Perioperative Nursing
Emily McKisson MS, RN, CNOR
Jenny Stoner MS, RN, CNOR
Learning Objectives
 Introduce the members of the surgical team
 Communication and Teamwork
 Perioperative Environment
 Surgical Safety
 Aseptic Technique
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Perioperative Nursing Practice
 Fast paced
 Simple case can flip into an emergency
 High Impact Environment
 Critical Thinking
 No routine surgery
 Patient Advocate
 Knowledge of anatomy
 Instrumentation/Equipment
 Emotional support
 Reduce anxiety
 Patient Safety
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Attending Anesthesiologist,
Anesthesia Resident/CRNA
Attending Surgeon or Fellow
Assistant; Surgical Resident
Surgical Technologist or Scrub
Person
(Can be RN or ST)
Circulating RN or
circulator
(Can only be RN)
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Surgical Team
Circulating Nurse – Manages care of only one patient at a time
 “Nonscrubbed”
 Assess
 Positioning
 Prevent nerve injury
 Antimicrobial skin preparation
 Medications
 Implants
 Specimens
 Surgical Counts
 Documentation
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Pressure Points that can cause
injury during a lateral position
Surgical Team
Scrub Person- works at the sterile field
 Highly technical
 Assembles instruments and supplies
 In-depth knowledge of each step of the surgical
procedure
 Anticipation of surgeon needs
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Surgical Team
Registered Nurse First Assistant (RNFA)
Certified Surgical Technologist First Assistant
 Works collaboratively with the surgeon
 Handling/cutting tissue
 Provide surgical site exposure
 Suturing
 Wound management
 At OSUWMC, RNFAs assist in:
 Cardiac surgery
 Robotic surgery
 At OSUWMC, CSTFA assist in:
 Ortho surgery
 General oncology
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Surgical Team
Surgeon, Fellows, Residents
 Various levels of training
 OSUWMC
 Academic medical center
 Perform the procedure and
manage the patient post operatively
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Anesthesia Care Team
Anesthesiologist, Anesthesia Residents, Anesthesia Assistants &
Certified Nurse Anesthetist (CRNA)
 Meet the patient day of surgery
 Manage the patient’s ABCs (airway, breathing, and
circulation) throughout the surgical procedure and during
their post recovery phase
 Decide which type of anesthesia is safest for patient
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The Surgical Experience- Anesthesia & Sedation
General Anesthesia
 State of narcosis, analgesia, relaxation, & reflex loss
 Not arousable
 Lose ability to maintain ventilation
 Cardiovascular impairment possible
 Attempt to transition patient quickly & smoothly through
stages of sedation
The Surgical Experience- Anesthesia & Sedation
General Anesthesia
 Inhaled administration
 Intravenous administration
 Often used in combination with inhaled
 Used to achieve lighter sedation
The Surgical Experience
Regional Anesthesia
 Spinal, epidural, & peripheral nerve blocks
 Considered worn off when all 3 systems no longer affected
 Headache common symptom with spinal
The Surgical Experience
Moderate Sedation/Analgesia
 Also known as “conscious sedation”
 Reduce patient anxiety and control pain
 Allows for patient to respond to verbal & physical stimuli
 Can be given by anesthesia care team member or
operating room nurse/procedural nurse with specialty
training
The Surgical Experience
Local Anesthesia
 Block nerves in peripheral and central nervous system
 Degree of blockade determined by drug concentration &
volume
Put your knowledge to Practice
A nurse is caring for a client immediately following a
procedure that required spinal anesthesia. Which of the
following findings indicates the client is experiencing a
complication of the anesthesia?
A. Hiccoughs
B. Numbness in the legs
C. Headache
D. Absence of urge to void
Put your knowledge to Practice
A. Hiccoughs Rationale: Hiccoughs are associated with abdominal
surgery, but are not attributable to spinal anesthesia.
B. Numbness in the legs Rationale: Numbness in the legs is an
expected outcome in the immediate postoperative period following spinal
anesthesia.
C. Headache Rationale: When spinal fluid is lost through a leak at the
puncture site around the spinal column, a severe headache can occur,
which may last several days. This finding is a complication of the
anesthesia.
D. Absence of urge to void Rationale: Absence of the urge to void is an
expected outcome in the immediate postoperative period following spinal
anesthesia.
Put your knowledge to Practice
This person in the operating room has specialty training for
passing instrumentation.
