Perioperative Nursing

About

➀ Read and Learn

The following course content

Introduction   

Nurses have worked in surgical settings since the beginning of surgery. Nurses acted as the handmaiden (18) for physicians in surgical rooms, assisting with instrumentation patient care, and even as models for some procedures such as phlebotomy (7). Most training for nurses came from the physicians they worked under or religious orders.  

Florence Nightingale, known as the mother of modern nursing, established the first formal school of nursing in 1860 at St. Thomas Hospital in London, England, which began a new era of training nurses different from the medical model and emphasized a unique body of knowledge for nurses, including their role in the perioperative setting8. Initially, the nurse offered anesthesia by applying a cloth soaked in ether or nitrous oxide over the mouth and nose of the patient while the surgeons performed the surgery (9). Gradually, the role of anesthesia advanced into its specialty of anesthesiology. 

Case Study 

Maria Rodriguez is a 62-year-old female who is scheduled for a cholecystectomy today. She has had chronic right upper quadrant pain and diagnostic imaging confirmed she has multiple gallstones blocking the major bile duct. She has a medical history of hypertension, hyperlipidemia, and diabetes. She has a BMI of 40. She is anxious in the preoperative area and nervous about managing post-operative pain. As her perioperative nurse you begin your assessment.  

Introduction to Perioperative Nursing 

Nurses have worked in surgical settings since the beginning of surgery. Nurses acted as the handmaiden18 for physicians in surgical rooms, assisting with instrumentation patient care, and even as models for some procedures such as phlebotomy7. Most training for nurses came from the physicians they worked under or religious orders.  

Florence Nightingale, known as the mother of modern nursing, established the first formal school of nursing in 1860 at St. Thomas Hospital in London, England, which began a new era of training nurses different from the medical model and emphasized a unique body of knowledge for nurses, including their role in the perioperative setting8. Initially, the nurse offered anesthesia by applying a cloth soaked in ether or nitrous oxide over the mouth and nose of the patient while the surgeons performed the surgery (9). Gradually, the role of anesthesia advanced into its specialty of anesthesiology. 

(7) 

Perioperative nursing refers to nurses who specialize in surgical settings. Perioperative is a term that refers to the before, during, and after periods of surgery (3). The three phases include the preparation time known as pre-operative, during surgery is intraoperative, and the phase after surgery is post-operative. Nurses work in all three settings with different roles yet together help the patient through the surgical experience.  

The goal of any surgery is to treat a medical issue to repair or restore someone’s health. The objective of the preoperative stage (pre-op) is to prepare the patient for surgery emotionally, physically, and legally. The operative stage is to complete the interventional purpose of the surgery and includes controlling vital signs, assessing blood tests, maintaining operating room asepsis, providing appropriate anesthesia, and applying any diagnostic tests as needed such as tissue biopsy.  

The immediate post-operative phase focuses on the patient’s safe recovery from anesthesia in a post anesthesia care unit (PACU) where nurses carefully monitor vital signs and offer pain control while the patient wakes up from anesthesia.  

Once a patient has recovered from the anesthesia and is able to wake up, the patient is then moved to a surgical unit for continued recovery. The progressive post-operative phase is then extended to a surgical unit, or the patient may return home if the surgery was considered a “same day” surgery. In either setting, the patient now enters a phase of rehabilitation either at the hospital, at their own home, or a specialized rehabilitation center for days to weeks (4).  

 Surgical settings can vary based on the type of procedure, the medical facility, and the complexity of the surgical procedure. Primary surgical settings include in order of most common to less common:  

• Inpatient Hospital Operative Room: Hospitals have dedicated operating rooms or “suites” with specialized equipment, surgical tools, anesthesia, monitoring devices and a surgical team.  

• Ambulatory Surgical Centers (ASC): Outpatient procedures that do not require a patient to be monitored overnight can be done in an ASC. It is more cost-effective and often more comfortable for the patient to return to their own home. Examples of surgeries in an outpatient surgical center include cataract surgery, some plastic surgery, colonoscopies, and limited orthopedic procedures.  

