Operating Room Nurses

The perioperative nurse is responsible and accountable for the major nursing activities occurring in the surgical suite. These include, but are not limited to the following:

• Assessing of the patient's physiological and psychological status before, during, and after surgery

• Identifying priorities and implementing care based on sound nursing judgment and individual patient needs

• Functioning as a role model of a professional perioperative nurse for students and colleagues

• Functioning as a patient advocate by protecting the patient from incompetent, unethical, or illegal practices during the perioperative period

• Coordinating all activities associated with the implementation of nursing care by other members of the health-care team

• Demonstrating a thorough knowledge of aseptic principles and techniques to maintain a safe and therapeutic surgical environment

• Directing or assisiting with the care and handling of all supplies, equipment, and instruments, to ensure their economic and efficient function for the patient and personnel under both normal and hazardous conditions

• Performing as a scrub or circulating nurse as needed, based on knowledge and expertise for a specific procedure

• Participating in continuing education programs directed toward personal and professional growth and development

• Participating in professional organizational and research activities that support and enhance perioperative nursing practice

Perioperative nursing practice has one continuous goal: to provide a standard of excellence in the care of the patient before, during, and after surgery. As the only nonscrubbed member of the surgical team, besides anesthesia, the circulating nurse represents the coordinating link between the scrub team and all other departments and personnel associated with the surgical patient and the procedure. Other departments that may be involved in the patient's surgical experience include, but are not limited to, x-ray, pathology, blood bank, laboratory, blood gas lab, tissue banking, mammography, and radiation oncology.

The Circulating nurse, by virtue of her professional educational preparation and specialized skill, is responsible for managing patient care activities in the operating suite, so his/her duties begin long before the patient arrives in the operating room and continues until the final dispensation of the patient, operating room records, and specimens is completed.

The following list depicts some of the activities performed by the circulating nurse prior to induction of anesthesia, during the procedure, and upon conclusion of the procedure:

• Assisting and preparing the procedure room

• Supervising the transporting, moving, and lifting of the patient

• Assisting anesthesia as requested during induction and reversal of anesthesia

• Positioning the patient for surgery

• Performing the surgical skin prep

• Conducting and maintaining accurate records of counts

• Maintaining accurate documentation of nursing activities during the procedure

• Dispensing supplies and medications to the surgical field

• Maintaining an aseptic and safe environment

• Estimating fluid and blood loss

• Handling special equipment, specimens, etc

• Communicating special postoperative needs to appropriate persons at the conclusion of the case

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The perioperative nurse as a scrub nurse performs another essential role in the operating room. Her expertise includes knowledge of anatomy and physiology and the procedure to be performed, ability to recognize the instrumentation used in a particular surgery, and critical thinking skills to gather specialty items that may be needed during a procedure and in event of an emergency.

The scrub nurse is a member of the sterile surgical team. His/her primary responsibility is maintenance of the sterile field. Other activities of the scrub nurse includes:

• Assisting and preparing the procedure room

• Gathering sterile supplies needed for the procedure and those that may be needed

• Setting up the sterile back table

• Dressing the surgeon and other members of the surgical team in their sterile attire

• Assisting in the placement of the sterile drapes

• Passing the instruments to the surgical team and assisting as needed to enhance the continuity of the procedure

• Constant surveillance of the surgical field thus maintaining sterility

• Anticipating the needs of the surgeon and asking for items before they are needed

• Reporting to the circulating nurse the names of the specimens obtained during surgery

• Helps with the application of the sterile dressing at the end of the procedure

• Removal of bioburden from used instrumentation before sending it to be processed in Central processing.

• Assist in the cleaning of the procedure room to make ready for the next surgical procedure.

I passed the CNOR exam on September 8, 2009. I felt great accomplishment. I was so nervous when I went to take the exam. I've been out of school for 15 years and it's been over 14 years since I took my state board exam. I had studied well for this exam and I have a total of 27 years of OR experience between being a surgical tech and a RN. Just the thought of a "test" made my palms sweaty.

The CNOR is a national certification exam for operating room nurses. The exam covers sterilization techniques, maintaining a sterile field, critical thinking skills in the operating room, dosage calculations, emergency situations like malignant hyperthermia and cardiac arrest, and more. The exam consists of 200 questions and 4 hours are allowed to complete the exam.

I finished the exam in 2 hours and 45 minutes. I sat in front of the computer staring at the screen and afraid to click the "submit" button for about another 15 minutes. I finally mustered the courage to click the button. I filled out the survey questions and when that was done a screen appeared that said "Congratulations! Our calculations indicate you have passed the CNOR certification exam". It was unofficial, but I had passed. What a relief!