A. Circulating nurse
B. Surgical technologist or scrub person
C. Anesthesia care provider
D. Surgical resident
Put your knowledge to Practice
A. Circulating nurse
B. Surgical technologist or scrub person. Rationale: This is a
highly technical trained member of the surgical team who
assembles instruments and supplies, has an in-depth
knowledge of each step of the surgical procedure and
anticipates the needs of surgeon
C. Anesthesia care provider
D. Surgical resident
Communication and Teamwork
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Perioperative Nursing
Communication and Teamwork
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Perioperative Nursing
Closed Loop Communication
Attending
Surgeon
Communications Not
Acknowledged Are
Communications That
Didn’t Happen
Surgical tech/scrub person
Circulator
RN to RN Handoff
Oh my… I’ve been running all case. It’s like no one checked the preference
card…. Do they every update these? When I got back from lunch, the case turn
into a dumpster fire. I’m so glad you are here, but it looks like you pulled the short
straw to come in here. This was supposed to be a simple L/S nephrectomy, but the
trocar went through the renal artery. We had to convert to open immediately. I’m
so ready to get my weekend started and get out of here. SO… this is a patient of
Dr. Williams.. We had to order a type and cross because we got into bleeding. So,
the specimen is out. Patient has NKDA. Here are the count sheets. I like your
hat. Are those new glasses?
RN to RN Handoff: ISBAR Format
Introduction / Situation
Hi ________, this is Joe Smith, MRN 90501235. We are doing a right Nephrectomy.
through the renal artery with a trocar, so we converted to open.
We went
Background
NKDA
History of right renal mass
No OSA risks
No Skin variations
Position is left lateral
We have 0.9% saline and sterile water on the field
We gave 4 units of RBCs and we have 2 more units in the frig
Specimen is right kidney is out and still on the sterile field
He has a 18g in the Right AC, and a 20g in the left hand
Bovie pad right lateral thigh
We counted the L/S instruments and they are blue toweled. We currently have open instruments
and vascular instruments.
Family are in the atrium. They were last updated at 0630
Assessment
We currently don’t have any red flags
ICU passport was filled out
What questions to you have?
Surgical Safety
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Surgical Safety
 Pre-procedure verification
 Informed consents
 Surgical site marked
 Safety Surgical Checklist
 Sign in
 Time out
 Sign out
 Prevention of Retained Surgical Items
 Care of handling surgical specimens
 Surgical Fire
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Informed Consent
Sally Smith
Dr. Eiferman
Acute cholecystitis
Laparoscopic possible open cholecystectomy
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Surgical Site Marking
Prevention of wrong sided surgery
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Surgical Counts
Prevention of Retained Surgical Items
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Surgical Counts
Prevention of Retained Surgical Items
 Imperative to maintaining patient safety
 The entire surgical team responsible
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Do you see the missing item?
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Here is another view
K-wire
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Do you see the missing item?
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Retained Lap Sponges
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Surgical Counts
 Initial Count
 Incremental Count
 First Closing Count
 Final Closing Count
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Surgical Counts
Items that are counted
 Surgical Laps (Sponge)
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Surgical Counts
Items that are counted
 Sharps
 Needles, blades, hypo needles
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Surgical Counts
Items that are counted
 Instrumentation
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Surgical Count Board
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The Perioperative Environment
Traffic Patterns, Perioperative Attire
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Perioperative Environment
Traffic Patterns
Restricted Zone
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Semi-Restricted
Zone
Unrestricted Zone
Masks and proper
OR attire required
Proper OR attire
required
Street Clothes
Sterile room
OR hallways, Core
and Sub-sterile
rooms
Full Length Lab
Coats
Minimum Traffic
No Eating and
Drinking
Eating and
Drinking
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Perioperative Attire
Semi-Restricted and Restricted Areas
Head covering (bouffant or surgeon’s cap)
Eye protection (if scrubbing into surgery)
Masks (if open, sterile supplies present)
Warm-Up Jacket
(buttoned in and
around sterile field)
Hospital-laundered green scrubs
or bunny suit for vendors
Shoe covers (if wearing outside shoes)or
dedicated shoes to the operating room
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Perioperative Attire
Unrestricted Areas
Mask removed
Full Length Lab Coat
(buttoned closed)
Shoe covers removed
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Put your knowledge to Practice
You notice a person in scrub attire walking in the operating
room hallway without a surgical hat. You stop and give this
person a hat and educate them that this location is
considered which type of surgical zone?
A. Restricted zone
B. Semi-restricted zone
C. Unrestricted zone
D. I would pretend I did not see this
Put your knowledge to Practice
You notice a person in scrub attire walking in the operating
room hallway without a surgical hat. You stop and give this
person a hat and educate them that this location is
considered which type of surgical zone?
A. Restricted zone
B. Semi-restricted zone; Rationale: The OR hallways are
considered semi restricted and require surgical scrubs,
hair coverings and shoe coverings
C. Unrestricted zone
D. I would pretend I did not see this
Skin Prep
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Aseptic Technique
Preventing Surgical Site Infections
 Skin Preparation
 Chloraprep
 Fire risk
 3 minute dry time
 Betadine scrub and solution
 Chlorahexidine gluconate/Hibclens
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Potential Complications
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Potential Complications
 Hypoxia & Respiratory Issues
 Hypothermia
 Malignant Hyperthermia
 Look out for hypercarbia, sinus tachycardia, rapidly ↑ temp
 Immediately discontinue anesthesia, provide 100% oxygen
& administer dantrolene sodium IV
 Surgical Site Infection
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Thank You
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