SELF/Perioperative Nursing/Setting up the Sterile Field

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This module trains healthcare workers, particularly scrub and circulating nurses, on how to correctly open surgical instrument sets, lay out sterile instruments in proper sequence, and maintain a sterile field throughout the setup phase. It emphasizes aseptic technique, role clarity between the scrub and circulating nurse, and efficient, deliberate movements to prevent contamination.

The target learner has a total of 5 years of work experience (3 in General Nurse training and 2 post qualification) with limited to no exposure to the perioperative environment.

They are already capable / confident at the basics of aseptic technique, can safely handle sterile packs and supplies without contamination, and maintain controlled movement, spatial awareness, effective communication and organizational skills within a clinical environment.

A perioperative trainee practicing in a resource-limited setting, characterized by a critically constrained infrastructure. This learner must navigate systemic challenges including chronic instrument and supply shortages, severe understaffing, and a high-volume workload within an overcrowded and inadequately equipped clinical space.

• Describe the essential sterile supplies and their functions in setting up a sterile field.
• Explain how sterile items should be arranged and sequenced on the sterile tables to support surgical workflow.
• Identify the procedures for verifying sterility of packs and supplies before use.
• Explain the correct methods for opening sterile packs and adding items into the sterile field.
• Describe the steps for establishing and maintaining sterility of the surgical field.
• Explain how instruments, sharps, and sponges are organized and accounted for within the sterile field to ensure safety.

Establishing a sterile field begins with assembling the correct sterile supplies and organizing them according to their intended function. Proper preparation supports an efficient surgical workflow, minimizes unnecessary movement during the procedure, reduces handling of sterile items, and helps maintain aseptic technique. Every item placed on the sterile field should have a defined purpose and location so that instruments and supplies can be located quickly without compromising sterility. Before opening any sterile item, the operating room should be prepared. Surfaces should be clean and dry, unnecessary traffic minimized, and distractions such as phones, radios, and non-essential conversation eliminated. Air movement should be reduced as much as possible to decrease airborne contamination. The World Health Organization (WHO) Surgical Safety Checklist should be used before establishing the sterile field to confirm that equipment, supplies, and emergency items are available and functioning correctly.

The supplies required for sterile field setup can be grouped according to their function.

Sterile table drapes, patient drapes, and sterile towels are used to establish and maintain sterile surfaces while isolating the operative site from contamination. Drapes define the boundaries of the sterile field and should be selected according to the size and type of surgical procedure. They should provide adequate exposure of the operative site while covering surrounding non-sterile areas. Proper draping reduces microbial migration from adjacent skin and the surrounding environment. Sterile towels help frame the operative site, secure drapes, absorb small amounts of fluid, and establish clearly defined sterile working areas. Preparing drapes and towels before beginning the setup allows the sterile field to be established efficiently without unnecessary repositioning once surgery begins.

Instrument trays and sterile basins organize surgical instruments and contain irrigation or antiseptic solutions. Instruments should be arranged according to both their function and the order in which they are expected to be used. Common groupings include:

• Cutting instruments
• Grasping instruments
• Clamping instruments
• Retractors
• Suturing instruments

Heavy trays and basins should be positioned on stable portions of the back table to reduce pressure on sterile drapes and minimize movement during surgery. Basins containing irrigation or antiseptic solutions should be placed securely to prevent tipping, splashing, or strike-through contamination.

Sterile packs commonly contain:

• Sterile gowns
• Sterile gloves
• Sutures

Additional patient care supplies include:

• Surgical sponges
• Sterile suction tubing

Sterile gowns and gloves provide a protective barrier between the surgical team and the patient. Gloves should be available in appropriate sizes to reduce tearing and maintain dexterity.

Surgical sponges absorb blood and fluids, protect tissues, improve visualization, and assist with gentle tissue handling. Because retained sponges are a serious patient safety hazard, they should remain grouped in standardized counts throughout the procedure.

Sterile suction tubing connects the sterile field to the suction system and removes blood, irrigation fluid, smoke, and secretions. Tubing should be arranged to avoid tangling, pulling, or contamination.

