Perioperative Nursing

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Perioperative Nursing
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• Surgery has been performed since ancient times.
  The earliest recorded surgical operations were
  circumcision and trepanation.
• (Circumcision removal of the foreskin of the
  penis.
• Trepanation making a hole in the skull to
  relieve pressure and/or release spirits.)
• The earliest instruments used in these procedures
  were flint or obsidian (shiny stone) knives and
  saws.

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• Nursing did not exist as an occupation in the
  United States before the Civil War.

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• A typical "operating room" was in the open air
  where the surgeon had plenty of light.
• Otherwise, it was the room of a farmhouse, the
  center of a barn, or under a tree.
• Assistants held lamps over the surgeon to provide
  light.
• Patients were placed on a door removed from its
  hinges and set on sawhorses.
• With little more than a rag to wipe his hands,
  the surgeon then began the examination of the
  wounded soldier and then decided on what course
  to take.

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• Although the women who tended the sick and
  wounded during the Revolutionary War were not
  nurses as known in the modern sense, they helped
  blaze the trail for another generation nearly one
  hundred years later, when, in 1873, civilian
  hospitals in America began operating recognized
  schools of nursing.

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• Anesthesia was discovered by two American
  dentists, Horace Wells (1815-1848) and William
  Morton
• Before the advent of anesthesia surgery was a
  traumatically painful procedure and surgeons were
  encouraged to be as swift as possible to minimize
  patient suffering.
• Also meant that operations were largely
  restricted to amputations and external growth
  removals.
• Beginning in the 1840s surgery began to change
  dramatically in character with the discovery of
  effective and practical anaesthetic chemicals
  such as ether and chloroform. In Britain, John
  Snow pioneered the use of these two anaesthetics.
  
• In addition to relieving patient suffering,
  anaesthesia allowed more intricate operations in
  the internal regions of the human body. The
  further discovery of muscle relaxants also
  facilitated safer applications.

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• At that time, the OR was a true theater

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O.R. 1908
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This was a typical OR during WWII
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OR today
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Perioperative Phase

• Period of time that constitutes the surgical
  experience includes the preoperative,
  intraoperative, and postoperative phases of
  nursing care.

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Preoperative phase

• Period of time from when the decision for
  surgical intervention is made to when the patient
  is transferred to the operating room table.

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Intraoperative phase

• Period of time from when the patient is
  transferred to the operating room table to when
  he or she is admitted to the postanesthesia care
  unit (PACU).

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Postoperative phase

• Period of time that begins with the admission of
  the patient to the PACU and ends after a
  follow-up evaluation in the clinical setting or
  home.

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• Operating Room (OR) nurses
• referred to as perioperative nurses to more
  accurately reflect their specialized duties

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• As surgical care evolves, so does the role of the
  registered nurse who assists with patient care in
  the operating room.

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Perioperative nurses

• RNs
• work in
• hospital
• surgical departments
• day-surgery units (ambulatory surgery)
• physicians offices
• Work closely with the surgical patient, family
  members and other health-care professionals to
  help
• Plan
• implement
• evaluate treatment

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Being a nurse in the OR

• Offers you the opportunity to acquire and use
  professional, technical, and practical skills,
  and problem-solving skills.

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• As with everything else in nursing and medicine
  and nursing, the OR is a fluid environment .

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The effect of technology on OR nurses

• The nurse has to have knowledge of the working of
  and be able to trouble shoot problems with any
  and all equipment used in the OR's
• Microscope
• Fluid pumps
• Video equipment
• Lasers

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• If there is a problem with any of the equipment
  the nurse hasto be able to initiate corrective
  action for the malfunctioning equipment.

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• The exponential growth of OR technology during
  the past 10 years has placed increased demands on
  perioperative nurses.

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Other equipment that is used in the OR

• Surgical lights
• OR tables, accessories and furniture
• Oxygen and nitrous oxide lines
• Computerized monitors and video equipment
• Lasers
• Robotic equipment
• Nitrogen tanks
• Drills saws
• Cement system
• Emergency cardiac equipment
• Warming blanket/Bair hugger

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• Proficiency is required not only in patient care
  but also in the understanding, operating, and
  troubleshooting of video systems, computers, and
  cutting edge medical devices

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OR Terminology

• excision - cutting out an organ, tumor, or other
  body part.
• resection - partial removal of an organ or other
  bodily structure.
• reconnection of organs, tissues, etc.,
  particularly if severed. Resection of organs such
  as intestines involves reconnection. Internal
  suturing or stapling may be used. Surgical
  connection between blood vessels or other tubular
  or hollow structures such as loops of intestine
  is called anastomosis.
• ligation - tying off blood vessels, ducts, or
  "tubes".
• grafts - may be severed pieces of tissue cut from
  the same (or different) body or flaps of tissue
  still partly connected to the body but resewn for
  rearranging or restructuring of the area of the
  body in question. Grafts may be taken from one
  area of the patient's body and inserted to
  another area of the body or may be from other
  persons, cadavers, or animals.

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The Nursing Process in Perioperative practice
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Like all nurses, OR nurses use

• Knowledge
• Skills
• Judgment

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• Implements nursingactions to ensure and maintain
  a safe environment for thepatient

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• Manages the overall nursing care in the operating
  room and helping to maintain a safe, comfortable
  environment.