• Clinic/Physician Office: Minor surgical procedures can be done in a physician’s office such as wisdom teeth extraction, skin lesion removals, and biopsies, which require limited anesthesia and less surgical equipment.  

• Emergency/Trauma Centers: Severe life-threatening injuries and acute medical conditions may be done in an emergency trauma center such as chest tube insertion, thoracotomy, tracheostomy, etc. when the intervention requires immediate repair at the bedside. The same sterile environment and safe procedures must still be adhered to.  

Surgical procedures are categorized on the timing and need for the surgery and include elective, urgent, and emergency. Elective surgeries that are not emergent can be scheduled in advance, based on the preferences of the patient, type of surgical procedure, location setting of the surgery, and surgeon’s availability. Urgent surgeries are necessary to improve the patient’s quality of life and may be needed within 24-48 hours. Examples include bone fractures, infections that require drainage, acute gallstones, and some gynecological procedures such as dilation and curettage after a miscarriage. Emergency surgeries occur immediately and must be performed to save a patient’s life or prevent a severe disability. Acute or life-threatening conditions could include acute appendicitis, severe trauma, active hemorrhaging, or organ damage5.  

Principles of surgical asepsis and sterile technique form the foundation of infection control and safeguard the client from potential complications to promote successful surgical outcomes. Nurses who work in the perioperative settings must be well skilled in aseptic technique practices including rigorous hand hygiene, sterile attire, and the proper handling of surgical instruments and supplies. Surgical attire, a visible manifestation of the commitment to asepsis, plays a crucial role in infection prevention. Surgeons, nurses, and other members of the surgical team don specialized attire, including gowns, gloves, and masks to maintain a barrier between their microbiota and the sterile field.  

The attire is designed to be impermeable and covers the entire body, minimizing the risk of microbial contamination. Proper donning and doffing procedures are followed to maintain the integrity of the sterile environment. Surgical attire not only serves as a protective measure for healthcare professionals but also reflects the dedication to patient safety, ensuring that the surgical team operates within the highest standards of cleanliness and sterility throughout the perioperative phases. (19) 

Additionally, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires specific actions to prevent surgical errors by having a two-minute surgical time-out before anesthesia and the first surgical instrument incision is applied to a patient to prevent wrong-site, wrong-procedure, or wrong-person injuries (9). It is the role of the circulating nurse to uphold the Joint Commission standards with the team.  

Each team member is a valued part of the team and offers specialized skills to help the patient achieve the best possible outcomes from the perioperative setting. Personnel involved in the intraoperative setting may include operating room technicians, who help with the set-up and organization of the operating room equipment. Anesthesia technicians may assist the anesthesia provider by preparing equipment, monitoring patient vital signs, and ensuring proper functioning of the actual anesthesia and analgesia response.  

There may also be surgical reps in the operating room who assist the surgeon in using special or new surgical equipment. Additionally, the team may include medical students, residents, or interns whose role is to observe during their learning process.  

It is critically important to remember that the patient/client is the core member of the team whose preferences and unique physical needs are paramount to the success of the surgery (19, 20). Accommodation should be made to adjust to the patient’s physical and emotional needs. Preoperative education can help decrease patient anxiety and prepare for postoperative recovery. Each nurse the patient encounters should confirm the correct identity and scheduled surgery of the patient. Nurses play a key role in ensuring the safety, comfort, and well-being of the patient receiving the surgery.  

Perioperative Nurse Role and Responsibilities 

There are more nurses involved in the perioperative experience than any other team member, and as such their role involves a range of responsibilities to contribute to the overall success of the surgery and recovery of the patient. Various healthcare professionals make up the dynamic team who work in various surgical settings. From the surgeons, and anesthesia providers, to the surgical technicians and nurses, each offers their unique skills to provide safe, efficient, patient-centered care.  

There is a large variety of roles for nurses in the perioperative setting, which includes the following responsibilities (20, 21):  

• Pre-admission clinic nurse: Nurses who prepare the patient for surgery before the patient even comes to the surgical center. The nurse offers patient education about what to expect, documents to bring, and diagnostic tests to complete before the surgery. This nurse helps confirm the patient is ready for the perioperative experience. Special skills: attention to detail, organization, effective patient education and communication.  