Medication management supplies include:

• Sterile medication vials or ampoules
• Sterile markers
• Adhesive labels

All medications and solutions introduced onto the sterile field must be identified immediately after preparation. Labels should clearly indicate the medication or solution name and, where required, the concentration or preparation time according to institutional policy.

The circulating nurse and scrub nurse should verbally confirm every medication and solution before it is placed onto the sterile field.

Safety equipment includes:

• Sharps containers
• Back table
• Mayo stand

Sharps such as scalpels, hypodermic needles, and suture needles should be isolated in a designated sharps zone to reduce needle-stick injuries and support accurate counting.

The back table serves as the primary sterile workspace where instruments and supplies are organized systematically.

The Mayo stand is positioned closest to the operative field and contains only those instruments expected to be used during the earliest stages of the procedure. Instrument, sponge, and sharps counts begin during setup and continue throughout the procedure according to institutional policy.

Emergency preparedness is part of sterile field setup.

Before surgery begins, verify that the following are available and functioning:

• Suction unit
• Oxygen source
• Resuscitation equipment

Electrical cords, suction tubing, and monitoring cables should be positioned safely to prevent tripping hazards, accidental disconnection, and contamination of the sterile field.

Correct arrangement of sterile supplies supports both patient safety and efficient surgical workflow.

After the back table and Mayo stand have been draped, supplies should be organized immediately according to:

• Function
• Frequency of use
• Sequence of the procedure

Random placement increases retrieval time, unnecessary handling, contamination risk, and sharps injuries.

The back table serves as the primary sterile work area. Arrange items as follows:

Lower section

• Heavy instrument trays
• Metal basins

These heavier items improve table stability and reduce the risk of tearing sterile drapes.

Upper section Arrange lighter items including:

• Sponges
• Sutures
• Syringes
• Sterile towels
• Sterile markers

These items remain visible and readily accessible throughout the procedure.

Establish one clearly defined sharps zone containing:

• Scalpels
• Suture needles
• Hypodermic needles
• Other sharp instruments

Keeping all sharps together improves counting accuracy and reduces accidental injury.

Some operating rooms also establish a neutral zone or hands-free passing area for safe transfer of sharp instruments.

The Mayo stand should contain only the instruments needed immediately after surgery begins, such as:

• Scalpel
• Scissors
• Hemostats
• Forceps
• One needle holder loaded with the appropriate suture

Avoid overcrowding the Mayo stand because it increases contamination risk and delays instrument retrieval.

The operating room environment directly influences sterile field integrity.

Before establishing the sterile field:

• Clean all working surfaces.
• Minimize unnecessary personnel movement.
• Limit door opening.
• Reduce talking around the sterile field.
• Remove or silence personal electronic devices.
• Position tubing and cables safely.
• Verify emergency equipment.

Every movement during setup should be deliberate and efficient. Once organized, unnecessary handling or rearrangement of supplies should be avoided.

Self-Assessment

Please complete the following: OR Supplies Basics Quiz

Sterile packs contain the instruments, supplies, and equipment required to establish and maintain a sterile field. Every sterile pack must be handled using strict aseptic technique to prevent contamination before surgery begins. Sterility should never be assumed simply because a package is labeled "sterile." Every item must be inspected, opened, transferred, and received correctly before it becomes part of the sterile field.

The circulating nurse and scrub nurse work together throughout this process. The circulating nurse, who remains non-sterile, verifies and opens the outer packaging, while the scrub nurse receives and arranges the sterile contents without contaminating them. Clear communication and deliberate movements are essential to maintain sterility.

Every sterile package must be inspected before it is opened.

Check the following:

• Package is clean and dry.
• Wrapper is intact with no tears, punctures, or broken seals.
• Sterilization indicator has changed appropriately.
• Expiration date has not passed.
• Package shows no evidence of moisture, stains, or tampering.

Moisture is particularly important because microorganisms can pass through wet packaging, a process known as strike-through contamination. Any pack that is wet, torn, damaged, expired, or has a failed sterilization indicator must be considered contaminated and removed from use immediately.

Reusable instrument trays should also be inspected for completeness, cleanliness, and correct assembly before they are opened.