National certification examinations are an important part of a nurse's career. It increases the continuing education requirements beyond the state license requirements. To maintain the CNOR certification the nurse must obtain 150 continuing education units specific to the OR every 5 years. State continuing education requirements differ, but are a lesser amount and are general in nature.

JCAHO, aka Joint Commission, implemented new regulations in 2009. For the operating room these new regulations are referred to as Universal Protocol. Universal Protocol consists of three new expectations for the perioperative nurse:

• Conduct a pre-procedure verification process

• Marking the procedure site so the staff can identify without ambiguity the intended site for the procedure

• A time out is performed immediately prior to starting procedures

The pre-procedure verification is an ongoing process of information gathering and verification, beginning with the decision to perform a procedure, continuing through all settings involved in the pre-procedure preparation of the patient, up to and including the time-out just before the start of the procedure. The purpose of the pre-procedure verification process is to make sure that all relevant documents and related information or equipment are available prior to the start of the procedure, correctly identified, labeled, and matched to the patient's identifiers, and reviewed and are consistent with the patient's expectations. Missing information or discrepancies are addressed before starting the procedure.

Verification of the correct person, correct site, and correct procedure occurs at the time the procedure is scheduled, at the time of preadmission testing and assessment, at the time of admission or entry into the facility for a procedure (whether elective or emergent), before the patient leaves the pre-procedure area or enters the procedure room, and anytime the responsibility for care of the patient is transferred to another member of the procedural care team (including anesthesia providers) at the time of, and during, the procedure. Preferrably, the patient will be involved, awake and aware, if at all possible.

Items that need to be accurately matched to the patient and available include:

• Relevant documentation (i.e., history and physical, nursing assessment, and pre-anesthesia screen)

• Accurately completed, and signed, procedure consent form

• Correct diagnostic and radiology test results that are properly labeled

• Any required blood products, implants, devices and/or special equipment for the procedure.

Marking the procedure site is done for all procedures involving laterality (side), the surface (flexor or extensor), the level (spine), or specific digit or lesion to be treated. The procedure site is initially marked before the patient is moved to the operating room and takes place with the patient involved, awake and aware, if possible. The site is marked by a licensed independent contractor (MD, Nurse Practitioner, Physician Assistant) that will be directly involved in the procedure and will be present at the time the procedure is performed. The method of marking must be unambiguous and used consistently throughout the hospital. The mark is made at or near the incision site, includes the marking person's initials, is made with a marker that is sufficiently permanent to remain visible after completion of the skin prep and sterile draping, and is positioned to be visible after the patient's skin has been prepped, is placed in the final position, and sterile draping is completed.

The time-out is conducted prior to starting the procedure and, ideally, prior to the introduction of the anesthesia process, unless contraindicated. The time-out has the following characteristics:

• It is standardized (as defined by the hospital).

• It is initiated by a designated member of the team, usually the circulating nurse.

• It involves the immediate members of the team including the surgeon, the anesthesia providers, the circulating nurse, the operating room technician or scrub nurse, and other active participants as appropriate for the procedure.

• It involves interactive verbal communication between all team members, and any team member is able to express concerns about the procedure verification.

• It includes a defined process for reconciling differences in responses.

During the time-out, all other activities are suspended, to the extent possible without compromising patient safety, so all relevant members of the team are focused on the active confirmation of the correct patient, correct procedure, correct site, and other critical elements. The completed components of the Universal Protocol and time-out are clearly documented.

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What Do Operating Room Nurses Do?


The RN specializing in Perioperative Nursing practice performs nursing activities in the preoperative, intraoperative, and postoperative phases of the patients' surgical experience. Based on the Standards and Recommended Practices for Perioperative Nursing--A.O.R.N., the operating room nurse provides a continuity of care throughout the perioperative period, using scientific and behavioral practices with the eventual goal of meeting the individual needs of the patient undergoing surgical intervention. This process is dynamic and continuous, and requires constant reevaluation of individual nursing practice in the operating room.
I have been an Operating Room Nurse since 1995. Previously, I worked in the Operating Room as a LPN/Surgical Technician from 1980-1994. I love working in the OR. I do tire of hearing comments from other nurses that OR nurses don't really do nursing duties,so I'm here to set the record straight. I am as much a RN as the next nurse and I do patient care. Operating Room Nurses assess, diagnose, plan, intervene, and evaluate their patients just like every other nurse. Let me explain how.