• Nurse screener: This nurse welcomes the patient to the surgical area and confirms all the preparatory documents, labs, and tests have been done. This nurse may also complete initial vital signs. Special skills: attention to detail, assessment of risk factors and social issues that may impact the surgery, organization, effective patient education, ability to closely follow checklists, and clear communication. 

• Day surgery nurse: This nurse will guide the patient through the preoperative experience in each phase for continuity. Because the surgery is done in one day this nurse helps with direct patient care, patient monitoring, and transitioning back home or to a rehabilitation center after the surgery.  

Valuable skills include organization, time management to keep the patient and surgery on time with the schedule, IV management, medication administration, effective communication skills to coordinate with the family and other team members in other phases of surgery.  

• Certified registered nurse anesthetist (CRNA): This is an advanced practice registered nurse who has received specialized master’s degree education and training to work with anesthesia. Special skills: advanced nursing practice education and training, meticulous attention to detail, strong understanding of pharmacology, full knowledge of the effects of anesthesia and analgesia, and strong assessment skills to recognize compromise of vital signs.   

• Preoperative surgical nurse: The preop nurse prepares a patient physically for surgery by having the patient change into a surgical gown, shaving any hair around the surgical area, starting an IV, offering patient education, and communicating with the operating circulating nurse regarding the time for entry into the operating room. Special skills: intravenous insertion, organizational skills, time management, physical assessment.  

• Circulating nurse: This nurse works in the operating room and helps with communication with all team members. The nurse does not surgically scrub and dress to be next to the patient during the operation but is able to circulate among the rooms to gather needed supplies and equipment. The nurse helps maintain a sterile environment during surgery and manages the flow of communication and materials needed. Special skills: organization, seeing the big picture, sterile technique and asepsis management, communication with team members.  

• Surgical scrub nurse: This nurse will wash and don a surgical gown and become part of the actual surgical team completing the surgery on the patient. Historically, this nurse was the one handing the surgical instruments to the surgeon and manipulating retractors, but this has been replaced more commonly with a surgical technician. Scrub nurses have the task of maintaining the sterility of the surgical instruments and counting surgical instruments and supplies to prevent any items being left inside the patient such as sponges, gauze, or even instruments. 

Valuable skills include meticulous sterile technique and asepsis management, knowledge of surgical instrumentation and surgical procedures, infection control methods, patient positioning, positioning devices, awareness of ergo metrics for the patient and surgical team and working well with surgeons.  

• PACU nurse: this nurse receives the patient from the operating room and cares for the patient during the initial 1-4 hours as the patient recovers from anesthesia. The primary goal is to secure the airway and help the patient with pain control, waking up, and recognition of any anaphylaxis or complications from surgery including hypoxia, or blood pressure extremes. The PACU nurse also manages common side effects of surgery including pain, nausea and postoperative nausea and vomiting (PONV). 

Valuable skills include excellent physical assessment of any complications from surgery such as pressure injuries, nerve and musculoskeletal injuries, compartment syndrome, allergies, eye injuries, airway management and detection of airway complications, patient positioning and detection of any pressure injuries and devices used.  

• Discharge nurse: some facilities will have a nurse dedicated to the transition from PACU and surgical setting back to their own home or a surgical unit in the hospital. The discharge nurse helps the patient with education about medications and durable medical equipment such as wheelchairs or elevated toilet seats, etc. Valuable skills include good communication and patient education, medication reconciliation, ability to problem solve, and coordinate with social services and insurance representatives to order special equipment.  

Educational Requirements and Skills 

Nurses play a pivotal role in ensuring the safety, comfort, and well-being of patients throughout the surgical journey. In the dynamic and intricate environments of the perioperative settings, nurses have advanced skills and serve as crucial members of the surgical team, with responsibilities that range from patient advocacy and communication to aseptic technique and surgical site care14.  

Because of the unique settings and advanced responsibilities in the perioperative experience, nurses who work in these areas must obtain additional and specialized training (22).  