Verification of sterility is a shared responsibility between the scrub nurse and the circulating nurse. Identifying compromised supplies before they enter the sterile field helps prevent surgical site infections.

Sterile packs should be opened on a clean, dry surface using a deliberate sequence that prevents contamination.

The circulating nurse opens the outer wrapper using the following order:

1. Open the flap farthest away first.
2. Open the side flaps.
3. Open the flap closest to the body last.

This sequence prevents the circulator from reaching over the sterile contents.

Only the outer edges of the wrapper may be touched because the outer 1-inch (2.54 cm) border is considered contaminated.

When opening peel packs, separate the wrapper slowly and evenly. Avoid sudden movements that may cause the sterile contents to fall, bounce, or become contaminated. Large instrument trays should be opened carefully so that the scrub nurse can receive the sterile contents without contaminating gloves, sleeves, or the sterile field.

Throughout the process:

• Keep movements slow and controlled.
• Avoid excessive talking over the sterile field.
• Do not reach across sterile items.
• Minimize unnecessary handling of sterile supplies.

Once opened, sterile items should be transferred safely from the circulating nurse to the scrub nurse.

Small sterile items may be dropped gently into the designated landing area without bouncing or splashing.

Large sterile items should be presented so the scrub nurse can lift or receive them without touching non-sterile surfaces.

The landing area serves as a controlled receiving zone between the non-sterile circulating nurse and the sterile scrub nurse. Items should first be received in this area before being arranged into their final positions on the sterile field. This reduces unnecessary reaching and minimizes contamination risk.

The circulating nurse must never reach over the sterile field while presenting sterile items.

Sterile medications and irrigation solutions require careful handling.

Before pouring:

• Read the medication name aloud.
• Confirm the medication and concentration with the scrub nurse.
• Remove the bottle cap without touching its sterile inner surface.

During pouring:

• Hold the sterile receiving basin near the edge of the sterile field or allow the scrub nurse to hold it.
• Pour slowly to avoid splashing.
• Do not allow the bottle lip to touch the sterile basin because it is considered contaminated once pouring begins.

Immediately after pouring, the scrub nurse should label every medication and solution before another medication is prepared.

Unused solutions should not be returned to the sterile field unless permitted by institutional policy.

Despite careful technique, contamination may occur.

Examples include:

• Torn or wet packages.
• Failed sterilization indicators.
• A sterile item touching a non-sterile surface.
• A package becoming wet.
• A glove tearing while handling sterile items.
• Sterile items falling below waist level.
• Sterile items dropped onto the floor.

Whenever contamination is suspected:

• Stop immediately.
• Remove the contaminated item from the sterile field.
• Replace it with a sterile item before continuing.
• Report and document contamination according to institutional policy.

Never attempt to "salvage" a contaminated sterile item. Prompt recognition and correction of contamination prevents downstream patient harm and helps maintain the integrity of the sterile field.

Safe sterile pack handling depends on teamwork.

The circulating nurse should:

• Verify package integrity.
• Open the outer wrapper using the correct sequence.
• Present sterile items without reaching over the sterile field.
• Read medication labels aloud before pouring.
• Assist with sterile counts.

The scrub nurse should:

• Receive only the sterile contents.
• Arrange items after they enter the landing area.
• Label medications immediately.
• Maintain sterility throughout setup.
• Communicate immediately if contamination is suspected.

Both nurses should use clear communication and pause whenever sterility is uncertain.

Self-Assessment

Please complete the following: OR Sterile Pack Quiz

Once sterile supplies have been verified, opened, and transferred correctly, the sterile field can be established. A sterile field is a designated area that contains only sterile items and is maintained free from contamination throughout the preparation phase and the surgical procedure. Establishing and maintaining a sterile field requires careful preparation, deliberate movements, continuous observation, and immediate correction of any break in sterility.

The sterile field is established after the scrub nurse has completed surgical hand antisepsis and donned a sterile gown and gloves. Sterile drapes are then applied to the back table, Mayo stand, and patient as required for the procedure.

The sterile field begins as soon as the sterile drapes are in place and remains sterile only if its integrity is maintained continuously. Every item introduced into the field must be sterile, and every action performed around the field should protect it from contamination.