Assessment

The patient enters the preoperative area and is assessed by the preoperative RN. The perioperative RN (Circulating Nurse), then interviews the patient with particular emphasis on ensuring the patient has informed consent, has been NPO for at least 6 hrs. prior to surgery, and current medical history to determine any special needs for the care plan. The perioperative nurse explains to the patient what will happen during the operative phase and tries to alleviate any anxieties the patient and their family may have. The nurse develops a rapport with the patient that enhances the operative experience for the patient by building trust and assuring the patient and the family of the best care possible.
The assessment includes, but is not limited to:

• Skin color, temperature, and integrity

• Respiratory status

• History of conditions that could affect surgical outcomes (i.e. diabetes)

• Knowledge base related to the planned surgery and complications that could arise

• NPO status

• What medications were taken the morning of surgery and the time taken

• Placement of any metal implants, especially AICD's and pacemakers

• Time of last chemotherapy or radiation therapies

• Verification of patient's name and date of birth

• Checking to verify all medical record numbers match the patient's name band and paperwork

This information is then used to develop the perioperative nursing care plan.

Diagnosis

The nursing diagnosis is written in a manner that helps determine outcomes. Some nursing diagnoses for surgical patients are:

• Impaired gas exchange related to anesthesia, pain, and surgical procedure

• Potential for infection related to indwelling catheter and surgical procedure

• Activity intolerance related to pain

• Anxiety related to anesthesia, pain, disease, surgical procedure

• Alteration in nutrition less than body requirements related to NPO status.

Planning

Planning the patient's care in the operating room is focused on patient safety. The nurse gathers supplies needed for the procedure according to the surgeon's preference card, positioning equipment, and any special supplies needed as determined by the nurse's assessment and the patient's history. Preparation assures that the nurse will be able to remain in the surgical suite as much as possible to provide care for the patient. The nurse leaving the room is avoided as much as possible, but unforeseen circumstances may require the nurse to leave to obtain equipment or supplies. When the patient is brought to the operating room and transferred to operating table, patient comfort and safety are the priority. The nurse provides warmed blankets for the patient and applies the safety strap across the patient. The surgeon is called to the OR suite and the "time out" is performed with the patient participating. Items verified in the time out are the patient's name, date of birth, allergies, procedure to be performed, correctness of consent, site marking, if applicable, special equipment or implants are in the room, and any antibiotics to be given within one hour prior to incision.



The patient is instructed to take deep breaths before and after anesthesia to maintain oxygen saturation above 95%. Strict aseptic and sterile technique are maintained throughout the surgical procedure to reduce the risk for postoperative infection. The nurse remains at the bedside during the induction phase and holds the patient's hand to help reduce anxiety. The patient is reassured as needed.

Nursing Intervention

The circulating nurse and the scrub nurse/technician work as a team to protect the sterility of the operative field by maintaining constant surveillance. Any breaks in sterile technique, such as a tear in the surgeon's glove, are remedied immediately.
The nurse provides for patient comfort by placing warm blankets, remaining at the patient's side until anesthesia has been successfully induced and the anesthesia provider releases the care of the patient to the surgical team. At this time a foley catheter will be placed, if indicated, using aseptic technique. The patient will be positioned and all pressure points will be padded to prevent altered skin integrity. The surgical skin prep is then performed aseptically and allowed to dry before placement of the surgical drapes. Fumes from a wet surgical prep can form pockets of gas that have the potential to be ignited by a spark from the electrocautery used in surgery.
Prior to the surgical incision, the anesthesia provider initiates the infusion of the antibiotic ordered by the surgeon. A preincision verification performed by the circulating nurse rechecks the patient's name, the surgical procedure, the site/side of the procedure, the antibiotic infusion has started, and the prep is dry.

Evaluation

The circulating nurse monitors the patient vigilantly during the course of the perioperative phase which includes preoperative, operative, and postoperative stages of surgery. He/she is responsible for the smooth transition for the patient between these phases. Evaluation of the patient's response to the surgical intervention is ongoing and continuous. Have the surgical outcomes been met? If not, reassessment takes place to plan further.

Conclusion

The patient under anesthesia is totally dependent on the surgical team for their well-being. The perioperative nurse advocates for the patient. He/she is their voice during the surgical intervention.
Whether scrubbing, circulating, or supervising other team members, the perioperative nurse is always aware of the total environment, as well as the patient's reaction to the environment and the care given during all three phases of surgical intervention. The perioperative nurse is knowledgeable about aseptic technique, patient safety, legal aspects of nursing, and management of nursing activities associated with the specific surgical procedure being performed. OR nursing is unique: it provides a specialty service during the perioperative period that stresses the need for continuity of care and respect for the individuality of the patient's needs.

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Perioperative Nurses' Week is November 8, 2010 through November 14, 2010. OR Nurses' Day is November 11, 2010.

The second week in November is known as OR Nurses' Week. Help us celebrate surgical nursing. Tell every OR nurse you know how much you appreciate him/her. This year's theme is "The Freedom to Speak Out". Much emphasis has been placed on Universal Protocol and Patient Safety. Help celebrate the OR Nurses of the world. Learn more about Perioperative Nurses Week here.

Order great Perioperative Nurse gift items from the Perioperative Nurse Week store.
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