1. Pre- and Post-operative Patient Assessment and Diagnosis
This topic focuses on the nurse’s role in evaluating and preparing patients for surgery, as well as their responsibilities in post-operative assessment. Key elements include:

• Preoperative Assessment: Gathering and reviewing patient history, conducting physical assessments, evaluating lab and diagnostic test results, and identifying any risk factors.

• Risk Assessment: Assessing for potential complications like anesthesia risks, bleeding disorders, or infection susceptibility.

• Postoperative Assessment: Monitoring vital signs, recognizing signs of complications (e.g., infection, respiratory issues), and ensuring pain management and comfort.

• Patient Education: Providing pre- and post-operative instructions regarding wound care, medication, and activity restrictions, ensuring the patient and family understand expectations and care procedures.

2. Individualized Plan of Care Development and Expected Outcome Identification

This topic covers the formulation of a tailored perioperative care plan that aligns with each patient’s unique needs and medical condition. Key elements include:

• Care Plan Creation: Developing a personalized plan based on patient assessment data, surgical procedure, and anticipated outcomes.

• Goal Setting and Expected Outcomes: Identifying specific, measurable goals for intraoperative and postoperative care, focusing on factors like pain management, wound healing, and mobility.

• Coordination with Surgical Team: Communicating the individualized care plan with other OR staff (anesthesiologists, surgical techs) to ensure a cohesive approach to care.

• Documentation of Expected Outcomes: Recording goals and anticipated outcomes in the patient’s chart, enabling effective post-op assessment and goal adjustment if necessary.

3. Management of Intraoperative Activities

This topic involves the nurse’s role in maintaining a safe and efficient operating room environment during surgical procedures. Key elements include:

• Patient Positioning and Safety: Ensuring the patient is positioned properly to prevent injury and facilitate the surgical approach, while regularly monitoring for pressure sores or other risks.

• Anesthesia Monitoring Support: Assisting anesthesia providers by monitoring vital signs and promptly reporting any changes.

• Surgical Asepsis and Sterility: Adhering to sterile techniques to prevent contamination, managing surgical instruments, and monitoring the OR environment for compliance with aseptic standards.

• Equipment Operation and Troubleshooting: Ensuring that all OR equipment functions correctly and addressing any technical issues during the procedure.

4. Communication and Documentation

This topic emphasizes effective communication and meticulous documentation to support continuity of care and legal requirements. Key elements include:

• Communication with Surgical Team: Collaborating with surgeons, anesthesiologists, and other team members to ensure patient safety and a coordinated surgical approach.

• Patient Handoff: Using standardized communication techniques (e.g., SBAR - Situation, Background, Assessment, Recommendation) to hand over patient care responsibilities smoothly during shift changes or transfers.

• Intraoperative Documentation: Recording all significant aspects of the procedure, including patient position, medications administered, instrument count, and any notable events or changes in patient status.

• Postoperative Report: Completing a detailed report for the recovery or postoperative team to provide a clear picture of intraoperative events and postoperative care needs.

5. Infection Prevention and Control of Environment, Instrumentation, and Supplies

This topic focuses on strategies for minimizing infection risk and ensuring a sterile operating environment. Key elements include:

• Aseptic Technique Maintenance: Proper gowning, gloving, and sterilization procedures to prevent infection.

• Instrument Sterilization and Handling: Ensuring all instruments and supplies are properly sterilized before use, and adhering to best practices in handling and storage to prevent contamination.

• Environmental Control: Monitoring and managing OR environmental factors, including air quality, temperature, and cleanliness, to minimize infection risk.

• Waste and Sharps Disposal: Following protocols for the safe disposal of waste and sharps to protect staff and prevent cross-contamination.

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6. Emergency Situations

This topic prepares nurses to recognize, respond to, and manage emergencies that may occur in the OR. Key elements include:

• Recognition of Emergencies: Identifying signs of emergent conditions such as cardiac arrest, respiratory failure, hemorrhage, or anaphylaxis.

• Response Protocols: Executing protocols for emergency situations, including calling for help, initiating CPR, and preparing emergency equipment like defibrillators.

• Crisis Communication: Communicating effectively under pressure with the surgical team and other support staff during emergencies to ensure rapid and coordinated response.

• Documentation of Emergency Events: Thoroughly documenting the details of the emergency, including the sequence of events, interventions provided, and patient outcomes.

7. Professional Accountabilities

This topic covers the ethical, legal, and professional standards expected of perioperative nurses. Key elements include:

• Adherence to Ethical Standards: Upholding patient rights, maintaining confidentiality, and advocating for patient welfare in all aspects of care.

• Regulatory Compliance: Understanding and following state and federal laws governing nursing practice, as well as adhering to hospital policies and OR standards.

• Continuing Education and Professional Development: Engaging in ongoing education, certification maintenance, and staying informed of advances in perioperative nursing.

• Role as a Patient Advocate: Acting as a liaison between the patient and the surgical team, ensuring that patient needs and preferences are respected throughout the perioperative process.