Before opening instruments onto the sterile field, inspect the draped surfaces to confirm that they are:

• Clean
• Dry
• Intact
• Large enough for the planned setup

Do not begin arranging instruments if the drape is torn, wet, contaminated, or too small for the intended sterile workspace. Any compromised drape must be replaced before proceeding.

Maintaining sterility depends on strict adherence to aseptic principles throughout setup.

The following principles should always be observed:

• The outer 1-inch (2.54 cm) border of sterile drapes and wrappers is considered contaminated.
• Sterile personnel should keep their hands above waist level and within sight at all times.
• Sterile personnel should not turn their back on another sterile field when passing.
• Non-sterile personnel must never reach or lean over the sterile field.
• Sterile items should not be held below waist level.
• Only sterile items may enter the sterile field.
• Once a sterile package is opened, unnecessary handling or repositioning of its contents should be avoided.
• A sterile field should remain under continuous observation and should never be left unattended.

Moisture also threatens sterility. Wet drapes, wrappers, or gowns permit microorganisms to pass through the barrier, a process known as strike-through contamination. Any wet or compromised area must be considered contaminated and replaced immediately.

Once sterile items have been transferred through the landing area, the scrub nurse should arrange them systematically to support efficient workflow.

General principles include:

• Arrange instruments according to sequence of use.
• Group similar instruments together.
• Place frequently used instruments closest to the scrub nurse.
• Keep unused instruments in clearly defined areas.
• Separate abdominal and perineal instrument sets when both are required.
• Minimize unnecessary movement and repeated rearrangement.

The back table serves as the primary storage and preparation area, while the Mayo stand contains only the instruments required during the initial stages of surgery.

A well-organized sterile field allows instruments to be identified quickly, reduces unnecessary handling, and helps prevent contamination.

A designated sharps zone should be established during sterile field setup.

This area should contain:

• Scalpels
• Suture needles
• Hypodermic needles
• Other sharp instruments

Keeping sharps together reduces needle-stick injuries and supports accurate counting.

Before surgery begins:

• Sponges should be separated into standardized groups for counting.
• Needles should be placed into an approved needle counter or magnetic pad.
• Instruments should be organized by category.

The scrub nurse and circulating nurse should perform the initial count together, confirming instrument, sponge, and sharps counts aloud. Both should verify that counts agree before the procedure begins.

Additional counts should be performed whenever items are added and at the completion of the procedure according to institutional policy.

Maintaining a sterile field is an active process that continues until the surgical procedure begins.

Throughout setup, the scrub nurse should monitor for:

• Torn or wet drapes
• Contaminated instruments
• Items that fall below waist level
• Excessive movement around the sterile field
• Unnecessary traffic through the operating room
• Air currents created by repeated door opening
• Equipment or tubing crossing the sterile field
• Any actual or suspected contamination

Prompt recognition of contamination allows immediate correction before patient safety is compromised.

If sterility is compromised at any time, immediate action is required.

Examples include:

• A sterile glove touches a non-sterile surface.
• A drape slips below waist level.
• A sterile item falls from the field.
• A non-sterile person reaches across the sterile field.
• A sterile package or drape becomes wet.
• An instrument contacts an unsterile surface.

When contamination occurs:

1. Stop the activity.
2. Identify the contaminated item or area.
3. Remove or replace the contaminated item immediately.
4. Inform the surgical team if necessary.
5. Document the event according to institutional policy.
6. Never ignore suspected contamination or attempt to continue using a compromised sterile item.

Maintaining sterility protects the patient from surgical site infection and preserves the safety of the entire surgical team.

Self-Assessment

Please complete the following: OR Sterile Field Quiz

A well-prepared sterile field depends not only on maintaining sterility but also on understanding the purpose, organization, and proper handling of surgical instruments and supplies. The scrub nurse should recognize the basic instruments used in common surgical procedures, understand their functions, verify that they are clean and functioning correctly, and arrange them to support an efficient surgical workflow.

Although individual procedures may require specialized instruments, the principles of instrument preparation and organization remain the same.

Most general surgical procedures use instruments from five main categories.

Cutting instruments are used to divide skin, tissue, or sutures.

Examples include:

• Scalpels
• Mayo scissors
• Metzenbaum scissors

These instruments are usually among the first used during surgery and should be readily accessible on the Mayo stand.

These instruments are used to hold tissue, dressings, or other materials during surgery.

Examples include:

• Tissue forceps
• Dressing forceps
• Allis forceps
• Babcock forceps

Different forceps are designed for delicate or firm tissue handling. Selecting the correct instrument helps reduce tissue trauma.

Clamps temporarily occlude blood vessels or grasp tissue during dissection.

Examples include:

• Mosquito forceps
• Kelly forceps
• Artery forceps
• Kocher forceps

These instruments are essential for achieving haemostasis during surgery.

Retractors improve exposure of the operative field by holding tissue away from the surgical site.

Examples include:

• Langenbeck retractors
• Richardson retractors
• Army-Navy retractors

Good exposure improves visibility and facilitates safe surgery.

These instruments are used during wound closure.

Examples include:

• Needle holders
• Sutures

Needle holders are designed to securely grasp surgical needles during suturing while minimizing damage to the needle.

Several sterile supplies are used alongside surgical instruments.

These include:

• Surgical sponges for absorption and tissue protection.
• Sterile basins for irrigation solutions.
• Suction tubing for removal of blood and fluids.
• Sterile markers and labels for medication identification.
• Towels and drapes for maintaining sterile boundaries.

Every supply should have a designated location on the sterile field to minimize unnecessary movement and handling.

Every instrument should be inspected before it is placed on the sterile field.

Check for:

• Cleanliness
• Corrosion
• Cracks or damage
• Proper alignment
• Smooth movement of joints
• Secure locking mechanisms
• Sharp cutting edges where appropriate

Reject any instrument that is damaged, dirty, or does not function properly. A malfunctioning instrument can delay surgery, compromise patient safety, or contaminate the sterile field.

If an instrument is removed from service, obtain a sterile replacement and update the instrument count according to institutional policy.

Arrange instruments in a logical sequence that follows the anticipated progression of surgery.

A common sequence is:

• Cutting instruments
• Clamping instruments
• Tissue-handling instruments
• Retractors
• Suturing instruments

Frequently used instruments should be positioned closest to the scrub nurse or placed on the Mayo stand. Reserve instruments should remain grouped by category on the back table for easy retrieval.

This systematic arrangement reduces unnecessary searching, improves efficiency, and supports smooth communication between the scrub nurse and surgeon.

Safe handling protects both instruments and personnel.

During setup:

• Lay instruments side-by-side rather than piling them.
• Protect delicate tips from damage.
• Prevent unnecessary metal-to-metal contact.
• Keep ring-handled instruments aligned in the same direction.
• Close box locks to the first ratchet to prevent tangling.
• Support heavy instruments securely.
• Keep sharp instruments separate from other instruments.
• Remove damaged instruments from service immediately.

Scalpel blades should never be stored loose in a metal basin because this can damage the blade and create unnecessary hazards.

Instrument accountability begins before surgery starts.

The scrub nurse and circulating nurse should perform counts together for:

• Instruments
• Sponges
• Sharps

Counts should be:

• Performed aloud.
• Verified by both team members.
• Documented according to institutional policy.

Additional counts should be completed whenever instruments or sharps are added and again before wound closure and at the completion of the procedure.

Accurate counting reduces the risk of retained surgical items and improves patient safety.

Before the surgical team arrives, confirm that: R

• equired instruments are available.
• Instruments are functioning correctly.
• Supplies are organized.
• Counts have been completed.
• Medications are labeled.
• Emergency equipment is available.
• The sterile field is complete and ready for surgery.

Careful preparation allows the procedure to begin efficiently and safely.

Self-Assessment

Please complete the following: Instrument and Supply Fundamentals Quiz

Healthcare workers frequently establish sterile fields in environments where supplies, equipment, and staffing are limited. These challenges may require careful adaptation, but they do not change the principles of aseptic technique. Regardless of available resources, the goal remains the same: establish and maintain a sterile field while protecting the patient from contamination and surgical site infection.

When supplies are limited, priority should always be given to items that are essential for maintaining sterility and patient safety.

These include:

• Sterile drapes
• Sterile gowns and gloves
• Essential surgical instruments
• Sterile suction tubing
• Sterile basins
• Sharps management equipment

Less critical items may be substituted only if the alternative maintains sterility and complies with institutional policy.

Never use:

• Torn or damaged sterile packs
• Wet sterile supplies
• Expired sterile items
• Supplies with failed sterilization indicators

Maintaining sterility is always more important than avoiding delays.

Resource limitations sometimes require practical adaptations.

Examples include:

• Using sterile towels to extend or reinforce a sterile working area.
• Carefully organizing limited instruments to minimize unnecessary handling.
• Conserving sterile supplies by opening only those required for the procedure.
• Any adaptation should continue to protect the sterile field.

Unsafe practices should never be accepted simply because resources are limited. Examples include:

• Reusing single-use items without approved reprocessing.
• Using damaged sterile packaging.
• Continuing with known contamination.
• Omitting required surgical counts.

When supplies or equipment are limited, communication becomes even more important.

Before establishing the sterile field, the surgical team should discuss:

• Available instruments
• Missing equipment
• Alternative supplies
• Emergency backup plans
• Any expected workflow changes

Early communication allows safe planning and reduces interruptions after the sterile field has been established. A simplified WHO Surgical Safety Checklist should still be completed before surgery begins.

Limited resources often require the scrub nurse to work with fewer instruments and less workspace.

To improve efficiency:

• Arrange instruments in sequence of use.
• Keep frequently used instruments within easy reach.
• Minimize repeated handling.
• Return instruments to consistent locations after use.
• Maintain a clearly defined sharps zone.

Good organization reduces unnecessary movement and helps preserve sterility.

Many healthcare facilities, particularly in low-resource settings, rely on reusable surgical drapes, gowns, and instruments as safe alternatives to single-use products. When properly cleaned, inspected, sterilized, and handled, reusable drapes provide effective sterile barriers while reducing costs and improving the availability of essential supplies.

Before use, reusable drapes should be inspected carefully for:

• Tears, holes, or worn areas.
• Moisture or dampness.
• Broken seams or damaged reinforcement.
• Stains or visible soil.
• Damage that could compromise the sterile barrier.

Any reusable drape that is damaged, wet, or shows signs of excessive wear should be removed from service because it can no longer provide reliable protection against contamination.

Reusable drapes should be selected according to the size and type of procedure. Whenever possible, choose a drape large enough to create an adequate sterile working area without excessive manipulation during setup. If additional sterile coverage is required, sterile towels or additional sterile drapes may be used to safely extend the sterile field according to institutional policy.

Efficient use of reusable drapes helps preserve limited resources. Handle drapes carefully during unfolding and placement to avoid unnecessary damage or contamination. Once a reusable drape has been positioned correctly, avoid repeated lifting, repositioning, or excessive handling, as this increases the risk of contamination and may weaken the sterile barrier.

After the procedure, reusable drapes should be handled according to institutional infection prevention and control procedures. They should be transported safely for cleaning, inspection, packaging, and sterilization before being returned to service. Reusable drapes should never be reused unless they have completed the full approved reprocessing cycle.

Proper care and efficient use of reusable drapes help healthcare facilities maintain safe surgical services while maximizing the lifespan of valuable resources without compromising patient safety.

Environmental control remains important regardless of available resources.

Reduce contamination by:

• Limiting unnecessary movement.
• Minimizing door opening.
• Reducing unnecessary conversation around the sterile field.
• Preventing unnecessary air disturbance.

Keeping the sterile field under continuous observation. These simple practices require no additional equipment but significantly reduce contamination risk.

Patient safety depends on maintaining accountability even when resources are limited.

Continue to:

• Perform instrument, sponge, and sharps counts.
• Document contamination events.
• Report equipment failures.
• Replace compromised sterile items whenever possible.

Safe practice should never be abandoned because resources are limited.

Self-Assessment

Please complete the following: Low-Resource EnvironmentsQuiz

Self-Assessment

Please complete the following: Cumulative Assessment