---

Operation Theatre (OT) Nursing - Complete Study Guide

---

Topic 3: Pre, Intra & Immediate Post-Operative Care

Pre-Operative Care

• Verify patient identity (name, ward, bed number, date of birth)
• Confirm the correct procedure and site (surgical site marking)
• Review consent form - ensure signed and witnessed
• Check NPO (Nothing by Mouth) status: solids 6-8 hrs, clear fluids 2 hrs before surgery
• Review history: allergies, current medications, previous anesthesia reactions
• Baseline vitals: BP, pulse, SpO2, temperature, weight
• Remove jewelry, nail polish, dentures, prosthetics, contact lenses
• IV access - ensure patent IV line with appropriate gauge cannula
• Pre-operative medications as ordered (anxiolytics, antacids, antibiotics prophylaxis)
• Enema/bowel preparation if indicated (bowel surgery)
• Skin preparation: shave/clip operative site if needed
• Pre-op investigations: CBC, blood group & crossmatch, BUN/Creatinine, coagulation profile, ECG, CXR
• Ensure blood/blood products are available if expected
• Patient education: explain procedure, post-op pain management, breathing exercises

• Confirm checklist before transfer (identity band, consent, investigation reports, X-rays)
• Transfer on stretcher/trolley with side rails up
• Maintain patient privacy and dignity

---

Intra-Operative Care

• OT nurse receives patient, re-verifies identity, procedure, site
• WHO Surgical Safety Checklist - Sign In (before anesthesia), Time Out (before incision), Sign Out (before patient leaves OT)
• Position patient correctly on OT table (see Topic 11)
• Apply monitoring: ECG, SpO2, NIBP, temperature probe, catheter if needed
• Apply grounding pad for diathermy
• Skin preparation with antiseptic (povidone-iodine or chlorhexidine) in concentric outward circles
• Draping to create and maintain sterile field

• Maintain sterile field integrity
• Pass instruments, sutures, sponges as requested by scrub nurse/surgeon
• Count swabs, instruments, needles before incision and before closure
• Monitor and document fluid intake/output
• Specimen labeling and handling
• Communicate any concerns immediately

---

Immediate Post-Operative Care (Recovery Room/PACU)

• Transfer patient with report to recovery nurse
• Monitor: vital signs every 5-15 min, level of consciousness (Aldrete score), pain score, SpO2
• Airway management: position in recovery position (left lateral), oxygen via mask
• Watch for: respiratory depression, laryngospasm, hypotension, tachycardia, excessive bleeding, nausea/vomiting
• Maintain IV fluids as ordered
• Pain management: administer analgesics as prescribed
• Wound check: dressing, drains (note output, color, amount)
• Urinary output monitoring (if catheterized, >0.5 mL/kg/hr is adequate)
• Warmth: blankets, warming devices (hypothermia common post-op)
• Discharge criteria: stable vitals, alert, pain controlled, no nausea, SpO2 >95%

---

Topic 4: Common Surgical Procedures

Laparoscopic Cholecystectomy

• Indication: Gallstones, cholecystitis
• Position: Supine, Trendelenburg with right side elevated
• Steps: CO2 pneumoperitoneum → 4-port entry → identify Calot's triangle → clip & cut cystic duct and artery → dissect gallbladder from liver bed → extract through umbilical port
• Nursing role: Ensure laparoscopic tower ready, CO2 cylinder, laparoscope, monopolar diathermy, clip applicator, retrieval bag

Laparoscopic Appendectomy

• Position: Supine, slight Trendelenburg, tilt left
• Steps: 3-port technique → identify appendix → ligate mesoappendix → apply endoloop/stapler at base → remove in bag
• Key instruments: Endoscopic stapler or endoloop, laparoscopic graspers, irrigation/suction

Abdominal Hysterectomy (Total)

• Indication: Uterine fibroids, cancer, endometriosis
• Position: Supine with slight Trendelenburg; legs in low lithotomy for vaginal component
• Steps: Pfannenstiel or midline incision → round ligaments ligated → uterovesical peritoneum opened → uterine arteries clamped/ligated → vagina entered and uterus removed → vaginal vault closed
• Key instruments: Hysterectomy clamps (Heaney, Kocher), long curved scissors, self-retaining retractor (O'Sullivan-O'Connor)

Cesarean Section (LSCS)

• Position: Supine with left lateral tilt (wedge under right hip) to prevent aortocaval compression
• Anesthesia: Usually spinal; GA for emergencies
• Steps: Pfannenstiel incision → rectus sheath opened → uterus incised (low transverse) → baby delivered → placenta manually removed → uterus closed in 2 layers → fascial closure → skin closure
• Time to delivery: Target <3 min from incision in emergency
• Key instruments: Doyen retractor, Green-Armytage forceps, curved scissors, uterine closure needles (large round body)

---

Topic 5a: Opening & Packing Used Sets & Single Packs

Opening Sterile Packs

• Check before opening: Label (contents), expiry date/sterilization date, indicator tape change, packaging integrity (no tears, moisture, holes)
• Technique for wrapped sets: Peel open away from sterile field; outer wrap opened first by circulating nurse using "open-peel" technique; contents dropped onto sterile trolley WITHOUT touching sterile field
• Single peel-packs: Hold at two corners of the peel edge, peel back slowly and evenly; present contents to scrub nurse or drop onto sterile field
• Rules: Never reach over sterile field; if in doubt, throw it out; wet packaging = contaminated

