Zander

CNOR Exam ®

Preparation Course
2025-2026

[Link]
803.271.0744 Certification Courses available for CNOR, CAPA/CPAN , and CST
 Zander Perioperative Education, LLC

Zander
CNOR Exam Preparation Course

Wendy Zander MSN/Ed, RN, CNOR

Wendy@[Link]

Instructor
Wendy Zander MSN/Ed, RN, CNOR
wendy@[Link]
803-271-0744

Wendy Zander MSN/Ed, RN, CNOR

239 Bradford Hill Rd
Mills River, NC 28759
803-271-0744
wendy@[Link]

Disclosure
• To receive contact hours nurses must attend 100% of this CNE
activity and submit an evaluation form.
• Neither the speaker nor members of the planning committee
have relevant financial relationships with ineligible companies
related to the content of this activity..
• This nursing continuing professional development activity was
approved by the North Carolina Nurses Association, an
accredited approver by the American Nurses Credentialing
Center’s Commission on Accreditation

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Test Taking Strategies

Objective:
Apply Test Taking Strategies for the CNOR exam

• Registering for the exam

• Exam Format
• Time Management
• Test Taking Strategies
• AORN Recommended Practices

Exam Requirements
• Currently working full or part-time
• Current RN license
• 2 years and 2400 hours of recent surgical practice
▫ 1200 of these hours in the OR
▫ 18 months for CST, TS-C instead of two years.
• $40 Discount Available
▫ DAISY award recipients
▫ Active CCI credential
outside of CNOR

Exam Requirements
• Take 2 Program
▫ For initial certification
▫ Two chances to pass in a 12-month period
 Application for first attempt by last day of month 5
 Application for final attempt by last day of month 9
• Facility Take 2 Program
▫ $467 per person
▫ At least five people
▫ Payment as a single transaction from facility

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Exam Requirements
• A percentage of applications are audited
▫ 30 days to comply
▫ Verification of nursing license
▫ Contact current and past employers
▫ No Refund for failed audit

• Accommodations
▫ Documentation from healthcare provider with
description and recommendations for
accommodation
▫ Notify CCI of request during application

Application Deadlines and Testing Windows

Application Application
Testing Months Testing Months
Approved Approved
January February, March, April July August, September, October
September, October,
February March, April, May August
November
October, November,
March April, May, June September
December
November, December,
April May, June, July October
January
December, January,
May June, July, August November
February
June July, August, September December January, February, March

[Link]

After Application Approval

• Authorization to test email
▫ Email From CCI with your candidate ID number

• Scheduling the exam

▫ [Link]
▫ 24-48 hours after application before you can schedule
▫ Special accommodations if you have a disability

• Remote Secured Proctored Exam (RSPE) 24/7

▫ Monday through Saturday at a PSI testing center
▫ System check of computer prior examination

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Delaying the test

• Reschedule in same test window up to 48 hours prior
with no penalty

• CCI does not permit withdrawal of application

▫ Application fee is forfeit

• Roll into next test window $75

▫ You can transfer two the next test window only twice
▫ You cannot transfer the Take 2 second attempt

The Day of the Exam

• Arrive on time
• What to bring with you
▫ Valid ID
▫ As little as possible
• Lockers
• The testing environment

About the Exam

• 200 questions / 3 hours and 45 minutes to
complete

• Multiple Choice only

• Scaled Score
▫ Pass/fail notice immediately after test
▫ A score of 620 is passing

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Subject Area Percent Number of

of Exam questions
1. Pre/Post Patient Assessment and 15% 28
Diagnosis
2. Plan of Care Development and Expected 8% 15
Outcome Identification
3. Management of intraoperative Activities
a. Patient Care and Safety 25% 46
b. Management of Personnel, Services and 9% 17
Materials
4. Communication and Documentation 11% 20
5. Infection Prevention and Control 16% 30
6. Emergency Situations 10% 18
7. Professional Accountability 6% 11
Total 100% 185

The Nursing Process

• The exam is presented in the nursing process

• Feel comfortable with it

▫ Assessment
▫ Nursing Diagnosis
▫ Identification of Outcomes
▫ Planning
▫ Implementation
▫ Evaluation

What if you don’t know?

• Umbrella answer
• Same answers are ruled out
• Opposite answers
• Odd man wins
• Repeated words
• Absolutes

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Test taking tips

• Read and follow directions carefully!

• Think AORN’s Guidelines for Perioperative Practice

• Nursing practice only!

• Consider other options before calling the supervisor

• Patient safety is top priority

Study Tips
• Assess your level of competency
• Study according to your competency level in each
area
• Organize a study group if you study best that way
• Practice tests until you feel comfortable

Choosing Study Aids

• Utilizes same test question structure as CNOR exam
• Utilizes as References:
▫ Berry & Kohn’s Operating Room Technique 15th ed.
▫ Alexander’s Care of the Patient in Surgery 17th ed.
▫ AORN’s 2025 Guidelines
▫ Odem-Forren Drain’s Perianesthesia Nursing 8th ed.

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Don’t Freak out

CNOR Recertification
®

• Earn 300 points to recertify your CNOR

▫ Precepting, Presenting, Microcredentials, ACLS/BLS/PALS
• Currently working in Perioperative Nursing
▫ 500 hours perioperative
And
▫ 250 of those hours intraoperative

Recertification: Points Jan 1 – March 31 $406

April 1- Dec 31 $446
Emeritus (Retired) Status $184
File for Extension $257

Test Taking Strategies Quiz

• 11 Questions
• 11 Minutes

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Test Taking Strategies Quiz

1. During a procedure under local anesthesia, the pa�ent complains of circumoral numbness,
blurred vision, and dizziness. What should be the immediate ac�on of the periopera�ve nurse
monitoring this pa�ent?

a. Recheck the dose of local anesthesia given

b. Ensure an airway
c. Set the IV line to full flow
d. Call for 20 lipid emulsion to be brought to the room

2. The circula�ng nurse reports that the needle count is incorrect. The surgeon con�nues to close
the wound, sta�ng, "I know it is not in the wound and I am not going to stop to look for it." The
best plan of ac�on is to:

a. Accept the surgeon's response without comment and fill out an incident report
b. Inform the surgeon of hospital policy and document subsequent ac�ons
c. Order X-rays regardless of the surgeon's wishes
d. No�fy the OR supervisor and ask for advice

3. A new employee unknowingly dispensed an unsterile solu�on to the sterile field. The following
day, the supervisor learns of the incident. The supervisor's first ac�on would be to:

a. Ini�ate an incident report

b. Instruct the employee on the technique of reading labels
c. Counsel the employee verbally
d. No�fy the surgeon of the break in technique

4. Due to an emergency, the periopera�ve nurse is unable to conduct the sponge, sharps, and
instrument counts. At the conclusion of the surgery, the nurse should:

a. Ask the surgeon to sign the count

b. Immediately no�fy the OR supervisor
c. Document the absence of counts
d. Document an occurrence report in the patient record

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5. The op�mum pa�ent posi�on provides:

a. Access and exposure, maintains circulatory and respiratory func�ons, and does not
compromise neuromuscular structures.
b. Op�mum access and exposure to surgical site, with no permanent compromise to
neuromuscular structures.
c. Access for the surgeon, does not compromise the neuromuscular structures, and
maintains an adequate airway for the anesthe�st.
d. Sustained circulatory and respiratory func�ons, does not compromise neuromuscular
structures, and maintains body alignment.

6. A pa�ent who is 8 months pregnant is to undergo an emergency laparotomy. In planning nursing

care for this pa�ent, the periopera�ve nurse should have available a wedge cushion or pillow to
place under the pa�ent's:

a. Knees
b. Le� side
c. Right side
d. Shoulders

7. You’re loading the sterilizer with trays and wrapped towels. The correct configura�on would be:

a. The towels are on the botom shelf and the trays on the top shelf
b. The towels are on the top shelf and the trays are on the botom shelf
c. The trays and towels go on the top shelf and leave the botom shelf empty
d. There is no specific configura�on when there is a mixed load of trays and wrapped
tex�les

8. During the induc�on of anesthesia, the periopera�ve nurse may no�ce fascicula�on as a
response to which of the following depolarizing muscle relaxants?

a. Tubocurarine chloride (curare)

b. Succinylcholine chloride (Anec�ne)
c. Atracurium besylate (Tracrium)
d. Pancuronium bromide (Pavulon)

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. The ER no�fies you that it has an 18-yr-old pa�ent who was in a sledding accident and who is
accompanied by his parents. The pa�ent is alert, oriented, in pain, has a blood pressure of
80/60, pulse of 120, and RR of 24. The abdomen is distended and tender. A�er being transferred
to the OR bed, the pa�ent is very apprehensive and complains of being cold. The nurse should
confirm the pa�ent's name, allergies, and opera�ve procedure by:

a. Speaking with the pa�ent and reading the pa�ent's chart

b. Telephone conversa�on with the ER nurse
c. Use of the ER record provided
d. onversa�on with a parent of the pa�ent

1 . A cri�cally injured pa�ent requires immediate surgery, but all unassigned personnel have limited
OR experience. In this situa�on, the charge nurse should:

a. Assist the available personnel in caring for the pa�ent

b. Reassign experienced personnel to the emergency procedure
c. Personally assume care for the cri�cally injured pa�ent
d. Call in addi�onal personnel to handle the emergency

11. The nurse's ini�al response to a pa�ent who develops signs of cyanosis during the preopera�ve
assessment is to:

a. Administer O2 and start an IV line

b. Begin CPR
c. Read the history and physical to determine health status
d. Assess for breath sounds and airway obstruc�on

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Study Plan
Objective:
Create a Personal Study Plan

• Learning Styles
• Study Plan

What is your learning style?

• How do you figure things out in an unstructured
learning situation?

• Learning Style Quiz

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WHAT IS YOUR LEARNING STYLE?

Here are some questions you can ask yourself to help determine the learning style you prefer.
The questions are organized by which modality (kinesthetic, visual and auditory) a person
prefers for different learning tasks: taking in and organizing new information, decision making,
and remembering and creating.

Questions to determine the taking in and organizing preference:

1. I learn new information best by:

k ( ) participating in an activity myself after a short explanation
v ( ) reading or looking at a diagram or demonstration
a ( ) listening to a lecture or spoken instructions

2. When I am inactive but need to stay alert, I :

k ( ) find ways to move
v ( ) stare, watch something, or doodle
a ( ) listen to sounds around me, hum, or talk to myself

3. I have these qualities:

k ( ) Interact best by moving, doing, physical contact and like hands-on activity
v ( ) Connect with others through eye contact and need visual order
a ( ) Interact easily by talking and like lectures and discussions

4. The kind of language I most commonly use is:

k ( ) how do you feel about this, I can’t grasp that, that is comfortable for me
v ( ) look at it this way, I just can’t see the point, that is crystal clear to me
a ( ) can I tell you how I think about that, do you hear me, that sounds right to me

5. My emotions are apparent to others by:

k ( ) muscular state and movement
v ( ) facial expression
a ( ) voice tone

Questions to determine the decision making or sorting preference:

1. As part of my sorting process, I:

k ( ) use my hands to find words
v ( ) use writing, drawing, or visual images to find words and feelings
a ( ) recall information through words such as a quote or the line of a song that fits
that fits the situation

2. If I am trying to make a decision, it helps me to:

k ( ) do something physical like go for a walk
v ( ) write, draw, or look at nature
a ( ) speak to someone or listen to something

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3. I can do these things at the same time:

k ( ) move or touch something and also feel emotions deeply
v ( ) see things externally and also have inner visual images
a ( ) listen to external sounds and to own thoughts, listen to radio and read

4. For me intimacy involves:

k ( ) talking about feelings and fantasies or having total silence and eye contact
v ( ) seeing and being seen, especially deeply receiving someone with own eyes
a ( ) hearing and being heard, speaking slower to become more personal

Questions to determine the remembering and creating preference:

1. It takes longer for me to access:

k ( ) physical sensations
v ( ) visual images
a ( ) words and sounds

2. A characteristic I have is:

k ( ) disliking most physical competition and being able to sit still a long time
v ( ) becoming overwhelmed by visual detail and disliking eye contact
a ( ) “spacing out” from lots of spoken words and navigating through questions

3. Another quality I have is that I:

k ( ) am relatively unaware of bodily sensations
v ( ) get lost in visual material
a ( ) get lost in conversation or listening to a lecture

4. If I am listening to someone on the phone, I would be most distracted by:

k ( ) someone putting their hand on my arm or massaging my shoulders
v ( ) someone giving me something they want me to read
a ( ) someone asking me a question or playing loud music

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AVK – Must talk to learn

• Get in a Study Group
• Handheld recorder
▫ Audio and visual version of notes
▫ Read along with your recording
• Share what you are learning with others
• Participate in study group discussion

AKV – Listen while moving

• Don’t be sedentary for long periods
▫ Not a study group
• Handheld Recorder
▫ Audio Notes directly
from textbooks
▫ Listen during
movement
• Must get up to move
about
• Memorize lists by putting to music or rhyme

KVA – Physical activity a must

• Don’t be sedentary for long periods
▫ Not a study group
▫ Short study sessions
▫ Flash cards – visual notes on the move
• Retype notes into a word document
• Fidgeting = learning

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KAV – Physical activity a must

• Hates to read directions – figures it out

• Don’t be sedentary for long periods
▫ Not a study group
• Handheld Recorder
▫ Audio Notes directly from textbooks
▫ Must be moving while listening

• Most ready to retain information during

or immediately after physical activity

VAK – Must teach to learn

• Study best with minimal visual clutter
• Organize and rewrite your notes as if you are
preparing to teach
• Video recording of yourself discussing the topic
• Great note taker
▫ Review notes often

VKA – Traditional Learning Style

• Study groups work well for you
• Flash cards – make your own
• Make up stories about the topics you are learning
• Take notes and review them often
▫ Highlight
▫ Write thoughts in the margin as you study

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How to study
• Tips from learning style
• Gather notes and study materials
• Assess your strengths and weaknesses
• Create study tools
• Schedule Study time

