of the procedure.
 Performs post-operative care to the patient.
 Assists in the cleaning of the operating room and thorough cleaning and
disinfection of instruments in preparation for re – sterilization.

The circulating nurse shall have the following duties:

 Coordinates patient care before, during, and after the surgical procedure
 Provides emotional support to the patient and assisting the anesthesiologist
during the initiation of anesthesia

 Ensures patient safety, positioning and monitoring the patient, and enforcing
policies and procedures throughout the surgery – including a “time out”

 Maintains sterile technique while providing supplies and equipment for the sterile
team
 Documents all nursing care during the intraoperative period

 Recognizes and resolves environmental hazards that involve the patient or

surgical team, including protecting the patient from electrical hazards

 Ensures with the scrub nurse that all sponge, instrument, and sharps counts are
completed and documented

 Communicates relevant information to family members and other healthcare

workers outside the OR

 Endorses special postoperative needs to the Post Anesthesia Care Unit nurse.

C. TERMINATION OF SURGERY

During this phase, the scrub nurse shall perform the following responsibilities:
1. In – charge in the care of specimens.
2. In – charge of the decontamination, disinfection, packing and sterilization
of surgical instruments and supplies.

The circulating nurse will have the following responsibilities:

1. Ensure that the surgeon has completely and properly filled – up the Operative
record in the Visual OR. In addition, the following forms must also be
accomplished by the surgeon along with the operative record:
- Summary of parturition (Vaginal delivery cases)
- Bronchoscopy report (Bronchoscopy procedures)
- Surgical Pathology Consultation form (for procedures with
specimens for histopathology, frozen section biopsy, etc)
2. Ensure that the anesthesiologist has properly accomplished the Anesthesia
record form.
3. Accomplish and record/encode all pertinent data on the following forms:
- Nurses Notes (Medsys)
- Therapeutic Sheet (Medsys)
 - IV fluids and blood transfusion sheet (Medsys)
- Operating room checklist (paper)
- WHO surgical safety checklist (paper)
4. Endorse the patient to the Post Anesthesia Care Unit nurse for post –
operative care.
- For a newborn, endorse to the nursery
- For patients under local anesthesia, endorse the patient to their
respective GNU or to another department if they are required to
undergo another procedure
5. Record all operations done in the 24 hours of surgery report, daily operations
logbook and post charges logbook.

D. PROPER HANDLING OF SPECIMEN

Describes the process of handling samples for various laboratory
examinations.

1. The surgeon will fill up the request for Surgical Pathology Consultation form
properly and completely.
2. Label the specimen bottle/container, as follows:
- the date of operation
- room number
- name of patient
- name of specimen
- requesting doctor
- birth date
3. Care/preservation of specimens according to different laboratory tests to be
performed:
a. Histopathology – immerse the specimen in 10% Formalin solution
Note: Breast tissue samples – immerse in NEUTRAL BUFFERED
FORMALIN only
 b. Cytology, Cell block, Gram staining, Culture and sensitivity, KOH, AFB
- Send/deliver specimen immediately to the laboratory, without
preservative

c. Frozen section - Send/deliver specimen immediately to the laboratory,

without preservative

d. Gene xpert – immerse 5mL NSS to specimen immediately after extraction

4. Submit the samples along with the properly filled – up Surgical Pathology
Consultation form.

5. Record the following in the OR Specimen Notebook:

- Date

- Room Number

- Name of Patient

- Operation performed

- Name of specimen

- Examination to be done

- Name and signature of scrub nurse

6. Let receiving laboratory staff sign in the OR Specimen Notebook.

POSTOPERATIVE NURSING

The postoperative phase of the surgical experience extends from the time the
client is transferred to the recovery room or postanesthesia care unit (PACU) to the
moment he or she is transported back to the surgical unit, discharged from the hospital
until the follow-up care.
 The patient must be stable and free from symptoms of complications in order to
transfer from the PACU to the clinical unit or home. However, the potential for
developing complications goes beyond the immediate postoperative phase and ongoing
nursing assessment is essential on the postoperative nursing floor as well.

References:

LMC ISO registered procedures of operating room handbook

LMC ATHENA IPSG 4

https://www.mometrix.com/academy/pre-operative-nursing/

https://www.mometrix.com/academy/intraoperative-nursing/

https://nurseslabs.com/postoperative-phase/