Packing Used Sets (After Surgery)

• Instruments sorted, counted, and placed in perforate trays/baskets
• Gross contamination removed (blood, tissue) under running water or with gauze
• Sharps (needles, blades) removed separately into sharps container
• Instruments placed in decontamination solution (enzymatic or 1% hypochlorite) for 30 min minimum
• Transported to CSSD in closed, labeled containers
• Never recap needles - place directly in sharps bin

---

Topic 5b / Topic 6: CSSD - Sterilization Methods & Storage Duration

Central Sterile Supply Department (CSSD)

---

Sterilization Methods

• At 121°C: kills spores in <5 min; standard cycle 15 min for safety margin
• Steam under pressure works by protein denaturation via hydrogen bond disruption
• Air must be fully removed - air pockets prevent steam penetration and lead to sterilization failure
• Pressure itself does NOT sterilize - it is only the mechanism to raise temperature

---

Topic 6: Storage Duration (Shelf Life) of Sterile Sets

• Wrapped sets: Check every time before use
• Label should show: Date of sterilization, batch number, sterilizer ID, contents, date to be used by (if institutional policy)
• Storage conditions: Dry, dust-free, temperature controlled, away from direct sunlight, elevated off floor

---

Topic 7: Disinfection, Decontamination

Definitions

• Sterilization: Destruction of ALL microorganisms including spores (absolute)
• Disinfection: Destruction of most pathogens (not necessarily spores)
• Decontamination: Process of removing/inactivating microorganisms to make items safe to handle
• Cleaning: Physical removal of dirt and organic material (must happen BEFORE disinfection/sterilization)

Instrument Decontamination

1. Rinse with cold water (hot water coagulates proteins)
2. Immerse in enzymatic detergent for 10-30 min
3. Manual scrub with brush (wear PPE: gloves, apron, eyewear)
4. OR: Washer-disinfector (automated, more reliable)
5. Rinse, dry, inspect, pack, sterilize

OT Table Decontamination

• After each case: remove gross contamination with paper towel
• Wipe with hospital-approved disinfectant (1000 ppm hypochlorite or 70% alcohol/quaternary ammonium compound)
• Allow contact time (usually 1-5 min)
• After contaminated/infectious cases: use 10,000 ppm hypochlorite (full decontamination)
• Check articulating parts, mattress covers for tears (replace damaged covers)

OT Room & Floor Decontamination

• Between cases: Damp mop with phenolic disinfectant; wipe all surfaces (tables, lights, equipment)
• End of day: Full terminal cleaning - mop floor, clean walls to 2m height, wipe all equipment
• Weekly: Ceiling, light tracks, vents
• Fumigation: Formaldehyde vapor (40 mL formalin + 20 g KMnO4 per 1000 cu ft) - 24-48 hrs, then ventilate; OR UV-C light (less effective, supplementary)
• OT surfaces should be non-porous, seamless, easy to clean
• Air: positive pressure ventilation in OT (min. 20 air changes/hr with HEPA filtration)

---

Topic 8: Roles of Scrub Nurse, Circulating Nurse & Anesthesia Nurse

Scrub Nurse (Instrument/Theatre Sister)

• Performs surgical hand scrub and wears sterile gown and gloves
• Sets up sterile trolley with instruments, sutures, swabs, drains
• Checks and records all instruments, swabs, needles BEFORE incision and BEFORE closure (count should match)
• Prepares and hands instruments, sutures, drains to surgeon
• Keeps instruments clean and organized during procedure
• Maintains sterility of the sterile field throughout
• Labels and handles specimens correctly
• Must report any breach in sterile technique immediately
• In HIV/Hepatitis B cases: works in close harmony with surgeon to prevent needlestick
• Reports correct or discrepant swab/instrument count to surgeon before closure

Circulating Nurse (Runner/Scout Nurse)

• Does NOT scrub; moves freely in non-sterile zone
• Receives patient, checks identity and documentation
• Assists scrub nurse before gowning (adjusts height of trolley, opens packs)
• Opens and presenting sterile packs/supplies to scrub nurse without contaminating
• Documents: operative procedure, time incision, count results, specimens, blood loss
• Counts swabs and instruments with scrub nurse (verifies the count)
• Operates equipment: suction, diathermy, tourniquet, image intensifier, lights
• Communicates with blood bank, pathology, X-ray as needed
• Manages specimens: labels, fills forms, sends to lab
• Connects suction, diathermy cables from sterile field to machine (with sterile technique)
• Assists anesthetist with non-sterile supplies

Anesthesia Nurse (OT Nurse for Anesthesia/Anesthesia Technician)