The general requirements for a nurse to work in any area of the perioperative setting include the following:  

• Nursing Degree: a perioperative nurse must be a Registered Nurse (RN). RNs may have either an associate degree or a bachelor’s degree from an accredited nursing school. Only the CRNA must have a master’s degree as an advanced practice nurse.  

• Licensure: A qualified graduated nursing student is required to then pass the national certification licensure exam (NCLEX), and be licensed in the state they practice in. 

• Medical Surgical Nursing Training: Most perioperative settings require the nurse to have 1-2 years of general medical surgical nursing to gain the necessary skills of medication administration, thorough physical assessment, prioritization, time management, intravenous fluid and electrolyte management, and knowledge of basic diagnostic tests and treatments. Basic knowledge of anatomy and pathophysiology are essential to understand what the patient’s medical condition is. Safe patient positioning and communication are essential skills.  

The fundamental nursing skills for a nurse in any perioperative role involve the same basic skills of physical assessment, monitoring vital signs, clinical judgment, strong communication skills with the patient, family, and team members, reviewing lab and diagnostic tests, completing doctor’s orders, and serving as an advocate for the patient among the professional team (22).  

Perioperative nurses must consider age and cultural needs in care planning. Patient education and even monitoring need to be adjusted when working with elderly or pediatric patients. Age-related pharmacokinetics reduced physiological abilities, communication styles, and assessments need to be modified when working with the elderly, persons with disabilities, and children. Helping clients regulate temperature during the perioperative experience as patients travel through the different phases of surgery requires extra attention for children and the elderly.  

Collaborating with the patient’s family or caregivers is vital as they play an important role in the recovery and support of the patient before and after surgery. Communicating may include navigating language barriers, which requires professional translators to ensure accurate information is shared. Cultural sensitivity and awareness extend beyond recognizing a patient is from a different ethnicity, but acknowledging their unique values, beliefs, norms, practices, and ability to adhere to physician orders after surgery. Perioperative nurses collaborate using a variety of nursing skills and expertise to deliver patient-centered and compassionate care throughout the perioperative experience (23).  

Perioperative Training 

After a nurse has gained experience in basic nursing skills, they may apply for a position in any perioperative area and receive on-the-job training (23). Nurses must learn the different phases of the perioperative experience and gain the skills for each area they will work in. Ideally, perioperative nurses can be cross trained to work in each area.  

The preoperative area requires the ability to manage many patients promptly and prepare them quickly for surgery for timely entry into the operating room to keep the surgical schedule moving forward. As a patient transitions from the preoperative preparation area to the operating room and then into the PACU, a dynamic process occurs that demands that the nurses at each phase work together, collaborate, and share critical information about the patient with each other. Nurses should be well-skilled in giving and receiving reports in the SBAR format (situation, background, assessment, recommendation).  

Vital signs should be updated and other relevant information pertinent and unique to the patient such as past medical history of diabetes, hypertension, COPD, or respiratory problems, etc. Scrub or circulating nurses should inform the PACU nurse about patient positioning, medications the patient received, and how the patient tolerated surgery, in addition to the time of surgery, and any airway problems (13).  

PACU and postoperative nurses need to be skilled in assessing and managing common postoperative complications, including nausea and vomiting (PONV), pain, anaphylaxis, hypoxia, blood pressure extremes of hypotension or hypertension, cardiac complications and dysrhythmias, fluid and electrolyte imbalances, residual muscle paralysis, hypothermia, malignant hyperthermia, and neurological problems such as difficulty waking up from anesthesia.  

These demanding nursing responsibilities require additional training to work in the perioperative settings (14). As PACU nurses must be skilled to deal with acute emergencies from threats to airway, breathing, and circulation from anesthesia, hospitals will often only hire RNs who have had additional training, education, and work experience in a critical care setting such as an intensive care unit or the emergency department. Working in a critical care unit also requires at least 1-2 years of general work experience in a medical or surgical unit and a course in critical care nursing (15).  