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• Performs sharps, sponge, and instrumentcounts
  per policy with the scrub tech or scrub nurse

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• Implements the safe transfer of the patient to
  and from theOR bed and ensures that the side
  rails and safety straps are used appropriately.
• Responsible for positioning of the patient using
  proper body alignment and body mechanics
  anddemonstrates proper positioning of the
  patient on the ORequipment that is appropriate
  to the operative procedure

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• Maintains the patient's skin integrity and
  ensuresthat clothing and bedding are clean and
  dry, uses proper techniques when prepping the
  surgical site and adjusts bedding and clothing by
  lifting rather than using shearing force

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• Checks sterility of items to be used during the
  operative procedure by verifying the expiration
  date, package integrity and by the sterile
  indicator color change

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• Opening instruments and sterile suppliesusing
  sterile technique to the back table
• Pouringsterile solutions into sterile containers
  
• Adjusting the ORlights

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• Preparing labels and taking care of specimens per
  policy
• Remaining with the patient during induction of
  anesthesiaand assisting anesthesia with the
  induction
• Assisting with gowning of surgical team members

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• Anticipating needs of thesurgical team members
• Supplying items as needed
• Sending forthe next patient in a timely manner
• Perparing forsubsequent procedures.

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Roles in the OR
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Circulating Nurse

• The circulators duties are performed outside the
  sterile field.
• The circulator is responsible for managing the
  nursing care of the patient within the OR and
  coordinating the needs of the surgical team with
  other care providers necessary for completion of
  surgery.
• Using critical thinking skills, the circulator
  nurse observes the surgery and the surgical team
  from a broad perspective and assists the team to
  create and maintain a safe and comfortable
  environment for the patient.
• The circulator nurse assesses the patients
  condition before, during, and after the operation
  to ensure an optimal outcome for the patient.
• Circulating during surgery is a perioperative
  nursing function. The role of the circulator may
  not be delegated to a UAP, Licensed Practice
  Nurse or Licensed Vocational Nurse.

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• In the operating room, most patients are
  anesthetized or sedated and are powerless to make
  decisions on their own behalf during the
  intraoperative phase. The circulating nurse
  serves as the patient advocate while the patient
  is least able to care for him or herself

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Scrub Nurse

• The scrub nurse works directly with the surgeon
  within the sterile field, passing instruments,
  sponges, and other items needed during the
  procedure.
• The sterile field is the area closely surrounding
  the OR table and instrument tray.
• Surgical team members who work within the sterile
  field have scrubbed their hands and arms with
  special disinfecting soap and generally wear
  surgical gowns, caps, eyewear, and gloves.
• This is a nursing role that may be delegated to a
  LPN.

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Surgeon

• MD or DO
• Credentialed by the hospital
• Must be a graduate of an accredited medical
  school and complete a surgical residency.

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Anesthesia Care Provider

• Anesthesiologist
• MD or DO
• Supervising physician for CRNAs
• CRNA
• RN with additional education
• Current entry level for practice is Masters
  degree

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Sterile processing

• Responsible for providing sterile instrumentation
  to OR for use in cases

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• Perioperative nurses also may work as an OR
  director, managing budgets, staffing, and other
  business aspects of the operating room.

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• Some perioperative nurses may later consider a
  career in business as a management consultant,
  clinical educator, researcher, or medical sales
  professional.

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• AORN is the professional organization of
  perioperative nurses representing over 40,000
  nurses

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Important information for your clinical
experience in the OR
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• Your experience starts where the patient enters
  the system.
• 2nd Floor Same Day Admission
• OPS prep area (basement)
• Change into scrubs when your patient moves to the
  holding area

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Holding Area

• Last chart review by RN to make sure all required
  paperwork is on the chart.
• IV started
• Interview with anesthesiologist

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In the OR

• Lockers are available for your use during the
  hours between 0700-1800 while you are in the
  operating room.
• You must bring your own lock.

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DRESS CODE - SURGICAL ATTIRE

• All persons who enter the semi restricted and
  restricted areas of the surgical suite should be
  in hospital laundered surgical attire intended
  for use only within the surgical suite at
  Presbyterian Hospital. Surgical attire includes
  hospital issued scrubs, scrub jacket and head
  cover. Shoe covers are not necessary.
• All possible head and facial hair, including
  sideburns and neckline, should be covered when in
  the surgical suite.

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• All persons entering an operating room or should
  wear a mask.
• Masks are located over the scrub sinks in each
  suite.
• All personnel entering the suite should have all
  jewelry confined or removed.
• Watches and plain wedding bands are acceptable.
• Earrings must be covered by the scrub cap.

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• Protective barriers (gloves, masks, protective
  eyewear, and face shields) are provided by the
  hospital and should be utilized to reduce the
  risk of exposure to potentially infective agents.
  
• Shoe covers are not required. If shoe covers are
  necessary, the wearer should remove them before
  leaving the operating room to avoid tracking
  blood and debris through the department.

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Points to Remember about Aseptic Technique

• The patient is the center of the sterile field.
• Only sterile items are used within the sterile
  field.
• Sterile persons are gowned and gloved.
• Tables are sterile only at table level.
• Sterile persons touch only sterile items or
  areas unsterile persons touch only unsterile
  items or areas.

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• Unsterile persons avoid reaching over sterile
  field sterile persons avoid leaning over
  unsterile area.
• Edges of anything that encloses sterile contents
  are considered unsterile.
• Sterile field is created as close as possible to
  time of use.
• Sterile areas are continuously kept in view.
• Non-sterile persons should stay at least 12
  inches from the sterile field

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• Sterile persons keep well within sterile area.
• Unsterile persons avoid sterile areas.
• Destruction of integrity of microbial barriers
  results in contamination.
• Microorganisms must be kept to irreducible
  minimum.

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• Enjoy your
• experience
• in
• Perioperative Services

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Remember

• Act interested
• Ask questions