• Prepares anesthesia machine: check circuit, gases (O2, N2O), vapourizer level, suction
• Prepares anesthesia tray (see Topic 13)
• Assists anesthetist during induction: positions patient, applies monitoring, assists with IV placement, holds mask
• Draws up and labels all drugs (in presence of anesthetist - double check)
• Assists with intubation: holds cricoid if RSI, hands tube, inflates cuff, confirms position
• Monitors patient continuously intra-operatively
• Administers drugs as directed by anesthetist
• Documents all drugs, fluids, vital signs on anesthesia chart
• Manages patient during regional anesthesia procedures (positioning for spinal)
• Assists with emergence and extubation
• Transfers patient to recovery with complete verbal and written handover

---

Topic 9: Types of Sutures, Staplers, Threads, Needles & Drains

Suture Classification

• Monofilament: Single strand (Prolene, PDS, Monocryl) - less tissue drag, less infection
• Multifilament/Braided: Multiple strands (Vicryl, Silk, Ethibond) - stronger, easier to handle, more tissue reaction

---

Needles

---

Staplers

---

Drains

---

Topic 10: Surgical Instrument Sets

Appendectomy Set

• Towel clips (4-6)
• Scalpel handle No. 3 + No. 4
• Dissecting forceps: toothed (Adson) and non-toothed (McIndoe)
• Artery forceps: curved and straight (Mosquito, Halsted, Kocher) x 6-8
• Babcock forceps x 2 (to hold appendix)
• Allis forceps x 2
• Scissors: Mayo (straight & curved), Metzenbaum
• Needle holders x 2
• Retractors: Langenbeck x 2, Morris retractor
• Abdominal swabs and gauze
• Suction tip (Yankauer/Poole)
• Diathermy lead
• Bowl for antiseptic

Laparotomy Set (Basic)

• Large self-retaining retractor (Balfour or O'Sullivan-O'Connor)
• Large Langenbeck retractors x 2
• Deep retractors (Deaver, Morris)
• Intestinal clamps (Allen, Lane)
• Large curved artery forceps
• Peritoneal forceps (toothed, long)
• Large needle holders (Mayo-Hegar) x 2
• Poole suction
• Abdominal packs (large) x 10-12
• Diathermy with long extension

Cesarean Section Set

• Towel clips x 6
• Scalpel handles (No. 3, No. 4)
• Dissecting forceps (long toothed x 2, non-toothed x 2)
• Artery forceps (Kocher x 6, curved x 6)
• Doyen retractor (specific for LSCS - retracts bladder)
• Green-Armytage forceps x 4 (uterine hemostatic forceps)
• De Lee's universal retractor x 2
• Scissors: Mayo + Metzenbaum
• Large needle holders x 2 (for uterine closure)
• Allis x 4
• Wound retractors
• Suction (Yankauer + Poole)
• Bulb syringe (for suctioning baby)
• Large absorbable sutures (Vicryl 1 or PDS 1 for uterus)

Incision & Drainage (I&D) Set

• Scalpel handle + blade (No.11 or 15)
• Sinus forceps/probe
• Artery forceps x 2
• Scissors
• Irrigating syringe
• Packing gauze/ribbon gauze
• Bowl for pus culture swab
• Towel clips x 2
• Wound swab for culture

---

Topic 11: OT Table Types & Patient Positioning

Types of OT Tables

1. Standard/General OT Table - for most procedures; multiple sections, hydraulic/electric
2. Orthopedic Table (Fracture table) - traction attachments, leg holders, image intensifier compatible
3. Gynecological/Urological Table - lithotomy poles and stirrups built in
4. Neurosurgical Table - head clamps (Mayfield), prone positioning attachments
5. Cardiac/Vascular Table - radiolucent top, arm boards
6. Ophthalmology Table - head section adjustment, reclining

Common Positions

• Check with anesthetist before repositioning after induction
• Protect IV lines and ET tube during position changes
• Pad ALL bony prominences
• Arms: padded arm boards, not hyperextended >90°
• Eyes protected (taped closed) in prone/lateral
• Log-roll technique for prone positioning (team of 4+)

---

Topic 12: Types of Anesthesia

---

Topic 13: Preparation of Anesthesia Tray

Anesthesia Machine Check (Before Any Case)

• O2, N2O, Air cylinders: check pressure and flow
• Breathing circuit: leak test (>30 cmH2O, <200 mL/min leak)
• Vaporizer: check level, calibration
• Suction: functioning
• Emergency O2 flush: working
• Scavenging system connected

Anesthesia Tray / Trolley Contents

• Face masks (sizes 0-5)
• Oral airways (Guedel) sizes 1-4
• Laryngoscope with blades (Mac 3, Mac 4; Miller 2)
• Check bulb/LED before use
• Endotracheal tubes (ETTs): sizes 6.0, 6.5, 7.0, 7.5, 8.0 (have range ready)
• ETT stylet/bougie
• Laryngeal Mask Airway (LMA) sizes 3, 4, 5
• Magill forceps
• 10 mL syringe for ETT cuff inflation
• Stethoscope for bilateral auscultation (confirm ETT position)
• Capnograph connected (ETCO2 monitoring - mandatory to confirm ETT placement)
• Tape/tie for securing ETT

• IV cannulas: 18G, 16G, 14G
• IV fluids: Normal saline, Lactated Ringer's/Hartmann's
• IV giving sets
• 3-way stopcocks
• Syringes: 2 mL, 5 mL, 10 mL, 20 mL