Certification in Perioperative Nursing 

The importance of perioperative nurses and their contribution to the perioperative team cannot be overstated as their skills and knowledge make a difference in the positive surgical patient experiences (17).  Although certification is not required, it can be highly recommended for perioperative nurses for personal satisfaction, skill validation, and increased respect among surgical team professionals.  

CNOR serves as a validation of professional achievement for perioperative nurses. The initials CNOR stand for Certified Perioperative Nurse, and not for “Certified Nurse, Operating Room” (16). It is the only accredited certification for perioperative registered nurses and applicants must work a minimum of two years in perioperative practice before taking the required exam. Over 40,000 nurses internationally have earned the distinctive certification which validates the nurse’s knowledge of advanced skills in perioperative settings.  

Candidates for the exam must first meet the eligibility requirements for certification, which include the following (16):  

• Current unrestricted RN license in the country and state of practice.  

• Currently working full or part-time in perioperative nursing practice, nursing education, research, or administration.  

• Minimum of 2 years and 2400 clinical experience with a minimum of 1200 hours in the intraoperative setting.  

The exam has 200 multiple choice questions, is computer based, and allows the candidate almost 4 hours to complete. The content includes topics such as professional accountability, emergency situations, infection prevention and control, instrumentation and supplies, patient assessment and diagnosis, development of a customized plan of care and outcome identification, patient care safety, and management of services and materials.  

The application and exam process can take several months after the candidate completes an application online through the website www.cc-institute.org/cnor. The process includes administrative oversight to confirm your eligibility, approval to schedule the exam with Professional Services (PSI Exam Scheduling), taking the exam and receiving notice of exam results. CNOR offers specialty designations by recognizing CNOR-certified nurses in a variety of work settings including pediatrics, orthopedics, obstetrics, robotic surgery, cardiology, and bariatrics. The application fee is $445 or $495 to have two chances to take and pass the exam (16).  

Nurses can use a variety of resources and textbooks to prepare and study for the exams found in the resources list of this continuing education course. Nurse candidates can also take practice tests offered by the CNOR organization online or review courses, like many other specialty certifications.  

Resources 

• AORN Position Statements and endorsed documents are found at http://www.aorn.org/guidelines/clinical-resources/position-statements 

• AORN. (current edition). Guidelines for perioperative practice.  

• Alexander’s Care of the Patient in Surgery: Chapters 1, 2, & 29  

• Berry & Kohn’s Operating Room Technique: Chapters 2, 3, 11, & 21 

• Odom-Forren, J. (Ed.). (2024). Drain’s perianesthesia nursing: A critical care approach (8th Ed.). Elsevier.  

• Phillips, N., & Hornacky, A. (2021). Berry and Kohn’s operating room technique (14th ed.). Elsevier. (Key=B&K) • Rothrock, J. C. (Ed.). (2023). Alexander’s care of the patient in surgery (17th ed.). Elsevier. (Key=Alexander’s)  

Organizations 

• Association for the Advancement of Medical Instrumentation (AAMI): • https://www.aami.org/  

• Association for periOperative Registered Nurses (AORN0: • https://www.aorn.org/ American  

• Society of PeriAnesthesia Nurses (ASPAN): • https://www.aspan.org/ Association for  

• Professionals in Infection Control and Epidemiology (APIC): • https://apic.org/ Association for  

• Nursing Professional Development (ANPD): • https://www.anpd.org/ Healthcare Sterile  

• Processing Association (HSPA) (Formally IAHCSMM): • https://myhspa.org/ 

Case Study 

Let’s revisit our original patient, Maria Rodriguez. In this case scenario, she had a previous medical history of multiple chronic conditions that could impact her outcomes, and she was fearful of having surgery. You now have a better understanding of the variety of perioperative nurses she will encounter. Knowing the process of how a patient will move from the initial screening before surgery and then the perioperative, intraoperative, and postoperative areas, can give you the knowledge to better prepare her for the surgical experience and recovery. Being able to tell her about the different areas, and the qualified and compassionate healthcare team professionals in each setting, can help calm her anxiety. Being able to provide appropriate patient education about how she will be cared for throughout surgery and recovery from anesthesia with pain management and comfort in mind, can help decrease her fear and enhance her confidence in the team.  

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate