Role Of The Perioperative Nurse

Description #

An introduction to patient-centered care will be presented as a holistic method of caring for patients about to undergo a surgical procedure. The topics of professionalism, communication/ collaboration, teamwork and leadership will be discussed in relation to perioperative nursing care. Overview of the roles of the Perioperative nurse, both the scrub role and the circulating role, will be discussed in detail.

Learning Objectives #

At the end of the session the nurse will be able to:

• Define Perioperative nursing as set down by the ORNAC standards
• Describe how using patient-centered care – the nursing process, standard nursing care plans and clinical pathways can be tailored to meet the individual needs of the patient in the operating room
• Recognize & utilize professionalism in perioperative nursing practice
• Recognize & utilize methods of effective communication practices in the perioperative nursing setting
• Recognize & utilize methods of effective teamwork in the perioperative nursing setting
• Describe the role of the scrub nurse and the circulating nurse

Patient-Centered Care #

Learning Objectives #

At the end of this unit the student will be able to:

1. Describe the core concepts of patient-centered care.

2. Describe the nursing process in relation to patient-centred care.

3. Describe how standard nursing care plans are adapted to meet the holistic needs of each individual patient.

The literature about patient centered care (PCC) is extensive within many disciplines of health care. Patient centered care is held as a standard of care throughout the world and is part of the core philosophy of the VCH (Vancouver Coastal Health) Perioperative Nursing Program. Patients undergoing specific surgical procedures will require specialized nursing care, e.g. careful positioning during surgery to keep the patient injury-free. In order to provide PCC, the perioperative nurse must look beyond a patient’s specific health problem or surgical procedure and consider the patient as a whole person.

It is important for the perioperative nurse to use the nursing process to to develop a plan of care that is unique to each patient. Patients may be frightened about the post-operative outcome or even the possibility of not surviving surgery. The patient may be worried about how they will cope at home post-operatively, the possible loss of independence and lack of contact with friends among many other concerns. Nurses have the opportunity to support patients during what may be the most frightening time of their entire hospital stay. It is the nurse’s responsibility to:

• Assess that patient
• Modify the plan of care to individual patient needs
• Communicate patient concerns to other members of the operative team
• Provide focussed attention and support to patients when under anesthesia as well as when they are awake
• Communicate necessary information to those looking after the patient post-operatively to ensure continuity of care

The time a nurse spends with each patient and their family members can have a significant positive influence on the patient’s surgical experience. Patients will be comforted by the words “I am your nurse and I’ll take good care of you.”

Application of PCC #

The patient-centred care approach will be foundational throughout this educational program. It is an expectation that PCC will be utilized every time a student has the privilege to encounter a patient in the perioperative nursing clinical program.

Professionalism #

Learning Objectives #

At the end of the unit the student will be able to:

• Define professionalism
• Understand the history of perioperative nursing
• Describe the characteristics of a profession
• Describe the elements that make perioperative nursing a distinct specialty within the nursing profession

History of Perioperative Nursing #

Due to the succession of wars during the 1800’s, nurses greatly expanded their experience and scope of practice. Florence Nightingale, a nursing leader of the time, had a significant impact in field hospitals, introducing such concepts as “surgical conscience” and “aseptic technique”.

The specialty of perioperative nursing emerged in the 1880’s as the number of surgeries increased and surgeons recognized the need for nurse assistance. Nursing schools helped to change the prevalent concept of nursing as a subservient and menial profession. Many physicians believed that the new Nightingale model of nursing education led to “over-trained” nurses who were “above themselves” and subsequently posed a threat to a well-established physician authority.

Two world wars projected nurses’ work into the national limelight as their contribution of service in the armed forces and volunteer organizations, such as the Red Cross, achieved public interest and recognition. In the mid-1940’s post-war nurses returned home from Europe and wanted to retain many of their expanded responsibilities including: anesthesia assistance, prepping of the surgical patient, control of asepsis, care of the operating room (OR) environment and supplies, supervision of operating room personnel and assisting the surgeon in surgical procedures.

Eventually, OR nurses began to organize their members, amalgamate professional knowledge and share ideas. This led to the formation of an independent association of OR nurses formed in 1949 in New York City, which later became, the Association Of  Perioperative Registered Nurses (AORN). In Canada a similar organization of OR members began, first in Quebec, in 1958 and later in BC, in 1966, with the formation of the British Columbia OR Nurses Group (BCORNG). Subsequently, the Operating Room Nurses Association of Canada (ORNAC) was formed in 1983 with membership from 6 provinces, including B.C. The British Columbia OR Nurses Group disaffiliated from the Canadian Registered Nurses Association of British Columbia (CRNABC) in 2009 (due to legislation from the Health Professions Act) to form the Perioperative Registered Nurses Association of BC (PRNABC).  Since the 1960’s, the perioperative nursing profession has identified a purpose and articulated goals in addition to developing new trends. The focus of perioperative nursing continues to be the support of nursing education, the recruitment and retention of nurses, the development of standards of practice and an OR credentialing model.

What is a Profession? #

Definition of a Profession #

The main factors that differentiate a profession from an occupation are:

Definition of Professionalism  #

“Professionalism” is not as easily defined as the term “profession”, as people may have different interpretations of what professionalism is. Professional behaviour can sometimes be more easily defined by its absence. Professionalism implies both a way of acting and being, which are open to interpretation by others. 

Think about a registered nurse from one of your practice experiences that demonstrated professional behaviour, in your opinion. What attributes did he/she exhibit that made you see their behaviour as professional? Conversely, describe behaviour that you have observed, that you would consider unprofessional.

Academic nursing programs help to socialize students to professional practices and values that engender a professional identity. Professionalism is difficult to measure but nurses express their professional identity through what is meaningful in their work. 

Students are taught the “ideals” or “gold standards” of a specialized body of knowledge and are educated to practice according to current collaborative standards of practice. In reality, standards of practices may be less than ideal, but it is important to remember that RNs are regulated and supported by a professional college (CRNBC) to uphold safe and appropriate registered nursing practice. The professional college (CRNBC) is committed to  promoting good practice, preventing poor practice, and intervening when practice is unacceptable.

Review the standards for nursing practice at:  CRNBC Standards ,and scope of RN practice at: CRNBC Scope of Nursing Practice

Professional nursing organizations (e.g. CRNBC, CNA) are instrumental in shaping nursing practice by developing standards of practice, education, ethical conduct and continuing competence. Unions, although primarily concerned with the development of legally binding agreements that regulate salaries, working conditions and other contract negotiations, also advocate for health and nursing policy related to scope of nursing practice. Professional organizations and unions have some common goals such as the welfare of members, improvement of working conditions and concern for professional ethics.

Professions possess certain structural and attitudinal attributes that set them apart from other occupations. Professional attitudes and behaviours develop through professional socialization – a process by which an individual will acquire the values and attitudes, interests, skills and knowledge (i.e. become a part of the culture – into the group of which they are, or seek to become a part of. 

One characteristic of a profession, suggested by Girard (2005), is that, members will continually engage in ongoing learning. “Critical refection can be considered an intrinsic process that stimulates an individual to question ingrained perceptions about interpretation of and response to various situations and to question such examination by others.”

Girard recommends that we analyze our attitudes, practice ethics, roles and appearance and ask ourselves the following questions:

• Do I have a personal code of nursing ethics and behaviour?
• Do I consistently act as a professional?
• Do I positively defend nursing and speak of being a nurse proudly?
• Do I lead by example, so others can follow?
• Do I assess the situations that I am in to ensure that I am practicing within my professional scope? Do I take direction from and collaborate with the appropriate individuals?
• Am I a mentor and do I share professional knowledge?
• Do I always use a surgical conscience, regardless of who is watching, or even, if no one is watching?
• Do I work to my highest potential?
• Am I a contributing representative member of my staff, profession, community and society as a whole?
• Do I strive for personal and professional growth and development?
• Do I set personal professional goals and accomplish them?
• Do I belong and participate in my professional nursing organizations?

We have discussed some of the major elements that make nursing a profession:

• Philosophy
• Body of Knowledge
• Leaders
• Guidelines for behaviour – ethics, guidelines, codes, oaths, belief statements
• Admission requirements – certification, requirement for ongoing education, testing, evaluation for admission and maintaining membership.

Summary #

Professionalism encompasses both the attitude and behaviour of members. Professionalism is demonstrated through a person’s knowledge and competency to do a job, willingness to learn, cooperation with others, respectful behaviour a commitment to practice. Nurses who possess a professional body of knowledge, advocate for patients and promote quality patient care, in all domains of practice.

The profession of perioperative nursing has come a long way, although some challenges still exist. One of those challenges is a chronic shortage of nurses, largely due to an aging nursing population and the inability to attract and retain nurses to the profession. The peroperative nursing program presents an exciting opportunity for students to potentially become a critical force in the future of perioperative nursing. The perioperative nursing program, with its challenges and rewards, will equip nurses with the knowledge, critical thinking and clinical expertise to validate perioperative nursing as a profession. 

Teamwork and Communication #

Learning Objectives #

At the end of the unit the nurse will be able to:

• List the key components and concepts of a team and how they relate to the OR
• Describe the different attributes between an effective and ineffective team
• Discuss some of the issues or challenges that affect communication in the OR
• Describe the barriers to good communication
• Describe how to deal with rude, demanding, and unreasonable behaviour in the OR
• Describe some of the sources of conflict in the OR and the strategies of conflict resolution

The Concept of Teamwork #

Teamwork is an integral part of nursing. The concept of communication is also included in this unit as it is such an important part of teamwork in the perioperative setting.The operating room is a place that depends on teamwork to make the patient’s experience successful.

The difference between groups and teams is defined as follows:

• A group is defined as: a number of individuals or things placed, assembled or acting together which may have common characteristics or interests.
• A team is: a number of persons associated together in a specific work or activity. A team has defined goals, objectives and ongoing relationships and is focused on accomplishing a task. Not every group is a team and not every team is effective.

Most teams work in an interdependent way to accomplish their tasks. The team’s success is dependent on the specialized contributions of individual members. This way of working characterizes the perioperative team.

Teamwork can also be accomplished when members function independently. Every person basically performs the same function, and the performance of one team member has no direct effect on the next member. Team members may help each other by offering advice or providing moral support, or background support, but each individual’s success is primarily due to their own efforts (e.g. a registered nurse working on the surgical patient unit).

Other styles of teams include: virtual teams consisting of members connected electronically; and project teams who are assembled for a defined period of time for a concrete purpose. The interdependent team is the focus of the periopertive nursing program.

The following key concepts are fundamental to successful teamwork in the fast-paced, high-pressure environment of the operating room.

1. Communication

It is important for perioperative team members to conduct interpersonal relationships with their peers in thoughtful, supportive and meaningful ways. deally, conflict resolution in ways that enhance, rather than inhibit, working relationships. It is critically important for team members lto maintain respectful, open communication.

Giving and receiving constructive feedback is also part of successful communication. The following guidelines outline the principles for giving positive feedback.

• Clarity; be clear about what you want to say.
• Emphasize the positive rather than the negative.
• Be specific; avoid general comments and clarify pronouns such as “it,” “that,” etc.
• Generalizations: avoid sweeping terms such as “all,” “never,” “always,” etc. Try to be more specific as these words often represent arbitrary limits on behaviour.
• Focus on the behaviour rather than the person.
• Refer to behaviour that can be changed.
• Be descriptive rather than evaluative.
• Own the feedback by using ‘I’ statements.
• Be very careful with advice. People rarely struggle with an issue due to a lack of specific information. It is often more useful to help a person come to a better understanding of the broader issue in question (i.e. how the issue developed and what actions would help to address the issue more effectively).

It is important for members of the perioperative team to be able to trust and depend on one another to complete the tasks and functions necessary to achieve positive surgical outcomes. To achieve effective communication, members of the perioperative team must be willing to confront issues and to openly express their ideas and feelings to each other in a respectful way. Providing constructive feedback in a skilful way is a challenge for nurses and other disciplines in healthcare.

2. Purpose

Sharing a common purpose is another concept that plays an important role in successful teamwork. The presence of a common purpose or mission that is clearly understood and embraced by all the team members can guide teams to work together.

3. Cooperation

A successful team demonstrates cooperation and a willingness to work together. An effective team does more than complete the tasks of the surgical procedure by merely working in an operating room together. Although technical expertise is important, it is the interpersonal connections and emotional investment that help to create a team.

4. Commitment

Commitment is an essential component of great teamwork. Ideally, all members involved in any undertaking are passionate and dedicated to the goal. Although it is possible to teach almost anyone the technical aspects of perioperative nursing, people who love what they do and truly care about patients and families are the most effective members of a periooperative team.

Challenges to Teamwork #

Teams must overcome many potential problems and issues to be successful. Some of these issues and ways to overcome them are discussed.

Participation is essential for teams to function well. Most team members want to be valued and recognized by others. When members are given the opportunity to participate in decision-making, it gives them a feeling of power and influence and they are more likely to work hard, cooperate and demonstrate enthusiasm. Conversely, when people feel that they have nothing to contribute or no opportunity to be heard, they are more likely to withdraw and become apathetic. This behaviour may create conflict or division within the team and ultimately interfere with the optimal performance of the surgical team. 

Issues of power and control may also negatively influence teamwork. If individuals feel that they have little control over the basic elements of their work environment, they may lose self-esteem and try to compensate in non-productive ways. Such behaviour can, consequently, influence teamwork in a negative way.

Appreciation for Individual Skills

It is important for individuals to feel that their skills and contributions are necessary and valued and that they are respected for what they have to offer. People respond better to acknowledgement for what they do well rather than having others attempt to “correct” their weaknesses. It is important to offer people praise or credit for things they do well in a professional way. The following guidelines may provide guidance for acknowledging others.

Guidelines for acknowledgment:

• Acknowledgment must be specific; the actual behaviour or action that is appreciated must be identified.
• Acknowledgment must be face-to-face (as opposed to when you are running down the hall to do something else).  Written acknowledgments are equally significant.
• Acknowledgment must be sincere.
• Acknowledgment is more powerful when delivered publicly; many people appreciate public acknowledgment.
• Acknowledgment must be timely; it is more meaningful when it occurs close to the time of the action.

Group Agreements

A team that functions well will often have “ground rules” for how they behave toward one another. Rules such as demonstrating support and respect for colleagues; honouring agreements; communicating clearly; and identifying common goals will enhance a team’s ability to work cohesively. When there are no ground rules, people may more readily display negative behaviours (i.e. anger, hurtful or acting-out behaviour). 

Trust

Trust is a key component of good teamwork, and is significantly influenced by actions, even more than words. Once trust is destroyed within a team, it is difficult to re-establish. 

Synergy

Truly effective teams are ones in which people work together to produce extraordinary results that could not have been achieved by any one individual. Some basic principles contribute to the development of synergy within a team, as follows:

Purpose:

It is important for a team to establish a clear purpose. Each member of the team must understand the purpose and value of the team.

 Listen actively:

“Acive listening” is listening to another person with focussed attention to the words, posture and tone of voice of the individual who is speaking. It is a non-judgmental way of listening and allows someone to express his or her thoughts completely.

 Be Compassionate:

Compassion is defined as feeling sorry for the sufferings or trouble of others, accompanied by the urge to help. Compassion can be demonstrated within a team through active listening with a caring perspective. It is important to understand the viewpoint of the other person rather than insisting on one’s own point of view.

Tell the truth:

To tell the truth means to clearly and accurately express personal viewpoints and perspectives. 

Be Flexible:

It is important to acknowledge that each person has something to contribute and a right to be heard. Flexibility within a team reflects a willingness of members to consider the points of view of others. This allows a team to utilize the various ideas of all members to effectively solve problems. 

Commit to Resolution:

It is important for all team members to listen to differing perspectives, identify the differences and creatively seek solutions to resolve any differences. All parties need to feel their point of view has been heard and that they agree to the resolution made. Commitment to resolution differs from compromise in that in compromise there is a relinquishing of a significant portion of what was desired. Often compromise leaves the involved parties with negative feeling about the process, the outcome and even themselves.

In conclusion, a team cannot be effective when one team member becomes the self-proclaimed expert, or when other members refuse to speak. It is important that each team member has the opportunity to share ggod ideas. The challenge each person faces is to push through discomfort levels and become full participants in problem identification and resolution for the overall benefit of the team goal or objective. 

Decision-Making in the Perioperative setting 

Registered Nurses (RN) work within a collaborative interprofessional environment. In the perioperative setting there is a team of professionals involved in the decisions regarding patient care. The partnership between professional groups makes the operating room a unique place to work. There is a blending of different professional cultures where skills and knowledge are shared and people work together toward a common goal of quality patient care. Each professional group contributes to the decision-making process regarding the patient’s care. 

Physicians, surgeons and anesthesiologists make decisions about the operative procedure and they work collaboratively with the perioperative nurses to develop the overall plan of care. Within the perioperative setting, RNs and Licensed Practical Nurses (LPN) function within their scopes of practice and also collaborate on a plan of nursing care based on a detailed patient assessment.

A wide range of patients with varying levels of stability and medical complexity require surgical intervention in the operating room. Some surgical centres also care for trauma patients who have multiple injuries. The status of a patient experiencing an anesthetic and/or surgical procedure can change quickly.

This requires nurses to constantly assess their patients and to clearly understand the parameters of the RN and LPN role. The RN works together with the LPN to determine if the circulating or scrub nurse roles would be the most appropriate for the LPN to assume for specific patients. (See next section for more detail regarding the roles.)

Role of the Perioperative Nurse #

Learning Objectives #

At the end of the unit the nurse will be able to:

• Define perioperative nursing.
• Define perioperative nursing as outlined by the ORNAC standards guidelines and position statements for perioperative registered nursing practice.
• Describe the role of the scrub nurse.
• Distinguish the differences between the role of the RN and the LPN in the scrub nurse role.
• Describe the role of the circulating nurse.
• Distinguish the differences between the role of the RN and the LPN in the circulating nurse role.
• Describe the role of the other health care professionals in the perioperative setting.

The Perioperative Period #

The perioperative period encompasses the time surrounding the operative procedure. The phases are:

Preoperative Phase

• Begins with the time a surgical intervention has been planned to the time the patient is taken to the operative suite

Intraoperative Phase

• Begins with the time the patient is taken to the operative suite to the time the patient is ready for transport out of the OR

Post-operative Phase 

• Begins with the conclusion of the surgical intervention through to the recovery phase and resolution of any rehabilitation activities

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The Perioperative Team #

The roles and responsibilities of the perioperative team may include:

• Surgeon: The surgeon is responsible for the overall care of the patient preoperatively, intraoperatively and postoperatively. The surgeon will be the only member of the team who has previously met the patient and knows the patient’s medical history. The decision to operate on the patient is made by the surgeon. Surgeons perform operations with the assistance of surgical residents or fellows (physicians in training) or medical practitioners who are trained to be surgical assistants.

• Anesthesiologist: The anesthesiologist is responsible for providing a patient with pain relief in the form of an anesthetic during the surgical procedure and for maintaining pain relief in the immediate phase of post-operative recovery (and sometimes when the patient is admitted to the surgical floor). The anesthesiologist may also have resident physicians assistants. The anesthesiologist is responsible for the physiological well-being of the patient and makes decisions regarding whether the patient is fit for surgery. They also monitor the hemodynamic stability of the patient during all phases of the surgical procedure. The anesthesiologist may visit the patient prior to the surgery to determine the level of risk for the patient and to make any corrective actions to reduce the potential risk. The anesthesiologist will formulate a plan of care to minimize any risks during all phases of the surgical procedure.

• Nursing Personnel: The scrub nurse and circulating nurse (see the next section for a more detailed description of these roles). Nursing personnel wil often meet the patient for the first time in the preoperative area. the patient care plan is developed utilizing information from th einitial assessment of the patient, previous nursing experience with similar operative procedures and from the patient histories obtained by the surgeon and the anesthesiologist. The development of the patient care plan is a collaborative effort between physicians and nurses.

The perioperative team may also include the following auxillary members:

• Anesthetic technicians: specialized repiratory therapists who assist the anesthesiologist (and nurses) in th emanagement of difficult airways
• Perfusionists: assist during cardiac surgery by running the cardiopulmonary bypass machine
• Perioperative assistants/aides: assist surgeons and nurses with positioning patients and other non-nursing duties
• EEG or ECG tehnicians: assist during operative procedures when pacemaker or brain function needs to be monitored
• X-ray technicians: assist by taking intraoperative x-rays
• Medical Device Reprocessing Department (MDRD) staff: trained in the decontamination, packaging, and sterilization of instruments and supplies
• Clerks: perform the clerical work required in the operating room (i.e. booking surgeries, computer input etc.)
• Translators: assist patients with language translation

Roles and Responsibilities of the Scrub and Circulating Nurses #

The purpose of this unit is to outline the roles and responsibilities of both the scrub and circulating nurses and to observe the interaction of these roles throughout the perioperative period.

The coordinated roles of the scrub nurse and the circulating nurse create a specialized team within the larger perioperative team. The scrub nurse has a predominant role during the surgery: passing the scalpel, instruments, sutures, etc. The circulating nurse plays an important support role for the scrub nurse, ensuring that all parts of the surgical procedure move along efficiently.

Although many of their duties are separate from one another, mutual cooperation between the scrub and circulating nurses is essential to keep the operating room running smoothly and efficiently. With a coordinated effort between the scrub and circulating nurses, the sterile and unsterile parts of the surgical procedure move along simultaneously. Ultimately, the team serves the best interests of the patient who is most vulnerable during the intraoperative phase of surgery.

Have you ever had surgery? If so, do you remember anything about the team? Think about what was good and what might have been negative about your experience. What do patients remember about the procedure? Hopefully, patients will remember a nurse who made them feel at ease, explained what was going to happen, and made them comfortable.

Scrub Nurse Role #

The scrub nurse may be an RN or LPN who has completed technical training in the following areas: principles of sterilization; aseptic technique; instrumentation and sutures.

The scrub nurse works within the sterile field and provides instruments and supplies to the surgeon during the operative procedure. The scrub nurse is responsible for collaborating with the surgical team to assemble supplies and to prepare and maintain the sterile field. The scrub nurse must anticipate the needs of the sterile team during the surgical procedure and provide for those needs (e.g. additional sterile supplies and/or equipment) in an efficient and safe manner.

Upon completion of the surgical procedure, the scrub nurse is responsible for the safe disposal of contaminated supplies, managing instruments and equipment and assisting with patient care as needed.

The scrub nurse acts as a patient advocate by:

• Maintaining a safe and efficient environment
• Practicing and monitoring aseptic technique
• Performing sponge, needle and instrument counts
• Handling and identifying specimens correctly
• Protecting the patient’s privacy, dignity, safety and comfort
• Identifying emergency situations during the procedure (i.e. bleeding) and informing the circulating nurse so that they can work together to provide corrective actions

The scrub nurse must be able to apply basic knowledge of surgical procedures and anatomy and physiology for each patient. It is the responsibility of each team member, including the scrub nurse, to seek opportunities to increase his or her knowledge base with regard to changes in health care and technology.

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Circulating Nurse Role #

The circulating nurse may be an RN or LPN, depending on the complexity of the patient’s medical history. Circulating LPNs will always work alongside an RN to carry out many of the responsiblities listed below.

The circulating nurse is responsible for the nursing care of the perioperative patient, primarily during the immediate preoperative and intraoperative periods, but also in the immediate post-operative phase (until the care of the patient is transferred to the post-operative recovery room nurse).

The circulating nurse is responsible for coordinating the nursing care of the patient throughout the intraoperative period. These activities include:

• Assessing the patient, including both physiologic and psychosocial health status
• Formulating nursing diagnoses pertinent to the perioperative period
• Establishing patient goals for optimal expected outcomes
• Developing a plan of care and outlining nursing activities that will achieve these goals
• Applying monitoring equipment
• Assisting the anesthesiologist

Nursing actions, directly or by delegating the action to a qualified team member, including:

• Creating, maintaining and monitoring a sterile field
• Providing equipment and supplies
• Performing sponge, needle and instrument counts
• Administering drugs and solutions as prescribed
• Evaluating patient outcomes and adjusting the plan of care too reflect the status of the patient throughout the perioperative period

The circulating nurse incorporates teaching activities into the care of the patient and family. Patient knowledge deficit is a common nursing diagnosis in perioperative nursing. The circulating nurse:

• Identifies the learning needs of the patient and/or family
• Assesses their readiness to learn, influenced by anxiety levels and attention span
• Provides instruction based on learning needs
• Evaluates the effectiveness of the teaching

The circulating nurse is responsible for the documentation of all nursing activities that take place during the perioperative period. Although documentation formats and methods differ among surgical settings, there are common elements in all settings.

The nurses in the preoperative admission area start the preoperative checklist. It usually contains, but is not limited to:

• Identification of the patient
• Patient assessment data
• Verification of the presence of the consent, physician history, laboratory, ECG, x-ray and other diagnostic results
• Presence and disposition of prosthetic devices, and/or sensory aids
• NPO status
• Allergies
• Disposition of jewelry
• Signature of persons providing patient care during the preoperative period

The operative record includes documentation about every aspect of the patient’s care during their time in the operating room. The elements include but are not limited to the following:

• Identification of persons providing patient care during the intraoperative period
• Skin condition on arrival and discharge from the surgical suite
• Positioning and devices used
• Skin prep, including solutions used
• Wound classification
• Electrosurgical unit (ESU) identification, location of the dispersive pad, and settings used during the procedure
• Other devices used—including temperature regulating devices, invasive and non-invasive monitoring devices, tourniquets, insufflators and lasers, with pertinent details regarding their use
• Administration of medications, irrigations, solutions, or blood products
• Specimens and cultures taken
• Implants, including lot numbers and other information required for tracking
• Documentation of sponge, sharp, and instruments counts
• Use of intraoperative x-rays
• Dressings and drains
• Time of discharge; method and place of transfer
• Any other significant or unusual occurrences that may affect patient outcomes

The count sheet contains a detailed account of the sterile items used: (i.e. sponges, sharps, miscellaneous small items and instruments). Counts are performed by both the scrub and circulating nurses prior to the commencement of surgery, at first layer of closure depending on the cavity entered and at skin closure. Both nurse participants sign this sheet.

Patient advocacy is the responsibility of each member of the surgical team but is an important part of the circulating nurse’s role. The circulating nurse has the overall responsibility for all nursing activities pertaining to the patient. The nurse in this role gathers specific data regarding the individual needs and desires of that patient. Advocacy implies acting on behalf of another, and the circulating nurse may speak for the patient during the intraoperative period when the patient is unable to speak for his or herself. Advocacy may include:

• Protection of the patient’s privacy (i.e. maintaining confidentiality and limiting exposure during positioning, prepping, and draping)
• Protecting the patient from infection (i.e. monitoring aseptic techniques of all team members)
• Protecting the patient from injury (i.e. improper positioning, ensuring proper function and use of equipment)
• Identification of spiritual and cultural/.ethnic beliefs that may include some special needs during the perioperative period (i.e. the refusal of blood products by a Jehovah’s Witness patient)
• Communication of specific needs and desires of the patient to the other members of the surgical team; and communication of care upon transfer to the post-anesthetic care unit