• ECG electrodes + leads
• SpO2 probe
• NIBP cuff (correct size)
• Temperature probe
• Capnograph line
• BIS monitor (if available)

• Induction: Propofol (10 mg/mL) or Thiopentone (500 mg powder)
• Opioid: Fentanyl (50 mcg/mL) or Morphine
• Muscle relaxant: Succinylcholine (1 mg/mL for RSI), Rocuronium or Vecuronium (for intubation)
• Reversal: Neostigmine + Glycopyrrolate (for neuromuscular blockade reversal)
• Maintenance: Volatile agent in vaporizer (Sevoflurane/Isoflurane)
• Antiemetics: Ondansetron, Metoclopramide
• Anticholinergic: Atropine (0.6 mg/mL ready)
• Vasopressor: Ephedrine, Phenylephrine (diluted, ready for hypotension)
• Emergency: Adrenaline (epinephrine) 1:10,000 in syringe

---

Topic 14: Complications of Anesthesia

General Anesthesia Complications

• Anaphylaxis/anaphylactoid reaction (to induction agents, antibiotics, muscle relaxants)
• Failed intubation / difficult airway
• Aspiration of gastric contents (Mendelson's syndrome)
• Laryngospasm / bronchospasm
• Hypotension (especially with propofol)
• Dental damage (during laryngoscopy)

• Awareness under anesthesia (rare, <0.1-0.2%)
• Malignant hyperthermia (rare, triggered by succinylcholine + volatile agents - life-threatening)
• Hypoxia / hypercarbia
• Arrhythmias
• Hypothermia

• Respiratory depression / apnea
• Post-operative nausea and vomiting (PONV) - very common
• Emergence delirium (especially children with sevoflurane)
• Sore throat (from ETT/LMA)
• Myalgia (from succinylcholine)
• Prolonged neuromuscular blockade

Regional Anesthesia Complications

• High/total spinal (hypotension, respiratory arrest)
• Post-dural puncture headache (PDPH) - from spinal needle CSF leak
• Urinary retention
• Nerve damage
• Hematoma at injection site
• Infection/epidural abscess
• Shivering (very common with spinal)
• Nausea/vomiting (from hypotension)

---

Topic 15: Steps of Induction of General Anesthesia

1. Pre-oxygenation: 100% O2 via tight-fitting face mask for 3-5 minutes (fills functional residual capacity, gives ~8-10 min apnea tolerance)
2. Pre-medication (if ordered): Fentanyl 1-2 mcg/kg IV, Midazolam 0.02-0.05 mg/kg IV (given 1-2 min before induction)
3. Induction agent: Propofol 1.5-2.5 mg/kg IV slowly (or Thiopentone 3-5 mg/kg) - patient becomes unconscious
4. Confirm unconsciousness: Eyelash reflex lost, jaw relaxed, no response to name
5. Mask ventilation: Maintain airway with jaw thrust; ventilate gently with O2
6. Muscle relaxant:
   • For routine intubation: Rocuronium 0.6 mg/kg or Vecuronium 0.1 mg/kg (wait 60-90 sec)
   • For RSI: Succinylcholine 1.5 mg/kg (+ cricoid pressure applied by nurse/assistant)
7. Laryngoscopy & Intubation:
   • Sniffing position: neck flexed, head extended
   • Insert laryngoscope, visualize vocal cords (Cormack-Lehane grade)
   • Advance ETT through cords, inflate cuff
8. Confirm ETT placement:
   • Visual: see tube pass through cords
   • Auscultation: bilateral equal breath sounds
   • ETCO2: waveform on capnograph (most reliable)
   • Chest rise
9. Secure ETT: Tape/tie, note cm mark at teeth (usually 21-23 cm in adult)
10. Connect ventilator: Set parameters (TV 6-8 mL/kg IBW, RR 10-14, FiO2 0.4-0.5)
11. Commence maintenance: Volatile agent + opioid infusion as planned

---

Topic 16: Spinal Anesthesia (SAB - Subarachnoid Block)

Procedure

• Consent obtained; IV access secured; resuscitation equipment ready
• Baseline BP, HR, SpO2 recorded
• IV fluid preloading: 500-1000 mL crystalloid (Ringer's Lactate) before spinal

• Spinal needles: 25G or 27G Quincke (cutting) or Whitacre/Sprotte (pencil-point - less PDPH)
• Introducer needle (for small gauge needles)
• Syringe 2 mL + 5 mL
• Local anesthetic: Bupivacaine 0.5% heavy (hyperbaric) - most common; Lidocaine 2%
• Antiseptic solution (iodine or chlorhexidine)
• Sterile drape, gloves, gown

• Sitting: Legs hanging, back curved (C-shape), lean forward on pillow - best for obese, easier midline
• Left lateral decubitus: Knees to chest, spine curved

1. Position patient (sitting or lateral), identify L3-L4 or L4-L5 interspace (line between iliac crests = L4)
2. Skin prep with antiseptic x 3 in circular motion; drape
3. Infiltrate skin with 1% lignocaine (local anesthetic)
4. Insert introducer if using fine needle
5. Advance spinal needle perpendicular to skin, midline, slightly cephalad
6. Feel "two pops" (ligamentum flavum, then dura) - or one pop for combined structures
7. Remove stylet - confirm CSF flow (clear, drips freely)
8. Attach syringe, aspirate CSF gently to confirm position, inject drug slowly
9. Aspirate at end to confirm still in intrathecal space
10. Remove needle; apply small dressing

---

Patient Care - Pre, Intra, Post Spinal

• Explain procedure; consent for regional
• IV access x 2; IV fluid preload
• Check coagulation (avoid if anticoagulated)
• NPO for same duration as GA
• Check for contraindications: coagulopathy, infection at site, raised ICP, hypovolemia, patient refusal, some cardiac diseases

• Monitor BP every 2-3 min for first 15-20 min (hypotension most common side effect)
• SpO2, HR continuous monitoring
• Test block level with ice/alcohol swab, pinprick, or ethyl chloride spray before surgery
• If hypotension: IV fluids + Ephedrine 5-10 mg IV or Phenylephrine 50-100 mcg IV
• If bradycardia: Atropine 0.6 mg IV
• High block warning signs: difficulty breathing, hands becoming weak, patient anxious - treat urgently

• Keep supine (1-2 hrs) - do NOT sit upright until block wearing off (fall risk)
• Monitor: BP, HR, SpO2, motor block regression, urinary output
• Post-dural puncture headache (PDPH): worse when sitting/standing, better lying flat
  • Treatment: bed rest, IV fluids, analgesics, caffeine; if persistent >48 hrs → Blood patch
• Urinary retention: may need catheterization (block of S2-S4)
• Reassure patient as sensation and motor power return
• Documentation: level of block achieved, drugs used, complications, timing

---

Topic 17: OT Hazards, Prevention & Management

Physical Hazards

Chemical Hazards

Biological Hazards

Psychological Hazards

• Burnout, stress, compassion fatigue
• Prevention: adequate staffing, rotation, debriefing after traumatic cases, peer support

Fire Triad in OT (must remember):

• Oxidizer (O2, N2O) + Fuel (drapes, alcohol prep, bowel gases) + Ignition (diathermy, laser)
• ALL THREE must be present for fire - remove ANY one element

---

Summary Table: Key Drugs in Anesthesia Tray

---

• Pye's Surgical Handicraft, 22nd Edition - scrub/circulating nurse roles, intraoperative care
• Schwartz's Principles of Surgery, 11th Edition - GA induction, airway management
• Barash, Cullen & Stoelting's Clinical Anesthesia, 9th Edition - spinal anesthesia
• Morgan & Mikhail's Clinical Anesthesiology, 7th Edition - GA induction, regional anesthesia
• Sherris & Ryan's Medical Microbiology, 8th Edition - sterilization methods

---

---

OPERATION THEATRE POSTING REPORT

---

INTRODUCTION

---

Topic 3: Pre, Intra & Immediate Post-Operative Care

Pre-Operative Care Observed

• The ward nurse sent the patient to OT with a completed pre-operative checklist that included: patient identity band, signed informed consent, NPO status (6-8 hours for solids, 2 hours for clear fluids), and all investigation reports (CBC, blood group, coagulation profile, ECG, X-ray).
• On arrival in the OT reception area, the OT nurse re-verified the patient's identity by checking name, age, diagnosis, and the procedure to be performed.
• The patient's IV line patency was checked, pre-operative medications (such as IV antibiotic prophylaxis) were administered as per the surgeon's order, and a urinary catheter was inserted where required.
• The patient was counseled briefly to reduce anxiety. Dentures, jewelry, and nail polish had been removed before transfer.
• The WHO Surgical Safety Checklist was followed: Sign In (before anesthesia induction), Time Out (before surgical incision), and Sign Out (before patient left the OT).

• Patient Name: _________ Age: ________ Sex: ________
• Diagnosis: ____________________
• Planned Surgery: ____________________
• Surgeon: Dr. _____________ Anesthetist: Dr. _____________

---

Intra-Operative Care Observed

• The patient was transferred to the OT table and positioned correctly (as described in Topic 11).
• Monitoring was attached: ECG, SpO2 probe, NIBP cuff, and temperature probe.
• The diathermy grounding pad was applied to the patient's thigh.
• Skin preparation was done with povidone-iodine solution in concentric outward circles, and sterile draping was applied to expose only the operative site.
• I observed the scrub nurse and circulating nurse performing the instrument, swab, and needle count before the incision was made.
• Throughout the surgery I observed the surgeon, assistant, and scrub nurse working together. The circulating nurse was seen connecting suction, operating the diathermy machine, and recording all details.
• A specimen (__________) was collected, labeled, and sent to the laboratory by the circulating nurse.
• Final swab and instrument count was performed and confirmed correct before wound closure.

---

Immediate Post-Operative Care Observed

• After the procedure, the patient was transferred to the Post-Anesthesia Care Unit (PACU)/Recovery Room.
• The anesthesia nurse gave a verbal handover to the recovery nurse: name, procedure, type of anesthesia used, blood loss, IV fluids given, and any intra-operative complications.
• I observed vital signs being monitored every 5-15 minutes: BP, HR, SpO2, RR, and temperature.
• The patient was placed in the recovery position (left lateral) until fully conscious, with oxygen given via face mask.
• The wound dressing and drain output were checked.
• Pain was assessed using the pain scale; analgesics were given as prescribed.
• The patient was discharged to the ward once the Aldrete Score was satisfactory (≥9/10): consciousness, airway, BP, SpO2, and activity all within normal limits.

---

Topic 4: Surgical Procedures Observed

Case 1: ___________________________ (e.g., Laparoscopic Cholecystectomy)

• The patient was positioned supine with slight Trendelenburg and right side elevated.
• Pneumoperitoneum was created with CO2 gas via a Veress needle inserted at the umbilicus.
• Four ports were inserted. The laparoscopic camera was introduced and the gallbladder was visualized.
• The surgeon identified Calot's triangle. The cystic duct and cystic artery were clipped with metal clips using a clip applicator and divided with scissors.
• The gallbladder was dissected from the liver bed using monopolar diathermy and extracted through the umbilical port in a retrieval bag.
• The ports were removed, pneumoperitoneum released, and port sites closed with absorbable sutures.
• I observed the circulating nurse documenting the operative details and the scrub nurse performing the final count.

---

Case 2: ___________________________ (e.g., LSCS - Cesarean Section)

• Spinal anesthesia was administered at the L3-L4 interspace with the patient in the sitting position.
• A wedge was placed under the patient's right hip to provide left lateral tilt, preventing aortocaval compression.
• A Pfannenstiel (transverse) incision was made. Rectus sheath was opened and the uterus was exposed.
• A Doyen retractor was placed to retract the bladder downward.
• A low transverse uterine incision was made, and the baby was delivered. The airway was suctioned with a bulb syringe. Time of delivery was noted.
• The placenta was delivered manually. Green-Armytage forceps were used to control uterine bleeding.
• The uterus was closed in two layers with Vicryl 1 suture. Abdomen was closed in layers. Skin closed with Prolene or staples.
• I noted the scrub nurse passing instruments and sutures in a systematic manner throughout the procedure.

---

Case 3: ___________________________ (Write your 3rd case here)

---

Topic 5a: Opening & Packing Used Sets and Single Packs

What I Observed:

• Before opening any pack, I observed the scrub nurse checking: the name/contents of the pack, the chemical indicator tape (color change confirms sterilization was completed), the expiry/sterilization date, and the integrity of the packaging (no tears, no moisture, no holes).
• The circulating nurse opened outer wraps using a peel-open technique, touching only the outer surface, and presented the inner sterile contents to the scrub nurse without crossing over the sterile field.
• Small single peel-packs (e.g., sutures, drain tubes) were peeled open at the corners and the contents were either dropped onto the sterile trolley or handed to the scrub nurse.
• The rule I observed being followed was: "When in doubt, throw it out."

• After the procedure, instruments were counted and sorted onto a tray.
• Gross contamination (blood, tissue) was wiped off with gauze.
• All sharps (needles, blades) were removed directly into the sharps container - no recapping.
• Instruments were placed in a closed, labeled container and transported to CSSD for decontamination and re-sterilization.

---

Topic 5b & 6: CSSD - Sterilization & Shelf Life of Sterile Sets

What I Observed in CSSD:

• Paper/plastic peel-sealed pack: 6 months to 1 year
• Double-wrapped linen/muslin: 1-2 weeks (if stored dry and undisturbed)
• Flash/unwrapped autoclaved items: Must be used immediately - no storage
• Hard-case rigid container: Up to 6 months (or event-related)

---

Topic 7: Disinfection, Decontamination of Instruments, OT Table & OT Room

What I Observed:

1. Instruments were rinsed with cold water first (hot water coagulates proteins and makes cleaning harder).
2. They were then immersed in enzymatic detergent solution for 10-30 minutes.
3. Staff wore PPE (gloves, apron, eye protection) while scrubbing with a brush.
4. After scrubbing, instruments were rinsed, dried, inspected for damage, packed, and sent for sterilization.

• Gross contamination was removed with disposable paper towels.
• The table was wiped down with hospital-approved disinfectant (1000 ppm sodium hypochlorite or 70% isopropyl alcohol), and contact time was maintained before wiping off.
• After any contaminated/infectious case, a stronger solution (10,000 ppm hypochlorite) was used.
• Mattress covers were inspected for tears (replaced if torn, as torn covers cannot be properly disinfected).

• Between cases: Damp mop with phenolic disinfectant; all surfaces wiped (OT lights, trolleys, equipment).
• End of each day (terminal cleaning): Floor mopped, all surfaces (walls to 2 m height, OT table, equipment, overhead light) thoroughly cleaned with disinfectant.
• Weekly: Ceiling, vents, and light tracks cleaned.
• I observed that the OT maintained positive pressure ventilation (so air flows out, not in) with HEPA-filtered air and a minimum of 20 air changes per hour.

---

Topic 8: Roles of Scrub Nurse, Circulating Nurse & Anesthesia Nurse

What I Observed:

• She performed a surgical hand scrub (2-3 minutes) and wore a sterile gown and gloves using the closed-glove technique.
• She set up the sterile instrument trolley and counted all instruments, swabs, needles, and sutures with the circulating nurse before the operation began.
• Throughout surgery she passed instruments to the surgeon in a firm, deliberate manner, kept the trolley organized, maintained the sterile field, and alerted the team if any breach occurred.
• At the end, she performed the final count and reported to the surgeon: "Count is correct" before wound closure.
• She handled and labeled all surgical specimens.

• She moved freely in the non-sterile area and supported the scrub nurse by opening sterile packs and presenting them to the sterile field.
• She operated the suction machine, diathermy unit, and OT lights.
• She documented: patient details, procedure, time of incision, anesthesia given, swab and instrument counts, specimens dispatched, blood loss, and IV fluids administered.
• She communicated with the blood bank, pathology lab, and X-ray department as needed during surgery.

• She prepared the anesthesia machine and tray before the case (described in Topic 13).
• She assisted the anesthetist with positioning the patient, attaching monitoring, and IV insertion.
• During spinal anesthesia, she held and supported the patient in the sitting position, keeping their back curved.
• She drew up and labeled all drugs in the presence of the anesthetist.
• She monitored and recorded vital signs continuously on the anesthesia chart.
• After surgery, she gave a complete verbal and written handover to the recovery nurse.

---

Topic 9: Types of Sutures, Threads, Needles & Drains I Observed

Sutures Observed in OT:

Staplers Observed:

• Skin stapler - used for rapid skin closure
• Linear cutter (Endo-GIA) - for bowel in laparoscopic procedures
• Ligating clips (Hem-o-lok/metal clips) - for cystic duct and artery in lap cholecystectomy

Drains Observed:

---

Topic 10: Instrument Sets I Observed in OT

LSCS (Cesarean Section) Set - Instruments I Noted:

• Towel clips x 6
• Scalpel handles (No.3 and No.4) with blades (No.22, No.10)
• Toothed and non-toothed dissecting forceps (long)
• Kocher's artery forceps x 6, curved artery forceps x 6
• Doyen's retractor (to retract bladder downward)
• Green-Armytage uterine hemostatic forceps x 4
• De Lee's retractor x 2
• Mayo scissors (straight), Metzenbaum scissors (curved)
• Large needle holders x 2
• Allis tissue forceps x 4
• Poole suction tip + Yankauer suction
• Bulb syringe (for suctioning baby's airway)

Appendectomy Set - Instruments I Noted:

• Scalpel handles + blades
• Artery forceps (Mosquito, Halsted, Kocher) x 6-8
• Babcock forceps x 2 (to hold appendix without crushing)
• Allis forceps x 2
• Dissecting forceps (toothed + non-toothed)
• Metzenbaum scissors, Mayo scissors
• Langenbeck retractors x 2
• Needle holders x 2
• Suction tip
• Swabs and abdominal packs

Laparotomy Set (additional items beyond appendectomy set):

• Balfour or O'Sullivan-O'Connor self-retaining retractor
• Deaver retractors (deep)
• Intestinal clamps (Allen/Lane)
• Long artery forceps
• Poole suction tip (wide bore, for abdomen)
• Large abdominal packs x 10-12

---

Topic 11: OT Table Types & Patient Positioning I Observed

OT Table Used:

• General/Standard hydraulic OT table (electric and manual adjustment of head, back, leg, and height sections)

Positions I Observed:

• Patient lying flat on back
• Arms on padded arm boards at <90°
• Heels, sacrum, and occiput padded
• For LSCS: wedge placed under right hip (15° left tilt to prevent aortocaval compression)

• Legs placed in stirrups, hips and knees flexed
• I observed padding placed under the popliteal fossa to protect the common peroneal nerve
• Sacrum padded

• Table tilted head-down
• Shoulder braces placed to prevent patient sliding

• Team of at least 3-4 for transfer to OT table
• Anesthetist protected the ETT during any repositioning
• All bony prominences were padded before draping
• Eyes were taped closed in lateral or prone positions

---

Topic 12: Types of Anesthesia I Observed

---

Topic 13: Preparation of Anesthesia Tray - What I Observed

• O2 cylinder pressure checked (should be >1000 psi full)
• Breathing circuit leak test performed
• Suction tested and functional
• Vaporizer level (sevoflurane) checked and filled
• Emergency oxygen flush button tested

• Face masks (multiple sizes)
• Oral airways (Guedel sizes 2, 3, 4)
• Laryngoscope with Mac-3 blade (bulb checked)
• ETTs: sizes 7.0, 7.5, 8.0 (for adult female/male) - cuff checked
• Stylet/bougie
• LMA (size 3, 4) as backup
• Magill forceps
• 10 mL syringe for cuff inflation
• Tape for securing ETT
• IV cannulas (16G, 18G), syringes, IV fluids

---

Topic 14: Complications of Anesthesia - What I Observed/Learned

• I observed Post-Operative Nausea and Vomiting (PONV) in a patient after GA - treated with IV ondansetron 4 mg.
• One post-spinal patient complained of headache when sitting up - suspected post-dural puncture headache (PDPH). Patient was advised bed rest and oral hydration.

• Sudden drop in SpO2 or ETCO2
• Severe hypotension or bradycardia after spinal
• Patient becoming restless or agitated (may indicate awareness)
• Rapidly rising temperature + muscle rigidity (Malignant Hyperthermia - emergency)

---

Topic 15: Steps of Induction of General Anesthesia - What I Observed

1. Pre-oxygenation: Patient breathed 100% O2 via face mask for 3-5 minutes. I understood this fills the lungs with oxygen to provide a safety margin during apnea.
2. Pre-medication: Fentanyl 100 mcg IV + Midazolam 2 mg IV given slowly. Patient became calm and drowsy.
3. Induction: Propofol 150 mg IV was given slowly. The patient lost consciousness within 30-40 seconds (eyelash reflex checked by anesthesia nurse - no response).
4. Mask ventilation: The anesthetist maintained the airway with jaw thrust and mask; the patient was gently ventilated with O2.
5. Muscle relaxant: Rocuronium 50 mg IV was given. I was told to wait 60-90 seconds for full relaxation.
6. Laryngoscopy: The anesthetist inserted a Mac-3 laryngoscope, visualized the vocal cords, and passed a 7.5 mm ETT through the cords.
7. Confirmation: Anesthesia nurse auscultated both sides of the chest - bilateral equal breath sounds. ETCO2 waveform appeared on the capnograph. The tube was secured at 21 cm at the teeth.
8. Maintenance: Sevoflurane (2%) via breathing circuit commenced. Vitals stabilized and surgery proceeded.
9. At end of surgery: Sevoflurane stopped, patient breathed down, neostigmine + glycopyrrolate given for reversal, extubation done when patient was awake and following commands.

---

Topic 16: Spinal Anesthesia - What I Observed

• IV access secured (16G, right hand)
• IV fluid (Ringer's Lactate 500 mL) started as preload before spinal
• Baseline BP, HR, SpO2 recorded
• Resuscitation drugs (ephedrine, atropine, adrenaline) drawn up and kept ready by anesthesia nurse

• Patient was positioned sitting on the edge of the table, legs hanging down, spine curved in a C-shape, leaning forward onto a pillow held in her arms. The anesthesia nurse stood in front, supporting and calming the patient.
• Anesthetist identified the L3-L4 interspace (using the iliac crest line as landmark for L4).
• Skin was cleaned with betadine in circles. Sterile drape applied.
• Skin infiltrated with 1% lignocaine.
• A 25G Quincke spinal needle was inserted in the midline.
• Clear CSF was seen dripping from the hub - confirming subarachnoid placement.
• Bupivacaine 0.5% heavy (2.5 mL = 12.5 mg) was injected slowly after aspiration confirmed CSF.
• Patient was immediately laid supine with left lateral tilt.
• Block level was tested with ice at 5-minute intervals - level confirmed at T4-T6 before incision.

• BP checked every 2-3 minutes for the first 20 minutes
• Patient experienced mild hypotension (BP 90/60) - treated with IV fluids and Ephedrine 10 mg IV
• Patient also experienced shivering - warm blankets applied; I was told shivering is common with spinal

• Patient kept flat (no pillow) for 2 hours
• Bladder monitored via urinary catheter
• Anesthesia nurse advised patient she would feel heaviness/tingling in legs as the block wore off - this is normal
• Patient was reassured when leg sensation and movement slowly returned over 2-3 hours

---

Topic 17: OT Hazards I Observed and Learned About

What I Observed in OT Regarding Safety:

• The diathermy grounding pad was always applied to the patient's thigh (large muscle, away from ECG electrodes, metal implants, bony prominence) before activating the unit.
• No fluids were allowed to pool under the patient near the diathermy pad.

• I observed that alcohol-based skin prep was allowed to dry completely before draping and before diathermy activation - to prevent fire.
• I was taught the fire triad in OT: Oxidizer (O2, N2O) + Fuel (drapes, alcohol prep) + Ignition source (diathermy, laser). Removing any one element prevents fire.

• I observed the "neutral zone" technique (also called hands-free technique): the scrub nurse placed sharps in a kidney tray/marked zone, and the surgeon picked them up, rather than hand-to-hand passing - to prevent needlestick injuries.
• All needles went directly into the sharps bin. No recapping was done.

• When the C-arm (image intensifier) was used, all non-essential staff stepped back behind a lead screen. Staff remaining wore lead aprons and thyroid shields.

• Standard precautions were followed for all patients.
• Surgical hand scrub was performed correctly (2-3 minutes minimum).
• Double gloving was used for suspected high-risk cases.

• The scavenging system was connected to remove waste anesthetic gas from the OT. I was told chronic exposure to trace anesthetic gases can cause liver damage, kidney toxicity, and reproductive harm - hence the scavenging system is mandatory.

• Glutaraldehyde (used for endoscopes) was handled with gloves and in a ventilated area.

---

CONCLUSION

---

---

How to use this report:

• Fill in the blank spaces (_______) with your actual patient names, ages, diagnoses, surgeon names, and dates.
• In Topic 4, describe the actual 2-3 surgeries you watched (the format is already there - just fill in the details).
• Change "I observed" to "I assisted" wherever you actually participated (e.g., held a retractor, helped position the patient, drew up a drug).
• Add your college/hospital name at the top.
• If you need this as a Word document (.docx) to print and submit, just say so!