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Sterile Processing
Objective:
Describe the preparation of the sterile supplies for use in surgery

• Spaulding Classification System • Endoscopes

• Decontamination of instruments • Quality Control
• Sterilization of instruments • Packaging

Spaulding Classification System

• Critical
▫ Must be sterile
▫ Will enter sterile tissue or the vascular system

• Semi-critical
▫ Should be sterile but High-level disinfection acceptable if
manufacturer’s instructions require
▫ Contacts broken skin or mucous membrane

• Non-critical
▫ Intermediate or low-level disinfection or cleaning
▫ Will come in contact with skin

Spaulding Classifications Examples

• Critical
▫ Instruments
▫ Cutting endoscopic accessories and endoscopes Cardiac and
urinary catheters
▫ Needles

• Semi critical
▫ Respiratory Therapy / anesthesia equipment
▫ Bronchoscopes / GI endoscopes

• Noncritical
▫ OR bed
▫ Linens

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Workflow for sterile processing

• There should be a physical separation between a
decontamination and processing area

• Workflow should progress from:

▫ Decontamination
▫ To preparation and packaging
▫ To sterilization processing
▫ To clean distribution / storage

Decontamination of Instruments
• Cleaning is the most critical step to prevent infection
• Pre-treating recommended
• Disassemble anything that can be
• Brush lumens, channels, crevices and joints
• Automated cleaning
▫ Ultrasonic
▫ Washer

Sterilization - Steam
• Pre-vacuum autoclave (Dynamic Air-Removal)
▫ Sucks air out of the chamber
▫ Clean drains are essential
▫ 270°F to 276° F (132° C-135.5° C)
 Porous/lumen items in 4 min
 Nonporous in 3 min
• Gravity displacement autoclave
▫ Steam forces air from chamber
▫ Thermometer closes drain
▫ 270°F to 276° F (132° C-135.5° C)
 Porous/lumen items in 10 min
 Nonporous in 3 min

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Short-Cycle Sterilization
• Common to ophthalmology centers
• Dry time shortened according to manufacturerer’s
IFU

Steam Sterilization –
Avoiding Condensation
• Allow air flow between trays
• Remove loads immediately. Leaving the door ajar
to cool increases likelihood of condensation
• Don’t put hot items on a cool solid surfaces or racks
• If condensation occurs and the items are moist,
they are considered non-sterile

Chemical Indicators

• Class 1 – Heat
• Class 2 – Pressure – Bowie Dick
• Class 3 – Single parameter
• Class 4 – Multi parameter
• Class 5 – Integrated
▫ All parameters
• Class 6 – Emulating Indicator
▫ All parameters of a particular cycle

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Immediate Use Steam Sterilization

• No packaging, wrapped items or textiles

• Same decontamination process
• Rigid Sterilization containers with lid
• Must use a class 5 chemical integrator
• Never an implant unless emergent.- biological 1st
• Sterilization log must be kept

Sterilization - Glutaraldehyde
• “Cold sterilization”
• Point of care use only.
• Takes 10 hours of immersion
• Bad for instruments
• Suboptimal form of sterilization
▫ Environmental problems
▫ Poor ease of use

Sterilization – Ethylene Oxide

• For heat and moisture sensitive items
▫ 99-145° F and 45-75% humidity
• 2-5 hours exposure
• Aeration time 8-12 hours
• Human Carcinogen
▫ Exposure limited to 1 ppm
in an 8-hour period
• Lumens must be completely Dry
• Environmentally hazardous

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Low Temp Hydrogen Peroxide

Plasma Sterilization
• Sterrad or V-PRO
• Used for Heat and moisture sensitive items
• No aeration cycle needed. This is Dry Sterilization
• Cycle time is 75 minutes
• Environmentally sound

Peracetic Acid
• Automated Endoscope Reprossesor (AER)
• For items that can be immersed
• Corrosive to instruments and people
• Temp 120°-130°F
• 20-30 min
• Micron filtered tap water rinses – four of them
• For point of care use only
• Documentation

Ozone
• Low Temperature Sterilization
• Only one manufacturer in the USA
• FDA has cleared ozone for sterilization of metal and
plastic.
• Exhaust is passed through a catalytic converter
• Environmentally sound
• No aeration cycle is necessary

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Dry Heat
• High Temperature
• Best for heat stable powders and oils
• Dental instruments
• Burrs
• Reusable Needles
• Glassware
• Don’t use tape

Quality Control
• Items should be traceable from the method of
sterilization.

• Lot control #,load or cycle # and date and time

should be documented for each item

• Sterile technique is founded in individual’s surgical

conscience.

Biological Challenge (Spore Testing)

• Autoclave
 Daily biological (Ideally) for gravity displacement and
Pre-vacuum
 Daily Bowie-Dick for Pre-vacuum
 Uniform pattern indicates that the vacuum cycle has
functioned properly
 With every implant
• Ethylene Oxide
 With every load
• Sterilization Log required

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Sterilizer Testing
Type of Sterilizer Type of testing

Steam – Gravity Displacement and Prevacuum Geobacillus Stearothermophilus spore testing at

least weekly and preferably daily
Prevacuum An air removal test like Bowie Dick should be done
daily in an empty chamber. For new, renovated or
moved equipment three consecutive successful air
removal tests should be done before the biological

Ethylene oxide Bacillus atropheus spore testing should be done

with every load
Plasma Bacillus atropheus spore testing done at the same
interval as other sterilizers in the facility

Ozone Geobacillus Stearothermophilus spore testing

done daily
Peracetic Acid Geobacillus Stearothermophilus daily

Dry Heat Bacillus atropheus indicators upon installation and

after any repair. (Table top type monitored weekly)

Packaging
• Must work with the type of sterilization
• Must allow for identification of the contents
• Weight should not exceed 25 lbs.
• Lint free
• Free of holes
• Sterile storage areas must
not exceed 75° F or 60%
humidity

Packaging and Sterilization

• No textiles, peel pouches or rubber mats inside of
the tray
• Instruments disassembled
• Instruments in open, unlocked position
• Integrator in the corner of the tray
• Indicator on the inside and outside of the tray
• Count sheets on the outside of trays

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Peel Pouches
• Not stacked inside of Sterilization chamber
• Write on the plastic, not on the paper
• Not for use with heavy items i.e. drills
• Double pouching:
▫ With manufacturer’s instructions only
▫ Inner pouch fits without being folded
▫ Facing same direction

Endoscopes
• Manual cleaning on the field
▫ Clear lumen with water
▫ Wipe exterior
• Kept damp or wet but not submerged during delay or
transport to decontamination
▫ Not allowed to dry

Endoscopes
• Additional cleaning if:
▫ Simethicone
 Difficult to remove
 Don’t add it to the water bottle, add low concentration
directly into the working channel
▫ Radiographic medium
▫ Lubricants / tissue adhesive
▫ Poor bowel prep (emergent)
• Hand-over process includes this information

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Endoscopes
• Clean within an hour or follow delayed processing
instructions
• Hand-over process from transporter to
decontamination
▫ Communication about end of procedure time
• Leak testing is performed before placed in cleaning
solutions
• Visually inspected after manual cleaning
▫ Use 10x magnification and borescope

Endoscopes
• Sterilized when possible
• Disposable Endoscopes or components
▫ Distal end cap and elevator on duodenoscopes
• Sterilization validation daily
▫ ATP testing, Protein testing, Hemoglobin, etc.
▫ High risk flexible endoscopes every use
 Duodenoscopes, ultrasound endoscopes, bronchoscopes,
ureteroscopes, cystoscopes

Endoscopes
• Actively dried after processing
▫ Minimum of 10 minutes or no visible moisture
 Borescope inspection or moisture detection test
▫ Automated air purge cycle in AER doesn’t count as drying
unless extended time feature used
• Comfortable working conditions in processing area
▫ Ergonomics
▫ Frequent breaks from hot PPE
▫ Cooling devices

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Endoscopes – Storage
• Not stored in procedure rooms
• Stored in a drying cabinet
• Risk assessment to established storage times
▫ Frequency of use
▫ Patient population
▫ Handling
▫ Transporting and processing compliance
▫ Drying storage cabinet
▫ Restricted access storage area
▫ Type of endoscope

Sterile Processing Quiz

• 15 Questions
• 15 Minutes

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Sterile Processing Quiz

1. The bowie-dick test is used to determine

a. Proper func�oning of the vacuum system
b. The concentra�on of ethylene oxide gas
c. Achievement of steriliza�on
d. Adequate temperature requirements

2. A prosthesis is contaminated during an orthopedic case and a suitable replacement is not

immediately available. ow should this prosthesis be sterilized?
a. Immediate use steriliza�on 2 0° F for 3 minutes with a chemical indicator
b. Send the implant to sterile processing to be returned a�er the biological indicator has
been read
c. Double-wrap and autoclave 2 0° for 0 minutes with a chemical indicator
d. Immediate use steriliza�on 2 0 for 10 minutes with both chemical and biological
indicators

. A chemical indicator included with surgical instruments processed in a gravity displacement

steam sterilizer indicates that the instruments were:

a. Exposed to the sterilizing condi�ons

b. Free of all surface bioburden
c. Exposed to the necessary vacuum pressure
d. Sterilization has been achieved

4. What type of processing does an item classified by the Spaulding System as cri�cal require?

a. Steriliza�on
b. igh level disinfec�on
c. Environmental Cleaning
d. Low level disinfec�on

5. When items are heat or moisture sensi�ve which of the following steriliza�on techniques may be
used?
a. Dry eat
b. Low Temperature hydrogen peroxide gas plasma
c. lutaraldehyde
d. Saturated Steam under pressure

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6. Tape located on the outside of a sterilized package is considered a class ____ chemical indicator

a. IV
b. II
c. I
d. V

. Which of the following items is not considered cri�cal according to the Spaulding Classifica�on
System?

a. oley Catheter
b. Pneuma�c tourniquet cu
c. Acupuncture needles
d. IV catheter

8. When tes�ng sterilizer e cacy, which sterilizers below must include a biological indicator with
bacillus atrophaeus spore?

e. Steam
f. Dry heat
g. ydrogen peroxide gas plasma
h. Ozone

. The leak tes�ng of an endoscope should be performed:

a. a�er mechanical processing and before storage

b. on the surgical field, immediately a�er use
c. a�er handing o the field, prior to processing
d. before every use

10. Cleaning and decontamina�on of the endoscope begins

a. On the field throughout the procedure

b. A�er the pa�ent leaves the OR
c. With an alcohol based solu�on
d. Immediately a�er use

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11. Endoscopes must be stored…

a. In a drying cabinet
b. In a cabinet in the procedure room for easy accessibility
c. Ver�cally for no more than 5 days
d. In the hallway outside of the procedure room

12. Four laparoscopic tubal liga�ons have been scheduled for the same day. One of the four available
laparoscopes is contaminated during the prepara�on for the second tubal liga�on. The
laparoscopes will not withstand steam steriliza�on. In this situa�on, what would be the most
appropriate course of ac�on?

a. Soak the contaminated laparoscope in a high-level disinfectant for 20 min prior to use on
the fourth pa�ent
b. Inform the surgeon of the poten�al compromise in the fourth pa�ent's care and explore
alternate solu�ons
c. Inform the fourth pa�ent that her tubal liga�on can't be done due to the lack of sterile
equipment
d. a e ure the ur eon i not di turbed ith it and a the teri e proce in department
to hurr .

13. Which type of sterilizer must be tested with a Bowie-Dick chemical indicator daily?

a. ravity displacement
b. Dry heat
c. Dynamic Air Removal
d. Ozone

14. Which item according to the Spaulding Classifica�on System is considered cri�cal and therefore
must be sterile?

a. Laparoscope
b. Cystoscope
c. Bronchoscope
d. Colonoscope

1 . The total weight of an instrument containment device, including contents, should not exceed

a. Weight is irrelevant as long as the integrator has changed

b. 25 pounds
c. 35 pounds
d. 40 pounds

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Surgical Field
Objective:
Identify measures taken by the perioperative nurse to maintain
sterility of the surgical field

• Occupational Safety
• Surgical hand asepsis
• Surgical Attire
• Surgical Drapes
• Hazards to Sterility

Hand antisepsis
• Healthy short fingernails
▫ 2mm in length
▫ No artificial nails or extenders
• Do not use lacquer if scrubbing
• If your facility allows circulators to wear lacquer it
shouldn’t be chipped or cracked
• Do not wear jewelry on hands or wrists when
scrubbing
• Rings strongly discouraged while circulating

Hand antisepsis
• Use alcohol based hand sanitizer when able
▫ Rub hands until completely dry
• Use soap and water if hands are:
▫ Visibly soiled
▫ After blood or body fluid exposure
▫ After care of patient with norovirus / C-Diff

• Wash hands in cool water. (70-80 degrees)

• Dry hands completely
• Use hospital approved hand lotions

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Hand Asepsis
• Engage Patients and visitors
▫ Wash before touching patient

• Must have a way to evaluate and respond to

opportunities for improvement

• Auditing

Hand scrub
• Agent
▫ Broad spectrum
▫ Fast acting
▫ Persistent
▫ Time is as recommended by manufacturer
▫ Alcohol based
• Brushes are not recommended
• If gloves irritate your hands wear cotton glove
liners.
▫ Single use
▫ Dispose or launder

Surgical Attire
• Surgical attire should be hospital laundered
• Attire should be made of spun bound polypropylene
• Dress in a designated area
• Surgical attire removed before leaving the facility
• Shirt tucked into pants, Scrub dresses over pants okay
• Personal clothing under attire according to facility
policy

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Surgical Attire
• Personal bags/phones
▫ Cleaned before and after entering the OR
▫ Never placed on the floor
• Change scrub clothes daily and when visibly soiled
• Cover coats
▫ Freshly laundered
▫ When leaving semi-restricted or restricted area

Surgical Attire
• Non scrubbed personnel should wear long sleeves
while doing skin prep

• ID badges cleaned with alcohol regularly

• If using lanyards develop process and schedule for routine
disinfection

• Stethoscopes
▫ Cleaned before and after each use
▫ Not worn around the neck

Surgical Attire
• Don’t save worn hats, coats, jackets or scrubs in your
locker for later use

• Head covering – hospital policy

▫ Completely covers hair and scalp
▫ Should not remove cap until wearing cover coat
▫ Head attire must be removed at the end of the shift or when
contaminated
▫ When working in the preparing and packaging area, beards
must be covered

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Surgical Attire
• Masks are on in restricted areas,
▫ Never as a necklace
▫ Change between cases
• Eye protection cleaned between cases
• Shoes
▫ Covers for unavoidable contamination
▫ Dedicated for use within the perioperative area
▫ Must have enclosed toes and heels

Surgical Attire
• Don’t gown from the back table.
• Gowns and drapes resistant to penetration by blood
/body fluids
• Avoid Strike through
• Double glove
• Change outer glove every 90-150 minutes and
between cases

Surgical Attire
• Changing contaminated gloves.
• Somebody else glove you
• Change both gown and gloves using closed method

• Gown cuff is considered contaminated after initially

gowning and gloving

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Surgical Drapes
• Drape everything within sterile field
• Don’t move them about
• Perforated = contaminated
• Cover tables during high activity or delay
• Folded drapes are held
higher than the back
table and draped from
operative site to periphery

Potential Hazards to Sterility

• Wrapped items
▫ Open wrapped flap
▫ that is furthest away first
▫ Sides and nearest last
• Pouring liquid
▫ The edge of the container
is considered
contaminated when cap
removed. Do not recap

Surgical Field
• Event Related Sterility • Isolation Technique
▫ Package integrity ▫ Instruments touched
▫ Storage conditions inside of bowel isolated
▫ Transport  No longer touched by
▫ Handling sterile team members
▫ Environmental Control ▫ Clean instruments used
▫ Not related to time to close
▫ Bowel technique
▫ Contamination
Technique

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Movement around the field

• Scrubbed Persons:
▫ Avoid changing levels
▫ Pass each other back-to-back
▫ Remain close to the field
 Within air curtain

• Non- Sterile Person:

▫ Always face the sterile field
▫ Remain far from field
 Outside of air curtain
▫ Do not walk between two sterile fields

Surgical Field Quiz

• 11 Questions
• 11 Minutes

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Surgical Field
Quiz

1. Which one of the following periopera�ve nursing interven�ons would most e ec�vely reduce
the possibility of contamina�on of the sterile field?

a. Consider the gown cu to be sterile during surgical cases.

b. The surgical field should be covered during �mes of high ac�vity in the OR.
c. own and glove from a sec�oned o por�on of the back table
d. Use open-glove method to change a contaminated glove during surgery.

2. ow o�en is it recommended to change surgical gloves during an invasive surgical procedure?

a. Every 60 minutes
b. idway through the procedure
c. Every 0 – 150 minutes
d. It is not necessary to change gloves during the procedure unless they become
contaminated.

. A�er the sterile field is set up there is a delay in the opera�ve procedure. Which of the following
is false?

a. Team members should observe for contamina�on.

b. The sterile field is sterile indefinitely unless something happens to make it not sterile
c. The sterile field should be prepared as close to the �me of surgery as possible.
d. The sterility of an opened sterile field is �me related

4. A recommended prac�ce to be implemented to reduce the poten�al for microorganisms in the

bowel being transferred to sterile �ssue within the surgical site is called:

a. Contamination technique
b. Infec�on preven�on technique
c. Consolida�on technique
d. Sterile �ssue technique

5. The preferred method for hand antisepsis is:

a. Wear gloves in lieu of hand hashing

b. Use hand sanitizer
c. Use a petroleum-based lo�on for hand moisturizing
d. Wash hands in very hot water

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6. When is it appropriate to perform hand washing with soap and water in lieu of hand sani�zer?

a. A�er care of a pa�ent with a history of RSA

b. A�er care of a pa�ent with C-Di
c. A�er removal of gloves
d. Before performing pa�ent care

. Contamina�on of a sterile surface by moisture that has originated from a non-sterile surface and
penetrated the protec�ve covering of an item is called:

a. azardous contamination
b. Penetrating injury
c. ross
d. Strike through

8. During the procedure the periopera�ve RN should maintain the integrity of the opera�ve suite.
Which of the following are appropriate ac�ons taken by the circula�ng nurse?

a. The non-scrubbed team member should limit time facing the field
b. Only move within the laminar airflow for short periods of time
c. Walk between two sterile fields if there is adequate distance to pass without accidental
contamina�on.
d. Remain as far as possible from the field and scrubbed team members

. All personnel moving within or around a sterile field should do so with the goal of maintaining the
sterile field. To best meet this goal, it is preferable that

a. The scrub person stays close to the sterile field

b. Open the double doors infrequently during the procedure
c. All unscrubbed team members maintain a 12-inch distance from the sterile field and pass
facing away from it.
d. All unscrubbed team members maintain a 6-inch distance from the sterile field and pass
facing the sterile field.

10. During the procedure the circula�ng nurse no�ces a bead of sweat drop onto the sterile field?
The nurse should:

a. Include this informa�on as part of the debriefing so the surgeon can order prophylac�c
an�bio�cs for the pa�ent
b. Interrupt the procedure to alert the team of the observed contamina�on
c. Ask the surgeon to lean back so you can mop his or her brow
d. It s too late to do anything. The contamina�on has already occurred. Complete an
occurrence report.

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11. our orientee quietly lets you know that she s just contaminated the field. ou should:

a. Admonish the error. Let her know that one day when she is good, things like this will not
happen anymore.
b. Praise her for le ng you know and show her how to professionally inform the team of
the contamina�on
c. Teach her how to quietly let the tech know to cover the contamina�on with a sterile
drape or towel
d. Tell your orientee to be quiet about it because the surgeon will be angry. Try to do beter
next �me.

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Operative Suite
Objective:
Identify measures taken by the perioperative nurse to maintain
the integrity of the operative suite

• Movement around the Field

• Traffic Control
• Infection Control
• Environmental Cleaning

Operative Suite
• Positive pressure
▫ Corridors
▫ Antechamber
▫ OR Doors remain closed

• Air Changes / Hour

▫ 20 Changes
▫ 4 with outside air

• Laminar Air Flow

▫ Alternate floor tile

Traffic Control
• Good Traffic control practices prevent cross
contamination

• There are three surgical areas

▫ Unrestricted
▫ Semi-Restricted
▫ Restricted

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Traffic Control
• Only necessary personnel in restricted and semi-
restricted areas

• Supplies should be transported in covered carts with

solid bottoms to semi-restricted / restricted areas
• Flow of sterile supply goes from clean core through
OR to peripheral corridor

Transmission-based precautions
• Don’t get any on you
• PPE and frequent hand washing
• Specimens
▫ Leakproof container
▫ Biohazard bag
• Don’t recap needles
▫ One handed if necessary
• Eating, drinking, handling
contacts, applying lip balm

Sharps Safety
• 2000 Needle-stick Safety and Prevention Act
▫ Nonsurgical settings: 31.6% decrease in injury
▫ Surgical Settings: 6.5% increase

• OSHA required
Blood borne
pathogens exposure
control plan
• Annual review of
exposure control plan
required

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Proper disposal of sharps

• Puncture and leak resistant containers
▫ Recognizable, visible in proximity to point of use

• Remove sharps before decontamination

• Perioperative RNs are to serve as role models for
other team members.
▫ Follow regulations
▫ PPE
▫ Timely reporting and treatment of injury
▫ Hep B immunization

Airborne Precautions
• Stay out of my OR unless emergent
• N95 Mask – Fit tested
• Intubate in Isolation room
▫ Bacterial filter on the ETT
• If not intubated
▫ Portable industrial grade HEPA filter
▫ PAS-HEPA (antechamber)
• Provide air exchanges as usual
• Room stands empty for 28 minutes after case
• Do not make room negative pressure

Droplet Precautions
• Released during, coughing, sneezing, and talking
• Does not remain suspended in the air
• PPE within 3 feet of patient

Contact Precautions
• PPE
• Precautions during transport
▫ Reverse Isolation
• Adequate disinfectant and cleaning

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Prions
• Creutzfeldt-Jakob Disease (CJD)
▫ Brain, spinal cord, CSF, Cornea
▫ Also present in low concentration in other tissue
• Use disposable instruments if possible
• Instruments can be steam sterilized
▫ Prevac – 18 minutes
▫ Gravity displacement – 60 minutes
• Clean area with Bleach or Lye
▫ Sodium Hypochlorite, Sodium Hydroxide
▫ 15-minute contact time

Environmental Cleaning
• Terminal Cleaning
▫ Includes restricted and semi-restricted areas in the OR
▫ Preoperative patient areas
▫ Postoperative patient areas
▫ Sterile Processing Department

• Environmental control temperature range

▫ Unrestricted – 70°-75°
▫ Semi-Restricted – 75°
 Decontamination – 60° -73 °
▫ Restricted 68°-75°

Turnover Cleaning
• Remove contaminated instruments and garbage
• Cleaned with a hospital-grade germicidal agent
▫ Patient transport vehicles,
▫ Equipment
▫ OR Furniture

• Mop the floor

▫ New or freshly laundered mop head
▫ New or ‘never double dipped’ water
▫ Hospital-grade germicidal agent
▫ Move the OR table
▫ Clean to dirty

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Environment of Care Committee

• Who?
▫ Perioperative nurses, sterile processing, environmental
services, and infection prevention personnel

• What?
▫ Education/competency
▫ Policy and Procedure
▫ Quality improvement

Provide Clean Safe Environment

• Any item that touches the floor must be disinfected
before patient use.
▫ Not just sterile stuff (leads, safety strap)

• If it will not withstand disinfectant or is difficult to

clean use a barrier or cover
▫ Keyboard

• Insects and Vermin in health care settings carry

pathogens with antibiotic resistance

Enhanced Environmental Cleaning - MDROs

• Stay in the environment longer, difficult to control
and increase morbidity and mortality
▫ MRSA
▫ VRE
▫ Vancomycin Resistant Staphylococcus Aureus
▫ Extended spectrum -Lactamase producing bacilli
▫ Clostridium difficile
▫ Carbapenem resistant Enterobacteriaceae
▫ Klebsiella Pneumoniae

• Cleaning with effective products

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Reestablish a Clean Environment

Reestablish a Clean Environment

Terminal Cleaning
• Performed daily when the areas are being used

• Completed in all restricted and semi-restricted areas

in the pre, intra and post op and Sterile Processing
▫ Should not occur in Sterile Processing when personnel are
actively decontaminating instruments

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Terminal Cleaning
Cleaned with a hospital-grade germicidal agent
• Surgical lights and tracks • Ventilation faceplates
• Fixed ceiling mounted • Horizontal surfaces
equipment • Sub-sterile areas
• Furniture and Equipment • Hallways
• Handles of cabinets and • Scrub and utility areas
push plates and scrub sinks
• Computer /work station • Wheels
• Anesthesia equipment • Telephones

Cycle Cleaning
According to an ‘established schedule’

• Clean and soiled storage • Sterilizers

• Sterile Storage • Refrigerators
• Shelving and storage bins • Ice machines
• Stairwells, corridors, • Walls
elevators • Offices
• Ceilings • Lounges
• Closets • Lavatories
• Warming Cabinets • Locker rooms
• Pneumatic tubes carriers • Privacy curtains
• Aerators on faucets • Ventilation ducts and filters
• Sinks and eye wash station • Linen Chutes

Policies
• Must be in written form
• Reviewed annually
• Readily available to staff

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Operative Suite Quiz

• 10 Questions
• 10 Minutes

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Zander Perioperative Education, LLC

Opera�ve Suite uiz

1. The circulator in Room has learned she is pregnant. During surgery her friends drop by
congratulate her. Why would sta excitedly talking and moving in and out of the room be a
problem?
a. Disrup�on in airflow allows microbes to enter the airspace above the surgical site
b. The most common contaminate in a surgical wound is Staph Aureus from the pa�ent s
skin so sta movement is less important
c. The friends should assist with circula�on since only people per�nent to pa�ent care
should be there
d. The noise and ac�vity would distract the surgeon possibly a ec�ng the pa�ent outcomes

2. ow o�en should the OR be terminally cleaned?

a. There is no need to clean an unused OR
b. At the end of each 8-hour shi�
c. irst thing in the morning and again at the end of each day
d. Daily or if unused, as determined by a mul�disciplinary team

. our pa�ent is coming for an acute unruptured appendici�s. e has disseminated herpes zoster
(Shingles). What kind of mask do you need?
a. N95
b. Surgical mask
c. Cloth mask
d. No mask is required

4. The pa�ent coming for a brain biopsy is suspected of having Creutzfeldt akob disease (C D).
ow do you clean the room a�er a pa�ent with C D?
a. With a hospital grade germicidal agent
b. With sodium hypochlorite or sodium hydroxide. Allow a 60 minute contact �me
c. With sodium hypochlorite. Allow a 15 minute contact �me
d. Regular turnover cleaning is required

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5. The Laparoscope is in a wrapped tray on a shelf in the sterile storage area. ow long does it
remain sterile?
a. It remains sterile as long as the package integrity and environmental condi�ons remain
within an acceptable range
b. It remains sterile for 0 days
c. It remains sterile un�l the expira�on date on the label
d. The �me is according to hospital policy as determined my a mul�disciplinary team

6. ow is the room cleaned a�er the debridement of an abscess?

a. The infec�ous case requires terminal cleaning before the next pa�ent enters the room
b. Regular room turnover cleaning is required
c. The room is cleaned with bleach allowing a 15 minute contact �me
d. The room should stand empty for 28 minutes before the supplies for the following case
are opened

7. Is the air pressure higher in the OR suite or the surrounding corridor?

a. The OR is nega�ve pressure and the surrounding corridors are posi�ve pressure
b. The OR suite and surrounding corridors are both posi�ve pressure
c. The OR suite is at a greater pressure than the surrounding corridors
d. The surrounding corridors are at a greater pressure than the OR suite

8. ow is the room turned over a�er a pa�ent with RSA?

a. The infected case requires terminal cleaning before the next pa�ent enters the room
b. Enhanced turnover cleaning is required
c. The room is cleaned with bleach allowing for a 15 minute contact �me
d. The room should stand empty for 28 minutes before the supplies for the following case
are opened

9. Environmental cleaning of the opera�ve suite is required:

a. Only if the room is visibly soiled
b. Only if terminal cleaning was not done the day before
c. At the end of the day
d. Before, during and a�er every case

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10. The surgeon has called to let the team know that he is stuck in tra c and will be delayed. The
back table is set up and the pa�ent is in the holding area. This is the only case scheduled in this
room. ow should the team respond?
a. Stay in the OR scrubbed and opened un�l the surgeon arrives
b. Break the field down and pull new supplies to open when the surgeon arrives
c. Cover the field and follow your facility s prac�ce for limi�ng tra c in the suite un�l the
surgeon arrives.
d. Let the pa�ent know that the surgeon is not in the hospital and the case will be
rescheduled to a new date

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Regulatory Compliance
Objective: Describe how the perioperative nurse maintains
regulatory compliance for patient safety as a nursing
professional.

•Tissue Banking •Product Selection

•Organ Donation •Nursing Process
•Specimens •Nursing Diagnosis

Surgical tissue banking

• Work together to provide oversight and standards
▫ American Association of Tissue Banks (AATB)
▫ Joint Commission (JC)
▫ Food and Drug Administration (FDA)

• Points to know
▫ Autologous tissue should be separated from allografts.
▫ Expiration time of tissue
▫ Refrigerator and freezer have limited access and
temperature monitoring with an alarm

Surgical tissue banking

• Records are kept for 10 years
▫ Consent
▫ Donor assessment
▫ Procurement processing
▫ Preservation, Labeling and Storage
▫ Quarantining
▫ Testing, Releasing and Distribution
▫ Quality control

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Uniform Anatomical Gift Act 1968

Tissue procured from suitable donors
Free from infection Patient cannot have been
Free from autoimmune ventilator dependent or
disease (lupus) immobile form more than 7
days prior to brain death
Neurological disease
Normothermic for the week
Bone disease prior to brain death
Systemic medication use Exclude patients at high risk
(chemotherapy) for blood borne pathogens
Exposure to toxic substances State Registries

Dropped the tissue

• Soak in povidone-iodine, antibiotic solution or both

• Steam Sterilization of Bone not recommended

Or

• Discard and use artificial materials

• Always report to infection prevention personnel

Tissue Banking
• Autologous tissue storage - Pass tissue off the field
immediately
• Nurse must confirm patient’s identity using two
unique identifiers
• Originating source of tissue including laterality if
applicable
• Type of tissue
• Diagnosis and any pertinent clinical information

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Specimens - Labeling
• Accuracy is expected
▫ Correct patient name + Correct specimen name = Correct
diagnosis
• Confirm all specimens with the surgeon
▫ Debriefing
• Label multiple specimens on sterile field
• Legal evidence
▫ Chain of custody
▫ Prevent alteration
▫ Prevent decomposition

Specimens
• Pathology – examines pieces of
tissue. Fresh, Frozen and preserved
• Cytology – Examines cell types of fluid
• Microbiology – Examines for microbial growth

• Dry container • Preservative • Culture Medium

▫ Fresh ▫ Preserved ▫ Microbiology
▫ Frozen ▫ Permanent
▫ Cytology

Product Selection
• A mechanism for product and medical device
standardization and evaluation is in place
▫ Select functional and reliable products
▫ Safe, cost effective, environmentally conscious
▫ Avoid duplication and ‘fads’

• Product and medical device evaluation based on

criteria specific to the item’s use
▫ Safety, ease of use, compatibility with other products
▫ Impact on quality patient care
▫ Cost, can we sterilize it, environmental impact

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Product Selection
• A clinical evaluation should be based on an identified
need or opportunity
▫ Don’t waste time or money in a clinical trial
▫ All departments affected should participate in trial
▫ Trial should have time and scope parameters
▫ Education and instruction before trial

• Personnel selecting ESU and accessories

▫ Make decisions based on safety features
▫ Minimize risks to patients

Nursing Process
• Nursing Process
▫ Assessment
▫ Nursing Diagnosis
▫ Identification of Outcomes
▫ Planning
▫ Implementation
▫ Evaluation

Nursing Process
Assessment Nursing Diagnosis
• Purpose is to formulate • Purpose is to identify
nursing diagnosis and classify data
• Collection of data collected in the
assessment
• Human response
• Actual or Potential
• Nursing treatment is
capable of correcting
the issue
• NANDA

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Preoperative Patient Assessment

• Baseline Vital Signs
• Medical History
• Medications
• Mobility
• Communication Barriers
• Diagnostic Results
• Allergies
• NPO status
• Detrimental Behavior
• Educational needs
• Diversity / Cultural considerations

Nursing Process
Identification of Outcomes Planning
• Purpose is to describe • Purpose is to select
the desired condition interventions to meet
achievable through desired outcome
nursing care
• Individualized plan of
• Criteria by which care
nursing interventions ▫ Write client goals
▫ Select interventions
are measured
▫ Communicate plan to
 Patient and family
• Goals = How will we
 Interdisciplinary team
evaluate?  Change of shift

Nursing Process
Implementation Evaluation
• Purpose is to carry out • Purpose is to identify
the plan of care if goal was met

• Nursing actions: • Steps

▫ Promote wellness ▫ Was the goal met or not
▫ Prevent disease met?
▫ Restore health ▫ What factors were met
▫ Cope with altered or not met?
functions ▫ Modify plan of care
accordingly

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Regulatory Compliance Quiz

• 12 Questions
• 12 Minutes

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Regulatory Compliance Quiz

1. A young male automobile accident vic�m with no iden�fica�on was brought to the emergency
room. e had a flat electroencephalogram upon arrival and died soon a�erward. This pa�ent
does not meet the criteria for organ dona�on because:
a. The exact age of the pa�ent is unknown
b. A history cannot be obtained
c. A valid donor card has not been found
d. No one may give consent for an unknown

2. When developing selec�on criteria for a new product for poten�al use in the OR, it is most
important to consider:
a. Performance
b. Ease of use
c. idden costs
d. Ethylene oxide compa�bility

. The three parts of the periopera�ve assessment process are:

a. Collec�on of data from the chart, physical assessment and preference card
b. Pa�ent interview, observa�on, evalua�on
c. Problem iden�fica�on, selec�on of interven�ons, implementa�on
d. athering supplies for star�ng an IV preopera�vely

4. Which of the following situa�ons best illustrates the implementa�on phase of the nursing
process?
a. Placing a forced air warmer on the pa�ent
b. Pulling the supplies and equipment for the upcoming procedure
c. Checking the records for the surgeon s preference for suture material
d. Reviewing the result of preopera�ve laboratory work

5. Autologous bone may be preserved and stored in a bone bank until needed bone used for
allografts must be clean and sterile and bone should never be used until negative results of
culture and serology are received (hepatitis B and IV) when protected from air and
contamination, how long can allograft bone remain in storage?
a. Sterilized bone can be stored indefinitely as long as it's in a sealed peel apart package
in appropriate storage conditions
b. Six months as long as it's in a sealed peel apart package in appropriate storage
conditions
c. A decided upon by a multidisciplinary team and written in hospital policy
d. ive years as long as it's in a sealed peel apart package in appropriate storage conditions

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6. A 2-year-old boy is undergoing an orchiopexy. In evalua�ng the intraopera�ve nursing care plan,
the periopera�ve nurse focuses on the statement the pa�ent will maintain normal body
temperature . This statement is an example of a(n):
a. Nursing assessment
b. Plan of care
c. Nursing diagnosis
d. Outcome criteria

7. Ascites was aspirated from the peritoneum and the surgeon requests it be sent to cytology. ow
does the circulator prepare the specimen?
a. ave the scrubbed person empty the ascites in a container so you can dip the swab into
it and then place the swab into the culture medium
b. Empty the ascites into a dry specimen cup. Send to cytology in this container
c. Place in formalin in an air �ght container
d. Let the scrubbed person drop a sponge soaked with ascites into a specimen cup

8. The authorita�ve organiza�on responsible for delinea�ng the accepted list of nursing diagnoses
is:
a. NANDA
b. T C
c. ANA
d. AORN

9. Consul�ng the surgeon on the surgical approach and required posi�oning for the upcoming
procedure is an example of:
a. Assessment
b. Diagnosis
c. Planning
d. Evalua�on

10. A pa�ent who is scheduled for surgery exhibits signs of severe an�cipatory anxiety reac�on.
Interven�ons for this pa�ent should focus on:
a. Redirec�ng the pa�ent s aten�on to something more pleasant
b. Providing a quiet unhurried environment with soothing mannerisms
c. Se ng �me limits for his behavior in a firm responsive manner
d. Assuring the pa�ent he or she has nothing to worry about

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11. The hospital wants to save unused suture and reprocess it to reduce costs. Who writes
the list of items approved for reprocessing to say whether or not this is okay?
a. The materials manager
b. A multidisciplinary product selection committee
c. The OR manager
d. The Sterile Processing manager

12. The periopera�ve nurse explains how the surgical site will be prepared for surgery a�er
induc�on. This is an example of what part of the nursing process?
a. Assessment
b. Planning
c. Implementa�on
d. Outcome iden�fica�on

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Legal Integrity
Objective: Identify the perioperative nurse’s role in
maintaining legal integrity during surgery

• Universal Protocol • Legal Implications

• Informed Consent • Documentation
• Nursing Code of Ethics

Universal Protocol
• Pre-procedural verification
▫ H&P and Anesthesia assessment are complete
▫ Blood, Implants and special equipment are available
▫ Consent is accurate, signed and witnessed

• Site marking
▫ Done outside of the OR
▫ Consistent mark used throughout hospital
▫ Patient is not sedated and participates
▫ Medical person participating in the procedure
▫ Site verification of child happens with the parents

Universal Protocol
• Time Out
▫ Prior to procedure and
ideally prior to
anesthesia
▫ Done by a designated
person, in a standardized manner defined by the organization

• Include Radiation Timeout and Fire Risk Assessment

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Time Out
• Two-way conversation
▫ Information given and acknowledged as correct …or not

• The process for reconciling discrepancy is

defined

• One time out is performed for each procedure

Informed Consent
• Elements of a Valid Consent
▫ Knowledge of the procedure
▫ Understand possible complications
▫ Understand the alternatives to surgery
▫ Competent to give consent
▫ Patient wants the procedure

• Consent may be withdrawn at any time

Informed Consent
• Perioperative nurse’s responsibility
▫ Ensure there is a consent on the chart
▫ Is the patient
1. knowledgeable
2. willing
3. competent
▫ Consent is properly signed and witnessed

• Two witnesses sign if

▫ Patient is unable to sign
▫ Telephone consent

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Informed Consent
• Competent to sign
▫ Legal Adult
▫ Minors require parent or guardian
▫ Emancipated minor
 Married
 In Armed Forces

• Exceptions to consent (implied consent)

▫ Pt is unable to give consent and there is a threat to life,
limb, function or organ
▫ Must have documentation of emergency in staff notes

Workplace Violence
• Intimidation • Bullying
▫ Sarcasm ▫ Verbal attack
▫ Incivility ▫ Intent to be hurtful
• Threat ▫ Withholding support
▫ Screaming • Harassment
• Physical Attack ▫ Patronizing comments
▫ Grabbing
• Property damage
• Sexual harassment

Workplace Violence = Patient Safety Issue

• Decline in quality patient care delivery

• Stress related illness
• Low morale
• Poor teamwork
• Sleeplessness
• Increased absenteeism
• Poor performance
• Decreased self confidence

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ANA Code of Ethics for Nurses

• Nurse practices with compassion & respect for every person
▫ To the patient and to each other
• Remain Professional and Civil
▫ Inclusion, Connection, Community

Ethical Principles in Nursing

• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• Veracity
• Fidelity

Legal Principles
• Statutory law – made by legislative branch

• Common law – derived from principles rather

than rules & regulations

• Civil law – based on rules & regulations,

compensation

• Tort law - civil wrong, allows compensation

• Criminal law – harmful to society

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Negligence
• Doing or not doing
something a
reasonable person
would or would not
do in similar situation
• Deviation from
standard of care

Malpractice
• Professional
negligence

• Misconduct or lack of
skill in carrying out
job

Elements of Malpractice
1. Duty of care
2. Dereliction of duty
3. Direct causation
4. Damages

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Intentional Torts
• Violating patient’s rights
• No actual harm necessary
• Most common:
▫ Assault
 Place person in fear of being touched
▫ Battery
 Touch without permission
▫ False imprisonment
 Unjustified detention

Quasi Intentional Torts

• No intent to injure or cause distress to another person

• Protect Patient rights

▫ Patient abandonment
▫ Defamation of character
▫ Invasion of privacy
▫ Breach of Confidentiality

Nursing Documentation
• The purpose is to provide goal directed care
• Nursing interventions
▫ When, where and by whom
• Reflects continuous evaluation
▫ Of nursing care
▫ Of patient’s responses
• Patient outcomes
• No unacceptable abbreviations
• Draw a single line through errors. Do not erase

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Nursing Documentation
• When there is an electronic record, document as
close to real time as possible

• Hand offs must have documentation of who care

was released from and given to
▫ Standardized hand-off tool
▫ Time for questions

• Perioperative Nursing Data Sets (PNDS)

▫ Standardized vocabulary for perioperative nursing
▫ Recognized by the ANA since 1990

DNR / AND
• End of life wishes

• Not automatically suspended

• Conversation between MD and Patient to make a
plan for surgery
• Cannot be altered by a nurse

Legal Integrity Quiz

• 11 Questions
• 11 Minutes

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Legal Integrity Quiz

1. Informed consent means that:

a. The form is accurate, signed, and witnessed
b. Poten�al risks and consequences of the intended procedure have been explained
c. Preopera�ve, periopera�ve, and postopera�ve phases of the intended procedure have
been explained
d. The surgeon and pa�ent have the same understanding of the intended procedure,
alterna�ves available, and risks involved

2. A pa�ent requiring emergency surgery for a life-threatening condi�on arrives in the OR without
a signed consent form. In this situa�on, the periopera�ve nurse should:
a. Atempt to contact the pa�ent s next of kin
b. Proceed with setup for the procedure
c. Call the nurse manager on duty
d. Ask the physician to sign the consent form

3. The periopera�ve nurse confirms with the chart and the parents of a 1-year-old boy that a right
inguinal herniorrhaphy is to be performed. A�er the surgeon discovers bilateral inguinal defects
and indicates that he will do bilateral inguinal hernia repairs. In response to the surgeons
decision, the nurse s first considera�on should be to :
a. Request that the surgeon talk with the parents and obtain a second consent
b. No�fy the opera�ng room manager of the change in schedule and obtain the manager s
advice
c. Alert the parents to the surgeon s decision and obtain a second consent
d. Document the surgeon s decision on the opera�ve nurse s notes and prepare an incident
report

4. A pa�ent is scheduled for a hysterectomy. She informs you that she wants to receive no blood
products because of religious preferences. What ethical principle is the pa�ent demonstra�ng?
a. us�ce
b. Autonomy
c. Fidelity
d. Beneficence

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5. ou overhear a coworker making rude comments about their pa�ent s beliefs. What do you do?
a. O er to switch assignments with your coworker so she doesn t have to care for a pa�ent
she doesn t like
b. Let it go. Confron�ng the coworker can lead to conflict and poor morale
c. Repot this unacceptable behavior to the manager
d. Tell the coworker that they have the right to their own beliefs but we are supposed to
remain unbiased

6. ailing to perform a surgical skin prep with an approved solu�on is an example of what? This act
of omission can contribute to injury of the pa�ent. This can result in a civil tort ac�on lawsuit?
a. Batery
b. Negligence
c. Assault
d. A Sen�nel event

. alprac�ce has four required elements to bring a successful suit. What are they?
a. Duty, Derelic�on of duty, Direct Causa�on, Damages
b. Duty, Devia�on from standards, Direct causa�on, Complica�ons
c. Obliga�on, Deflec�on of Obliga�on, o�ve, arm
d. Transgression, isdeed, Negligence, O ence

8. Obliga�on to prevent harm to pa�ents is the ethical principle of:

a. Autonomy
b. Nonmaleficence
c. Beneficence
d. us�ce

. Emily ones, 4 years old, is scheduled for a le� hemiarthroplasty. She arrives to the holding area
accompanied by her daughter. The pa�ent is disoriented. er daughter states her mother is
always like this. Which statement concerning informed consent is applicable to this situa�on?
a. Only the pa�ent may give consent
b. The pa�ent must be competent to give consent
c. No consent is necessary because this is an emergency situa�on
d. The patient cannot sign the consent because she received sedation

10. Doing surgery without a signed consent form is an example of

a. Negligence
b. A 'never event'
c. uasi intentional tort
d. Battery

11. The following is an example of corporate negligence:

a. Performing surgery on wrong knee
b. ailing to check that a new hire has a nursing license
c. ailing to secure the patient to the OSI bed resulting in a fall
d. Administering too little anesthesia resulting in awareness during the procedure

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Safe use of Equipment

Objective: Identify the nurse’s role as a patient
advocate during surgery

•Electrosurgery
•Fire Safety
•Radiological Exposure
•Laser Safety
•Pneumatic Tourniquet

Electrosurgery
• Personnel selecting ESU and accessories
▫ Make decisions based on safety features
▫ Minimize risks to patients
▫ Burn at dispersive electrode is still the most common
injury

• Personnel should demonstrate competency

▫ Orientation and continued competency
▫ Operating manual should be readily available

Electrosurgical Safety – ESU

• Test safety features before each use
▫ Lights, alarms, volume loud enough to be heard
• Keep clean and away from spills
▫ Use footswitch cover
• Check Preventive Maintenance – Micro shock
• Never use damaged equipment

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Electrosurgery - Active Electrode

• Confirm power settings orally

• Use non-conductive material to secure
• Prevent antenna coupling
• Disconnect contaminated active electrode

Electrosurgery - Active Electrode

• Do not use in the presence of flammable agents

▫ Wet prep solutions
• Use the safety holster
• Remove char with scratch pad
• Use according to manufacturer’s recommendations

Electrosurgery – Dispersive Electrode

• Keep dispersive electrode away from implanted
metal prostheses and tattoos

• Be sure the dispersive electrode is adhered in its

entirety – uniform body contact
▫ Avoid: Boney, scarred or hairy surfaces

• Large Muscle mass close to the surgery site

• Clean dry area, No pooling liquid
• Placed after patient positioned

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Electrosurgery
Endoscopic Considerations
• Use lowest possible settings

• Don’t use Hybrid Cannula (plastic and metal)

• Direct Coupling – active electrode touches another

instrument

• Capacitive Coupling – electrical current passes

through intact insulation to conductive material

• Insulation failure

Electrosurgical Safety
• Internal Cardiac Defibrillators and Pacemakers
▫ Use bipolar if possible
▫ Keep the pacemaker out of the path of the device
▫ Turn ICD off

• Use ONLY Bipolar with any nerve stimulator

• Argon
▫ Prevent Gas emboli avoid direct contact with tissue

Surgical Smoke
• Hospitals should provide an environment free of
surgical smoke for employees

• Evacuate all surgical smoke

▫ Not determined by physician preference

• Staff must have initial and ongoing education and

competency verification on surgical smoke safety

• Presence of quality / performance improvement

projects to reduce surgical smoke

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Fire Safety
• National Fire Protection Agency

• Materials saturated in
flammable fluids must be
thrown away at least six feet
from the patient
• O2 off for 1 min prior to use
▫ Head and neck
• ALL personnel should be able to
identify and shut off medical
gases

Fire Safety
• Safe medical Devices Act of 1990
▫ In the case of an incident send the equipment, supplies and
packages to biomed

• Be prepared for fire

▫ Water mist or CO2 fire extinguishers
 Water mist not good on liquid fires
 CO2 not good for paper drapes

• R.A.C.E. (Rescue. Alarm. Contain. Extinguish)

• P.A.S.S. (Pull, Aim, Squeeze, Sweep)

Radiology
• The patient should be exposed to radiation only if
medically indicated
▫ Consult the radiation safety officer regarding shielding
 Sometimes shielding can trap scatter radiation and increase
exposure
▫ Pregnancy, Gonads, Thyroid
▫ Document measures taken in patient record

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Radiology
• Dosimeter – Yes, you must have one
▫ One worn at neck or left shoulder
▫ One worn under lead
▫ Eye dosimeters
▫ Dosimeter report results annually
▫ Not taken home
• Pregnant staff
▫ Lead should protect front and back.
▫ wear 2 badges-one for baby one for you
▫ wear one device at neck and other under the gown

Radiology
• Lead shield goes under patient during fluoroscopy

• Body fluids and tissue from patients who have

radionuclides may emit radiation.

• If you have questions about radiation safety, you

should call the radiation safety officer

Radiology – Occupational
Exposure
• Stand 6 feet (2 meters) away and behind lead
• Lead aprons for those who cannot move away or
behind lead
▫ Appropriate fit
▫ Clean and disinfect between use
• Aprons, radioprotective gloves and thyroid collar
during fluoroscopy

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Radiology – Occupational
Exposure
• Greatest risk at 6 feet is head, neck and hands
• Do not fold aprons to store
• Test annually
▫ Label with last test date
▫ No cracks
▫ Provides protection to the level reported

Lasers
• Multidisciplinary Team
▫ Responsible for:
 Laser related policies and procedures
 Education and competency

• Laser Safety specialist (optional)

▫ Assistant to the laser safety officer
 Fill in for LSO
▫ Role recommended if multiple lasers might be operating
at the same time

Lasers
• Laser User
▫ Physician or PA with the education, credentials and
privileges to operate a specific laser

• Laser Operator
▫ Required for every laser case
▫ Annual Competency
▫ Cannot be the circulator

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Lasers
• Nominal Hazard Zone
• Warning signs should be specific to the laser being
used
• Appropriate Eye Protection
• Education specific to the laser should be facilitated
by the laser safety officer
▫ Part of orientation
▫ Continued Competency
▫ On file for Laser Operator and User

Lasers – Patient Safety

• Standby mode when not in active use
• Footswitch in proper position

• Protect exposed tissue with moistened materials

• Pooled liquid can retain laser heat and cause burns

• High voltage equipment – don’t set fluids on it

• Use a smoke evacuator

Laser – Patient Safety

• Protect patient’s eyes too

• Fire risk assessment part of time out

• Laser resistant ETT

▫ Balloon inflated with Methylene blue tented saline

• Ventilate with room air (21% O2) if possible

• Suction residual O2

• Head and neck procedures

▫ O2 off for 1 min before use

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Pneumatic Tourniquet
• Use as wide a cuff.
▫ Greater than half the circumference of the extremity

• Contoured cuffs available when needed

• Ideal cuff should allow bladder overlap

▫ 3-6 inches

• Apply a wrinkle free padding

• Gentle traction of adipose tissue distal to the cuff

for obese patients

Pneumatic Tourniquet
• Position at the point of maximum circumference

• Tubing on lateral aspect of extremity

• The tubing should be labeled identifying it as

pneumatic tourniquet.
▫ If more than one tourniquet is used it should be labeled
according to the extremity

Pneumatic Tourniquet
• Use Esmarch to exsanguinate the limb before
inflation.
▫ Pain reduction
▫ Esmarch is contraindicated in patients with risk of
thrombus, infection, dislocated fractures or malignancy
▫ Exsanguinated by elevation only in contraindicated cases

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Pneumatic Tourniquet
• Tourniquet placement should be part of the time
out process.

• Prophylactic Antibiotics infused before inflation.

▫ Ideally infusion complete 20 min prior to inflation

• Nerve damage – most common injury

▫ Excessive pressure / uneven padding
▫ Excessive inflation time
▫ Can result in permanent motor/sensory deficits

Pneumatic Tourniquet
• No Recommended Time limits
• Monitor patient for
▫ Watch for increasing core temp
▫ Monitor Pediatric patients for acidosis
 Especially if >75 min

• Inform surgeon of inflation time every 15 minutes

after the first hour

▫ Can deflate and allow reperfusion for a

minimum of 10-15 min and then re-inflate for
extended tourniquet time

Pneumatic Tourniquet
• Ideally, pressure settings are based on limb occlusion
pressure (LOP)
▫ Option on the tourniquet
▫ Mannual
 Use a doppler locate an artery distal to cuff
 Slowly increase pressure until pulse stops

▫ 40 mm/Hg greater for LOP < 130

▫ 60 mm/Hg greater for LOP 131-190
▫ 80 mm/Hg greater for LOP > 190
▫ Pediatric pressure set at 50 mm/Hg greater than LOP

• At minimum the pressure is based on systolic pressure

and limb circumference

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Pneumatic Tourniquet Complications

• Rapid deflation – Rush of metabolic waste and meds
▫ Ringing ears, numb tingling lips/fingers, Loss of
consciousness, seizures, arrhythmias
• Hyperthermia after inflation, Hypothermia after
deflation
• Emboli within one minute of deflation

Pneumatic Tourniquet Complications

• Increased ICP – cerebral vasodilatation –
isoflurane*
• Over pressurization – pain at tourniquet site, nerve
damage
• Excessive time - ischemic injury, nerve damage
• Under pressurization – bleeding, venous congestion

Pneumatic Tourniquet
• Documentation
▫ Location of cuff
▫ Skin protection measures
▫ Cuff pressure
▫ Limb Occlusion pressure
▫ Time of inflation and deflation
▫ Skin integrity before and after use
▫ Distal pulse before and after use
▫ ID number of tourniquet used
▫ Person who applied cuff

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Safe Use of Equipment Quiz

• 16 Questions
• 16 Minutes

“Whoa! Watch where that thing lands –

we’ll probably need it”

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Safe Use of Equipment Quiz

1. The back of the electrocautery machine suddenly erupts with flame and acrid smoke. The first
step taken by the periopera�ve nurse is:
a. R.A.C.E.
b. Unplug the electrocautery machine
c. P.A.S.S.
d. Leave the area immediately

2. Which of the following ac�ons would best prevent burn injuries resul�ng from use of the
electrosurgical unit?
a. Providing the surgeon with a hand-ac�vated electrode
b. Placing the ac�ve electrode �p on a moist sponge when it is not in use
c. Placing the ac�ve electrode �p in a container when not in use
d. Cleaning the ac�ve electrode �p with a sponge before each use

3. During an ORI of the ankle fluoroscopy is to be used. The periopera�ve nurse understands that
which of the following considera�ons is most important regarding pa�ent safety?
a. Leaded shields should be placed under the pa�ent
b. Leaded shields should be placed over the pa�ents gonads
c. luoroscopy produces more scater radia�on and sta require greater level of protec�on
d. Scatered radia�on is decreased during fluoroscopy

4. Adequate eye protec�on for sta members and pa�ents during laser procedures is determined
by the:
a. Op�cal density and laser wavelength marked on the eyewear
b. Surgeon opera�ng the laser equipment
c. Color of the eyewear
d. Laser safety o cer (LSO) in charge of the specific laser

5. A pa�ent undergoing a skin tag removal on his chest and scalp using electrosurgical unit. The
pa�ent has received conscious seda�on and 1 lidocaine to the surgical area. is face is covered
with drapes, and he reports feeling smothered . To alleviate the pa�ent s discomfort, it is
appropriate for anesthesia to:
a. Provide a nasal cannula at a low flow rate
b. Redrape the pa�ent between the removal on the chest and scalp to allow his face to
remain uncovered
c. Provide an oxygen mask with 0 or less O2
d. Tell the pa�ent the procedure will be very quick, and the drapes will be removed soon

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6. During a laser procedure, which of the following is an appropriate laser safety measure?
a. Applying eye pads moistened with lacrilube to the pa�ent s eyes
b. Pos�ng warning signs at all exits form the room
c. Using Polyvinyl chloride endotracheal tube
d. Performing a fire risk assessment as part of the �me out

7. The best posi�on for placement of a dispersive pad on a pa�ent with a le� metal hip prosthesis
undergoing a le� mastectomy is:
a. Le� upper thigh
b. Le� calf
c. Right calf
d. Right upper thigh

8. During a laser procedure, the disposable paper drapes ignite and begin to burn. What type of
ex�nguisher should be used on this fire?
a. alon fire ex�nguisher
b. CO2 ex�nguisher
c. Water mist
d. Class ABC

9. During the course of the surgical procedure, the surgeon has requested increased power se ngs
from the electrosurgical generator. Which of the following factors would contribute to the
request for increased power?
a. Obese pa�ent
b. Posi�on of the pa�ent
c. Pa�ent dispersive electrode is on a large muscle mass
d. inimal bleeding at the opera�ve site

10. Skin burns from the electrosurgical unit are most likely due to:
a. Low skin resistance
b. igh voltage
c. igh current on a small area of contact
d. igh leakage current

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11. The pa�ent has right and le� hip implants and is coming for a le� inguinal hernia repair. The
periopera�ve nurse should place the dispersive electrode where?
a. Le� quadriceps
b. Right quadriceps
c. Right torso outside of the surgical prep area
d. Le� deltoid

12. The pa�ent scheduled for inguinal herniorrhaphy has a pacemaker with internal cardiac
defibrillator. The anesthesiologist no�fies the preopera�ve nurse that the device se ngs cannot
be changed due to complete heart block. What is the best choice of electrocautery for the
procedure?
a. Monopolar
b. Bipolar
c. Argon
d. armonic scalpel

1 . The process of cataract removal in which the cataract is broken up by ultrasonic vibra�on and
then aspirated is called:
a. Cryoextractor
b. Diathermy coagula�on
c. Laser therapy
d. Phacoemulsifica�on

14. The periopera�ve nurse is preparing the pa�ent for an open reduc�on and internal fixa�on of
her ankle. The surgeon requests the use of the pneuma�c tourniquet. To prevent neurovascular
damage, the tourniquet cu should be posi�oned at the:
a. Two inches below the groin
b. As far up the groin as you can manage
c. Point of maximum circumference
d. ust below the knee

15. The pneuma�c tourniquet has been applied to the upper arm. The next ac�on taken by the
periopera�ve nurse is to:
a. Check the limb occlusion pressure prior to infla�on
b. Set the tourniquet to 00 mm g in prepara�on for infla�on
c. Verify the tourniquet is func�oning properly
d. Verify the pa�ent s vital signs and length of surgery

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16. Which of the following is true regarding tourniquet time?

a. Reperfusion is never required during surgery because it would increase blood loss
b. Every 0 minutes for 15 minutes the limb should be reperfused
c. Once every two hours the limb should be reperfused
d. The tourniquet time should be as short as possible but there is no time limit

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Patient Safety
Objective: Identify the nurse’s role as a patient
advocate during surgery

• Wound healing
• Medication Safety
• Counts

Wound Healing - Phases

• Inflammatory (0-3 days)
▫ Redness, edema, phagocytosis
• Proliferation (4-24 days)
▫ Granulation and epithelial tissue forms
• Remodeling (24 days – 1 yr)
▫ Scar formation and contracture

Wound Closure - Types

• Primary Intention
• All layers of wound are approximated
• Most surgical wounds
• Secondary Intention
• Granulation
• Pressure ulcer
• Tertiary Intention
• Delayed primary intention
• High suspicion of contamination
• Left open and packed

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Wound Healing – Risk factors

Patient Factors Environmental Factors
• Nutrition • Length of surgery
• Age • Trauma
• Immunosuppression • Prolonged Stress
▫ Steroids • Coagulopathies
▫ NSAIDS
• Circulation / Oxygenation
• Comorbidities

Wound Healing - Complications

• Infection
▫ Redness
▫ edema
▫ tenderness
▫ fever
▫ Leukocytosis (Elevated WBCs)
• Week out or more
• Defined by CMS as SSI if:
▫ Deep infection or implant - occurs within 90 days
▫ Superficial infection - occurs within 30 days

Wound Healing - Complications

• Separation
▫ Wound edges come apart
• Dehiscence
▫ Separation to the fascial layer
▫ New development of Drainage
• Evisceration
▫ Abdominal contents spilling out
▫ Surgical emergency

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Wound Surgical Classification

• Class 1 (Clean)
▫ Infection rate less than 5%
▫ Primary closure. No break in technique

• Class 2 (Clean / contaminated)

▫ Expected infection rate 8-11%.
▫ Includes cases in which GI, GU, Respiratory tract are
entered under controlled conditions and without spillage
▫ Bowel Resection, Hysterectomy, T&A, Cholecystectomy

[Link]

Wound Healing
• Class 3 (Contaminated)
▫ Expected infection rate 15- 20%,
▫ Fresh traumatic injury (<4 hours delay)
▫ Break in technique/spillage
▫ Appendectomy for appendicitis, cholecystectomy for
Cholecystitis

• Class 4 (Infected)
▫ Expected infection rate 27-40%,
▫ Clinical infection, perforated viscera, necrotic tissue
▫ I&D of abscess, ruptured appendix, GSW to abdomen
[Link]

Prepare for Skin antisepsis

• Patients should shower or bathe night before and
day of surgery
▫ 4% CHG most effective, 2% CHG impregnated cloths
good too
▫ Dry with a clean towel if shower or bath
▫ Not on face
▫ Multidisciplinary team responsible
for product selection

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Prepare for Skin antisepsis

• Remove Jewelry from surgical site

• Remove Makeup

• Check for allergies

• Patients with resistant organisms

▫ Hexachlorophene recommended as scrub for gram-
positive MRSA
▫ Chlorhexidine for VRE
▫ Decolonization preoperatively

Prepare for Skin antisepsis

• Verify the site before you prep

• Hair Removal at site only in select clinical

situations.
▫ Hair should be left in place
▫ Use clippers or depilatory creams to remove hair when
necessary
▫ Remove outside of OR or in a manner that prevents
dispersal of hair into the air
▫ Disposable Clippers are preferred

Prepare for Skin antisepsis

• Wash superficial dirt and debris from skin before
prep
▫ Alcohol and Chloroxylenol or Para-chloro-meta-xylenol
(PCMX) cannot penetrate organic material

• Areas of greater contamination should be cleansed

before prep

• Isolate highly contaminated areas with a sterile

barrier drape

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Apply in a Safe and Effective Manner

• Completed by non-scrubbed team member
▫ Sterile gloves for sponge, non-sterile gloves for long
applicator
▫ Covered arms to prevent shedding

• Prep from incision to periphery

• Povidone Iodine for the perineum, eye or ear

▫ Iodine allergy use PCMX (Technicare) or 3% H2O2 for
vaginal prep and Normal Saline for eyes. Normal Saline or
PCMX for ears

Apply in a Safe and Effective Manner

• Broad spectrum, fast acting and persistent

• No unprepped skin should show through the

fenestration in the drape

• Surgical site mark should remain after the prep

• Prep should be removed from skin outside of dressing

Apply in a Safe and Effective Manner

• Highly contaminated sites
▫ Prep low count area incision to periphery then Highly
contaminated site last
▫ Cover an ostomy in the site with a sponge soaked in prep
solution

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Apply in a Safe and Effective Manner

• Abdominal / Perineal Prep AORN Journal Jan 2015
▫ Prep perineum first with 10% Povidone iodine extending to
pubis
▫ Paint only on perineum
▫ Prep abdomen with antiseptic solution
▫ Apply same prep along the boarder of prepped abdomen
and perineum

Alcohol Based Skin Preps

• Recommended by AORN as primary choice
• Must dry to be effective
• Hair removal before prep recommended
• Alcohol and CHG can cause corneal damage
▫ Never on face
• No pooling or saturating electrodes, towels or drapes
▫ Fire hazard
▫ Chemical Burns
• Multiple applications of agent not recommended

Review Abdominal
Incisions

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Medication Safety
▫ Dispense when needed

▫ Don’t remove the rubber

stoppers. Use a sterile
transfer device

▫ Limit use of multi-dose vials

▫ Good for 28 days
▫ Multidose = single patient

Medication Safety
▫ Verify meds with ST or RNFA

▫ Label meds

▫ Keep med containers throughout case

▫ Relief personnel should verify all meds and labels

Surgical Count
• Scrubbed person is responsible for knowing how
many sponges are inside the patient at all times
• Counts done by two persons. One must be an RN
• Count in sequence.
▫ Sequence defined by facility policy
 Surgical site, mayo stand, back table then off field

• Pocketed Sponge holder with background color

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Surgical Count
• Scrub person should separate and point out items on
the field while audibly counting

• The RN circulator should separate and point out

items off the field while audibly counting

• Visible count board in every room

▫ Running count in only one place
▫ Ideally only count worksheet is visible count board.
 Be careful about transcription
▫ Placed retractor / packed sponges on count board

Surgical Count
Phase of Procedure Soft Sharps Instruments
Goods and
Misc.
Initial Before the procedure X X X
As new items are added Count item added
At permanent relief (circulator or scrub) X X Open cavity
Additional
Counts Am I supposed to count this or Count items in question
not?
When anyone requests it Count items in question
At intervals during long cases X X Open cavity
Cavity Before closure of cavity within a X X Open cavity
cavity. (e.g. uterus)
Closing When wound closure begins X X Open cavity
Final When counted items no longer X X Open cavity
in use

Surgical Count
• Additional count at designated intervals during
long procedures (all day)

• Facility Policy
▫ Procedures requiring interval count
▫ Timing (3-4 hours into the procedure)
▫ Items counted
▫ Communication
▫ Documentation

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Surgical Count
• If interrupted during count must recount that item
• If there is a discrepancy
▫ 1st make team aware
▫ 2nd recount

• Search for missing item

▫ Once found, recount that item
▫ Not found then radiology and
surgeon look at x-ray together

• Trash not removed from room

until patient leaves

Surgical Count
• Use adjunct technology device
▫ FDA approved
▫ Manufacturer’s instructions for use
▫ Can be waived in policy for certain procedures
▫ Implement this use all over the facility at the same time
▫ RSI usually had a correct count
 Use it even when you think the count is correct

Surgical Count
• Never open sponges in a room that are not part of the
count

• Package of sponges containing an incorrect number

must be isolated from the field, bagged and labeled
• Hospital policy can delete counts from a specific
procedure
▫ Cysto, Ophthalmology, ALIF

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Surgical Count

• Don’t cut sponges

• Only x-ray detectable sponges during surgery

• Use a read-back method for communicating the

number of needles added to the field and the number
added to the count board

Surgical Count
• Use verbal confirmation that guidewires are removed
and intact

• Wound Vac foam pieces

▫ Number of pieces within wound should be part of the hand
off communication

• Open instruments removed

▫ cannot be in the OR uncounted

• Standardize instrument sets with minimum number

of and types of instruments

Surgical Count
• If something is broken it must be accounted for in its
entirety
▫ Minimally invasive surgical instruments need additional
monthly inspection

• Count prep sticks used in vaginal antisepsis

• Methodical exploration of the cavity

▫ Include vagina if entered during surgery
 Frequent retention site

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Counts
• Documentation:
▫ Type and number of counts
▫ Name and title of persons performing the count
▫ Notification of surgeon
▫ Instruments remaining with patient or sponges intentionally
left as packing
 Add an order set for removal of packing into patient’s chart
▫ Actions taken if there is an unresolved count
▫ Rationale if counts are not performed or completed

Patient Safety Quiz

• 15 Questions
• 15 Minutes

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Pa�ent Safety Quiz

1. During an emergency procedure, the pa�ent s condi�on becomes unstable, and the surgeon
requests that there be no sponge count. The immediate ac�on of the circula�ng nurse would be
to:
a. Inform the surgeon of hospital policy regarding sponge counts
b. Instruct the scrub nurse to assist with the count
c. Call the supervisor for instruc�ons
d. Document the omited count

2. The RN circulator and scrub person should audibly review and confirm medica�ons:
a. Before the procedure begins
b. Before the end of the procedure
c. A�er transfer to the sterile field
d. Before transfer to the sterile field

. Documenta�on regarding wound classifica�on for a pa�ent having a vaginal hysterectomy would
iden�fy the would as:
a. Class I
b. Class II
c. Class III
d. Class IV

4. Which one of the following medica�ons would adversely a ect wound healing?
a. An�acids
b. Aminophyllin Inhaler
c. Aspirin
d. Lisinopril

5. The type of wound closure expected a�er the debridement of a decubitus on the pa�ent s
sacrum is:
a. Silver impregnated dressings
b. Wet to dry
c. Primary wound closure
d. Secondary wound closure

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6. While all childhood injuries are given consideration, the following injury in an ambulating
toddler should mandate an abuse evaluation:
a. Bruising over the lower legs
b. reenstick fracture of the humerous
c. Near drowning
d. Linear skull fracture

. When writing the medication dose on a patient's chart, it is appropriate to:

a. Use the leading zero: 0.5mg
b. Use the trailing zero: .50 mg
c. Use the abbreviation u for units
d. Write cc to show volume

8. ou're prepping the patient's face for scar revision on the right cheek. Which of the following
prep solutions is best for this patient?
a. Providone Iodine solution
b. Chlorhexidine luconate
c. ydrogen Peroxide
d. An alcohol based solution

. Which solu�on is not useful for prepping the eye?

a. Chloroxylenol or Para-chloro-meta-xylenol (PC )
b. Povidone Iodine 5
c. BSS
d. ydrogen Peroxide

10. A thyroid lobectomy is an excision of:

a. Both lobes
b. 5/6 of the thyroid gland
c. An en�re lobe
d. The en�re thyroid gland

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11. Which of the following has the highest tensile strength?

a. onocryl .0
b. Silk .0
c. Prolene 4.0
d. Vicryl 2.0

12. An appendectomy performed for acute, unruptured appendici�s is classified as which type of
wound?
a. Class I (clean)
b. Class 2 (clean contaminated)
c. Class (contaminated)
d. Class 4 (dirty)

1 . Which incision would likely be used for a splenectomy?

a. cBurney
b. Right subcostal
c. Le� subcostal
d. Pfannens�el

14. While the scalpel blade is being changed during a hemicolectomy, the blade snaps and breaks
into several pieces. The scrub nurse is unable to find a small piece of the blade. Which statement
regarding counts is true?
a. The count is considered correct if adjunct technology confirms no R ID recognition in the
wound
b. The count is considered incorrect unless the en�re blade is found
c. The count is considered correct a�er the room and sterile field are searched
d. The count is considered incorrect even if the en�re blade is found

15. What is the purpose of colorless prep solu�on for donor site when preparing a pa�ent for a skin
gra�?
a. To allow the surgeon the ability to properly visualize the skin, while taking the gra�
b. To prevent tatooing the removed skin with pigment from the colored solu�on
c. This is an individual physician s preference only
d. Colorless solu�ons are more e ec�ve at reducing microorganisms on the skin during gra�
procedures

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Preparing for Anesthesia

Objective: Describe various considerations when preparing a
patient for anesthesia

• Preoperative assessment
• Choice of anesthesia
• Pediatric Considerations

Underlying Medical Conditions

• Liver Disease
▫ Greater risk of anesthesia related complications
▫ Increased risk of bleeding

• Addiction
▫ Liver changes
▫ Esophageal Varices
▫ Pancreatitis
▫ Malnutrition
▫ Withdrawal

Underlying Medical Conditions

• Latex Allergies
▫ Latex risk assessment.
▫ First case of the day
▫ Do not remove rubber stoppers from medications

• Increased ICP
▫ Too much fluid increases ICP further
▫ Too little fluid decreases BP and perfusion to brain

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Underlying Medical Conditions

• Renal dialysis
▫ No BP cuffs or IVs on AV fistula arm
▫ Fluid and electrolyte imbalances common
▫ Medications metabolized in the kidneys avoided

• Burn Patients
▫ Prone to Hypothermia
▫ Fluid and electrolyte imbalances are common

Underlying Medical Conditions

• Diabetes
▫ Glucose control can be a challenge
▫ Prone to High Blood Pressure, GERD
▫ Delayed Wound Healing
▫ Glucometer in room

• Diabetes Insipidus
▫ Be mindful in surgeries involving the pituitary or
hypothalamus or head trauma
▫ Treat with fluid cc/cc urine output
▫ Vasopressin or DDAVP

Underlying Medical Conditions

• Smokers
▫ 7-8 weeks for ciliary function to return.
▫ Stop smoking ASAP

• Cardiac Complications
▫ Steady BP on the
low side of baseline
is the goal

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Underlying Medical Conditions

• Hemophilia
• Factor VIII deficiency
• Synthetic Factor VIII replacement throughout surgery
• Pregnancy
▫ Remember to check for pregnancy on all females of
childbearing age.
▫ Always position off Vena Cava
▫ Maintain BP for fetal perfusion
▫ Have fetal heart monitor

Underlying Medical Conditions

• CHF
▫ Prone to fluid overload
 NPO and don’t take the diuretic
 Under anesthesia they dilate and need fluid

• Morbid Obesity
▫ Wound healing compromised
▫ Difficult intubation common
▫ Positioning can make ventilation difficult

Underlying Medical Conditions

• Asthma
▫ Have them bring their inhalers
▫ Deeper sedation for intubation
• COPD
▫ Low O2 stimulates breathing not high CO2
▫ Take care during moderate sedation
• Do I need a post op ventilator?
▫ Vt lower than 500 ml in an adult
▫ PCO2 > 45

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Underlying Medical Conditions

• Rheumatoid Arthritis
▫ Joint Immobility / Creative Positioning
▫ RA causes anemia
▫ Steroid Coverage puts them at risk for an impaired stress
response. Hypo-adrenal Crisis

• Sickle Cell Anemia

▫ Specific anesthesia management
▫ Avoid triggers
 Hypothermia, Hypotension, Hypovolemia, Hypoglycemia,
Hypoxia

Pediatric Considerations
• Infant (up to 18 months)
▫ Sooth with pacifier,
▫ Hold and rock

• Toddler (18 to 30 months)

▫ Separation anxiety
▫ Communicate with simple sentences
▫ Sooth with distraction and familiar objects

Pediatric Considerations
• Preschooler (2 ½ – 5y)
▫ May believe they are in the hospital because they are in
trouble
▫ Fear pain and mutilation
▫ Fear of abandonment
▫ Provide independence when possible
▫ Communicate using
compound sentences

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Pediatric Considerations
• School age (6y – 11y)
▫ Give honest gentle
information
▫ Able to be more cooperative
▫ Give positive reinforcement
for cooperative behavior
▫ Watch for loose teeth!

Pediatric Considerations
• Adolescent (12y – 18y)
▫ Fear loss of privacy
▫ Body Image is important

• Adolescents are hypersensitive to

the opposite sex as caregivers

• Give honest information

Pediatric Considerations
• Young infants have short tracheas
▫ Maintain neutral neck alignment in intubated infants

• Weigh sponges to keep accurate count of blood

loss in small infants
• Very sensitive to heat
loss
• Don’t leave them
alone!

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Physiology of Thermoregulation

• Newborns
▫ Immature vasomotor control
▫ No shiver response
▫ Low muscle mass
• Elderly
▫ Poor peripheral vasomotor control
▫ Low muscle mass
 Ineffective shiver response

Pediatric Considerations
• Respiratory rate drives heart rate

• Decompensate more suddenly / Recover quickly

• Immature vasomotor control = faster heat loss

• Infants do have mature

pain receptors

Postoperative Pediatric Considerations

• Best post-op position is lateral

• Semi-prone for oral procedures

• Swaddle an infant to maintain

position and comfort

• May need safety restraints to

maintain tubes and drains

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Positioning
• How will the patient tolerate the planned
position? Think about it

• Positioning devices should be clean and in proper

working order

• Move unconscious patients using assistive devices

▫ Monitor the patient’s body alignment and tissue
integrity

Braden Scale
Scale Risk Factor Scored 1-4
• Severe <10 • Sensory Perception
• High risk 10-12 • Moisture
• Moderate 13-14 • Activity
• Mild 15-18 • Mobility
• Nutrition
• Friction/Shear

Transfer / Transport
• Always check with anesthesia 1st

• Four people to transfer

▫ >72 kg = 4 people
▫ <72 kg = 3 people
▫ <20 kg = 2 people

• Remove restraints

• Lock wheels

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Positioning – Obturator Nerve

• The obturator nerve can
be damaged during
lithotomy

• Devices or equipment
leaning on the patient

• Pain and numbness of

the inner thigh
▫ Year to recover

Positioning
Popliteal Nerve
• Common peroneal nerve and
tibial nerve in posterior knee
▫ Part of the sciatic nerve
• Boot stirrups
▫ Weight of leg on thigh and knee

• 1 to 4 months to recover
• Prone to reinjury

Positioning
Sciatic Nerve
• External rotation of the hips
▫ Lower vascular procedures
▫ Lithotomy
▫ Herniated Disc

• Recovers without surgery in

80-90% of patients

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Positioning
Peroneal & Saphenous
• Peroneal runs laterally
• Peroneal nerve injury
▫ Long leg casts
▫ Lateral hip and total knee procedures
▫ Positioning

• Saphenous is medial
• Saphenous nerve injury
▫ Vein harvest or stripping procedures

Positioning
Brachial Plexus
• Maintain neutral shoulder
• Support arm on an arm board
▫ Abduction less than 90°
• Injury occurs when extremity
is:
▫ Forcefully pulled or stretched
▫ ROM exceeded for extended time
▫ Risk increases when head is
turned to the side
• Some injuries recover, some
have permanent disability

Positioning - Supine
Pressure Points Safety Precautions
• Occiput • Spinal Alignment
• Scapula ▫ Legs parallel
• Olecranon Process ▫ Ankles uncrossed
• Sacrum / Coccyx • Pad the head / elbows
• Heels • Float the heels
Nerve precautions:
▫ Brachial Plexus
▫ Ulnar
▫ Radial
▫ Median

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Positioning Supine
Reverse Trendelenburg Trendelenburg
• Head up • Head down
• Craniotomy • Helps with difficult
• Breast reconstruction insertion of neck lines
• Neck procedures • Pelvic surgery

Positioning - Lithotomy
Indications Safety Precautions
• Perineal surgery • Stirrups should be even
▫ Hemorrhoidectomy • Buttocks to edge of bed
• Variation = Frog leg • Elevate legs together
▫ CABG for saphenous vein • Lower legs together
access • Minimal external rotation
of hips
• Place arms on abdomen
or on arm boards at <90°
• Protect hands

Positioning - Lateral
Indications Safety Precautions
• Thoracic • Pressure points
• Kidney ▫ Ear
▫ Acromion process
Safety Precautions ▫ Iliac crest
▫ Greater trochanter of
• Flex lower leg femur
• Pillow between knees ▫ Dependent knee
▫ Malleolus
• Support head and upper
arm

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Positioning - Prone
Indications Safety Precautions
• Spine surgery • Pressure Points
• Arms tucked for cervical ▫ Face
spine procedures ▫ Breasts
▫ Iliac Crest
Safety Precautions ▫ Male genitalia
• Arm boards should be ▫ Patella
lower than table ▫ Dorsum of feet
• Chest roll from clavicle • Cervical alignment
to iliac crest improves • Protect face
chest expansion

Positioning - Sitting
Indications Safety Precautions
• Craniotomies • Pressure Points
• Shoulder ▫ Scapula
▫ Ischial Tuberosities
▫ Heels
• Secure hands on lap
• Foot board maintains
dorsiflexion

Hemodynamic Monitoring
• Common types of monitoring
▫ Central Venous Pressure (CVP)
▫ Swan-Ganz Catheter
▫ Arterial Line

• Why do hemodynamic monitoring?

▫ Heart disease
▫ Respiratory disease
▫ High risk / type of surgery
▫ Shock

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Central Venous Pressure

• Pressure in the right atrium

• Normal 4-8 mmHg

• Low = Hemorrhage, venous pooling

• High = Pulmonary Hypertension, Pulmonary

edema, Right ventricular failure

Swan-Ganz Catheter
• Intrajugular or Subclavian
▫ Usually on the right side
• Measures
▫ Cardiac output (4-8 liters/min)
▫ RA (4-8 mmHg)
▫ PA pressures (1/3 systemic pressure)
▫ Wedge pressure (4-12 mmHg)
▫ Core Temp

• Risk: Micro shock

Arterial Line
• For continuous monitoring of blood pressure

• Required for infusion of Nipride or other

hemodynamic drugs requiring tight control

• Frequent blood tests

• Radial artery most commonly used

• Allen test before insertion

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Preparing for Anesthesia

• 17 Questions
• 17 Minutes

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Preparing for Anesthesia Quiz

1. The pa�ent posi�on most likely to compromise the respiratory system is:
a. Reverse Trendelenburg
b. Lateral decubitus
c. Trendelenburg
d. Si ng

2. Poten�al adverse e ects of the supine posi�on include:

a. Skin breakdown at the heals, sacrum, and elbows
b. Vasoconstric�on in the lower extremi�es
c. Increased mean arterial pressure
d. Re�nal detachment of corneal edema

3. In the posi�oning of a pa�ent in the prone posi�on, the primary reason for using chest rolls is to
provide for:
a. Beter exposure of the opera�ve site
b. Adequate circula�on
c. Unrestricted respiratory exchange
d. Protec�on of the nervous system

4. hat do ou do to protect the patient in upine po ition

a. ace paddin under the hee
b. Provide padding under the lower extremi�es allowing the heels to float
c. Place a fo ded pi o under the nee
d. P ace the arm at the ide p am do n

. ust before the transfer of a pa�ent with a fractured femur, the surgeon is called to the
telephone. In response to this situa�on, the circula�on nurse should:
a. Wait for the surgeon to return to assign responsibility for suppor�ng the fracture
b. Call the supervisor to request assistance with the transfer
c. Take responsibility for suppor�ng the fracture
d. Call for i tin he p and proceed to tran er the patient

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6. The proper way to tuck the pa�ent s arms at his or her sides is to place the upper flaps of the
draw sheet up over the arms and tuck it under the:
a. atress
b. Bed frame
c. Pa�ent
d. Sled

. Which patient is most at risk for inadvertent hypothermia during surgery?

a. An 86 year old bowel resection patient with cancer
b. An 18 month old bronchoscopy for removal of foreign object
c. 55 year old female for AV fistula for dialysis
d. 15 year old male for left knee arthoscopy

8. or a very obese pa�ent undergoing vaginal hysterectomy, addi�onal padding will be needed at
the lateral aspect of the knee to prevent compression injury to which nerve?
a. Scia�c
b. Peroneal
c. Obturator
d. Saphenous

. A�er transfer of a tonsillectomy pa�ent to the transporta�on vehicle, in which of the following
posi�ons should the pa�ent be placed to facilitate drainage?
a. Trendelenburg
b. Prone
c. odified owler s
d. Semi prone

10. An 8-year-old boy is being prepared for bilateral inguinal herniorrhaphy. As the anesthesia
provider is about to start the IV, the boy begins to cry. The most appropriate ac�on at this point
would be to:
a. ive the pa�ent psychological support though tac�le contact and verbal reassurance
b. Impress upon the pa�ent how important it is to be brave and not to cry
c. Distract the pa�ent s aten�on form the venipuncture by asking if he has a pet or hobby
d. Turn the pa�ents head to the side so that he cannot see the venipuncture

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11. A 49-year-old firefighter with 60 second- and third-degree burns on his torso and lower
extremi�es is undergoing split thickness skin gra� repair. Which nursing diagnosis is most
important to this par�cular pa�ent during the intraopera�ve period?
a. Poten�al for knowledge deficit
b. Poten�al for compromise in skin integrity
c. Poten�al for fluid and electrolyte imbalance
d. Poten�al for elevated body temperature

12. When gas cylinders are used during a pa�ent transport, recommenda�ons include:
a. Securing them to the transport cart or bed holder designed for this purpose
b. Placing the gas cylinder to one side of the pa�ent in the stretcher
c. The transporter carrying the gas cylinder
d. Placing the cylinder between the pa�ent s legs on the stretcher

13. In the instruc�on of an 8-year-old child, reasonable grasp of the informa�on can o�en be
ensured by the use of:
a. Audiovisual equipment
b. Group lectures
c. Reading material
d. Preparing the parents and they will instruct their child

14. The pa�ent has a Swan- anz catheter inserted prior to induc�on of anesthesia. The
periopera�ve nurse is especially careful to ensure that all electrical safeguards have been met,
because this situa�on represents an increased poten�al for:
a. icro shock
b. Thermal burns
c. acro shock
d. Electrical burn

1 . Criteria for the care of surgical pa�ents with a latex allergy may include:
a. Elas�c adhesive and tape
b. Egg crate padding on the arm boards
c. Paper tape to secure the post op dressing
d. A bou ant cap to cover the pa�ent s hair

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1 . When posi�oning the pa�ent s arm on an arm board, it is important to prevent abduc�on of the
arm at an angle greater than degrees to prevent injury to the
a. 60 ulnar nerve
b. 0 brachial plexus
c. 0 peroneal nerve
d. 45 brachial plexus

1 . our pa�ent is under general anesthesia. The purpose of lowering the legs slowly from the
lithotomy to the supine posi�on is to:
a. Promote cerebral per u ion
b. Prevent hypotension
c. Provide privacy
d. Prevent circulatory overload

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Pharmacology
Objective: Relate possible side effects and complications of
anesthesia agents

• Anesthesia Agents
• Analgesia
• Anxiety
• Sedation
• Paralytics
• Reversal agents

Types of Anesthesia
• Local
• Moderate Sedation
• Monitored Anesthesia Care
• Nerve Blocks
• Neuraxial
• General Anesthesia

ASA scoring system

• ASA 1 - normal healthy patient
• ASA 2 - patient with mild systemic disease
• ASA 3 - patient with severe systemic disease
• ASA 4 - patient with severe systemic disease that is
a constant threat to life
• ASA 5 - near-death patient who is not expected to
survive
• ASA 6 - declared brain-dead patient
▫ In an emergency the number is followed by an E

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Herbal Supplements
• Liver Damage: • Arrhythmias / Hypertension:
▫ Echinacea ▫ Goldenseal
▫ Kava ▫ Milk Thistle
▫ Licorice
• Increased bleeding: ▫ Ginseng
▫ Ginger ▫ Ephedra
▫ Ginkgo
▫ Garlic • Prolonged emergence:
▫ Fever Few ▫ Gingko
▫ Saw Palmetto ▫ St. John’s wort
▫ Fish Oil ▫ Valerian

Anesthesia Induction
• Achieved by • Nurse’s responsibility
▫ Inhalation (especially in • Remain with patient
children) • Limit sensory stimulation
▫ Barbiturates • Stress response can ^ BP and
 Brevital - ECT HR
▫ Sedative-Hypnotics • Know where the emergency /
 Propofol difficult intubation cart and
 Etomidate trach tray are located
• Slow deliberate positioning
 Compensatory vasoconstriction
is compromised

Induction - Potential Concerns

• Asthmatics
▫ Need to be deeper for intubation
▫ Bronchodilator use prior to intubation
• Malignant Hyperthermia
• At risk for aspiration
▫ GERD
▫ Trauma
▫ Awake intubation
▫ Pregnancy / obesity
• Use Cricoid Pressure

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Education and Competency

• Pharmacology • Completing pain
▫ Desired effect
assessment
▫ Contraindications
▫ Visual analog scale
▫ Onset and duration of
action • Patient teaching
▫ Adverse effects
▫ Reversal

Opioid Receptors
• We control our own pain with natural Endorphins
▫ We have receptors for our endorphins so we can build
muscle, move stuff and run from tigers
 Sometimes the natural ability to ignore pain is a big
advantage
▫ The word Endorphin derived from the words
Endogenous Morphine

• Synthetic opioids can cause a histamine release in

some people

Opioids
• Hydromorphone (Dilaudid)
▫ Push slowly
▫ 7x more potent than Morphine
• Meperidine (Demerol)
▫ Weak opioid used for shivering
• Sublimaze (Fentanyl)
▫ 100X stronger than MSO4
▫ Push slowly
• Duramorph (Morphine)
▫ High incidents of nausea/vomiting

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Opioid Reversal Agent

• Narcan (Naloxone)
▫ Competes for the opiate receptors
▫ Dose: 0.1 to 0.2 mg at two- to three-minute intervals
▫ Onset 1-2 min
▫ Duration 30-45 minutes
▫ Monitor for return of respiratory depression

Common IV medications
• Benzodiazepines
▫ Versed (midazolam)
 Short acting
 Amnesic/anti-anxiety
▫ Valium (diazepam)
 Burns on IV administration
 Potent respiratory depressant

• Flumazenil (Romazicon)
▫ Reverses benzodiazepines
▫ Contraindicated in patients with seizures and those
taking tricyclic antidepressants

Complementary Therapy
Holistic Care
• Music
• Massage
• Acupuncture/Acupressure
• Aromatherapy
• Hypnosis
• Reiki
• Guided Imagery

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Complementary Therapy
• Used in surgery primarily with local anesthesia

• Shared decision making with patient

• Qualified practitioner within your state should

perform the complementary therapy

• Good history of dietary and herbal supplements

• Essential oils are not to be given orally

Depolarizing agents (Succinylcholine)

• Succinylcholine (Anectine)
▫ Used primarily for induction to facilitate tracheal intubation

 Rapid onset 1 min

 Duration 5-10 min

• Metabolized by
Pseudocholinesterase
▫ Not the normal process
of acetylcholinesterase
 Takes longer

Depolarizing agents (Succinylcholine)

• Adverse reactions
▫ Bradycardia
▫ Increases intraocular pressure
▫ Hyperkalemia
▫ Oxygen depletion

• Contraindications
▫ Malignant Hyperthermia family history
▫ Degenerative neuromuscular disorders

• No Reversal agent
▫ Effects reversed quickly by metabolism only
 Pseudocholinesterase Deficiency

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Non-Depolarizing Muscle Relaxants

• Acetylcholine competitive antagonists
▫ Aptly called blocking agents
▫ Blocks acetylcholine
▫ Does not interact with receptor

• All work slower than

Succinylcholine
▫ Larger doses Rocuronium
come close

NDMR reversal agents:

Anticholinesterases

• Blocks acetylcholinesterase
▫ Increases acetylcholine concentration in the neuromuscular
junction.
▫ Displaces the muscle relaxant from the acetylcholine
receptor

• Numerous unwanted side effects

▫ Bradycardia
▫ Bronchospasm
▫ Enhanced GI peristalsis
▫ Enhanced oral secretions

NDMR reversal agents:

• Anticholinesterases
▫ Typically combined with a muscarinic antagonist
(anticholinergic)
 Glycopyrrolate or Atropine

▫ Neostigmine
 Always mixed with glycopyrrolate
 Atropine effects occur before neostigmine

▫ Edrophonium - Enlon Plus

 Premixed with atropine

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NDMR reversal agents:

• Sugammadex
▫ Sugammadex selectively binds rocuronium or
vecuronium

▫ Due to its 1:1 binding of rocuronium or vecuronium, it is able

to reverse any depth of neuromuscular block

▫ NOT an anticholinesterase

Inhalation gases
• Halothane • Ethrane
▫ Strongest ▫ Contraindicated in people
▫ Can cause arrhythmias in with seizures
conjunction with • Desflurane
epinephrine ▫ Fastest onset and offset
• Isoflurane (Forane ) ▫ Coughing is common
▫ Rapid recovery (lucid in 15 – • Nitrous Oxide
30 min) ▫ Gas
• Sevoflurane ▫ Odorless
▫ Can support combustion like
▫ Rapid onset and offset oxygen
▫ Diffusion Hypoxia

Occupational Safety
• Inhalation gases are exhaled in an unchanged
form
▫ Headaches, irritability, cognitive changes
▫ Miscarriage, birth defects, female and male sterility
▫ Renal and hepatic disease
▫ Cancer

• SDS (Safety Data Sheet) includes information on

chemical hazards, special handling and exposure

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Malignant Hyperthermia

• Who is at risk?
▫ Malignant Hyperthermia (MH) is an inherited syndrome
▫ MH has no racial boundaries although, at least in
America, those most often affected are Caucasian
▫ MH happens more frequently in older children and
young adults
▫ Consistently more frequent in men
▫ Pre-Op assessment for risk factors

Mitochondria

Malignant Hyperthermia
• Triggering an episode
▫ A genetically susceptible patient
▫ Succinylcholine is one of the most common triggers,
especially when used in conjunction with an inhaled
anesthetic such as Desflurane, Isoflurane and
Halothane
▫ An MH susceptible patient should never receive
Succinylcholine or one of these anesthetics

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Malignant Hyperthermia
• Early signs include:
▫ Trismus
▫ Rapid increase in body metabolism
 This is indicated by a rise in exhaled CO2 and
metabolic acidosis
 This is the earliest consistent indicator
▫ Intense muscle rigidity
▫ Increased heart rate
▫ Increased blood pressure

Malignant Hyperthermia

• Late Signs include:

▫ Rapidly rising body temperature
▫ Change in color of soda lime
▫ Hyperkalemia
▫ Hypoxia
▫ Myoglobinuria
▫ Cardiac arrest

Malignant Hyperthermia
• Immediately discontinue all triggering agents
• Hyperventilate the patient with 100%
• Call MHAUS-1-800-MH-HYPER
• Dantrolene 2-3 mg/kg
• Sodium bicarbonate IV for metabolic acidosis
• Hyperkalemia
▫ Calcium, insulin, glucose
• Myoglobinuria
▫ Diuretics, bicarb, fluids

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Malignant Hyperthermia
• No Calcium channel blockers
• Ice packs / hypothermia blanket
• Give iced NSS - Avoid Ringers
• Send labs - Correct electrolyte imbalances
• Monitor ECG - Correct arrhythmia
• Transfer patient to ICU when stable and monitor
for 36 hours for recurrence and complications

Pharmacology Quiz
• 12 Questions
• 12 Minutes

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Pharmacology Quiz

1. The following medication can cause chest wall rigidity if pushed too quickly:
a. ydromorphone
b. orphine
c. Succynilcholine
d. Atropine

2. Symptoms of benzodiazepine overdose include:

a. Urinary reten�on and seizure
b. Confusion and decreased respiratory func�on
c. Nausea and vomi�ng and decreased respiratory func�on
d. Nausea, vomiting, hypotension and agitation

. The hysterectomy pa�ent received midazolam preopera�vely for anxiety. She is obtunded and not
taking e ec�ve breaths. The periopera�ve nurse maintains respira�ons and an�cipates the need
for:
a. Narcan
b. Neos�gmine
c. Romazicon
d. Epinephrine

4. is an herbal supplement that has been linked to increased risk of bleeding.

a. Valerian
b. Kava
c. Gingko
d. Ephedra

5. Mr. S is exhibi�ng unexplained tachycardia, rapid respira�ons, and muscle rigidity. The anesthesia
team determines r. S is showing early signs of malignant hyperthermia. In response, the
periopera�ve nurse retrieves the cart and begins to recons�tute the Dantrolene Sodium with:
a. Normal saline
b. Preserva�ve free sterile water
c. ydrocor�sone acetate
d. A hypertonic saline solu�on

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6. Which of the following patients would be an ASA class 4?

a. A patient with a severe systemic disease that is a constant threat to life
b. A patient who is not expected to survive without immediate medical intervention
c. A patient with a mild systemic disease
d. A patient with a severe systemic disease

. The following are considered safe anesthe�c agents to use in pa�ents that are at risk for
malignant hyperthermia except:
a. Nitrous oxide
b. Propofol
c. Succinylcholine
d. Ketamine

8. The correct dose for Dantrolene is:

a. 25 mg/kg
b. 2.5 mg/kg
c. 250 mg/kg
d. 1.25 mg/kg

. Which is not considered a triggering agent for malignant hyperthermia?

a. Succinylcholine
b. Thiopental sodium
c. Halothane
d. Enflurane

10. During the periopera�ve interview, the pa�ent lists the following as current medica�ons: Timolol
maleate (Timop�c) and Pilocarpine for glaucoma, and metoprolol (Lopressor) and diazoxide for
hypertension. The preopera�ve medica�on ordered for r. P consists of atropine, 0.4 mg;
meperidine (Demerol), 25 mg and hydroxyzine (Vistaril), 25 mg I on call. The periopera�ve
nurse is aware that:
a. The pa�ent s daily medica�on should be taken on the morning of surgery
b. The pa�ent should ins�ll the eye medica�on on the morning of surgery
c. The preopera�ve medica�on is contraindicated for this pa�ent
d. The preopera�ve medica�on is no longer administered for narcolep�c analgesia

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11. All of the following medica�ons used in moderate seda�on/analgesia are classified as opiates
except:
a. Naloxone
b. Fentanyl
c. Morphine
d. eperidine

12. The primary purpose or premedica�on before surgery is to sedate the pa�ent and reduce
anxiety. The drug class used to reduce anxiety is:
a. Benzodiazepines
b. Narco�cs
c. ypno�cs
d. Barbiturates

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Safe Administration of Anesthesia

Objective: Define the perioperative nurse’s role supporting
safe administration of anesthesia

• Moderate Sedation
• Local
• Regional Anesthesia
• Epidural or Spinal
• General Anesthesia
• Post op complications

Moderate Sedation
• Monitoring
▫ Capnograph, depth of sedation scale, consider BIS
monitoring
▫ Audible alarms

• Older adults
▫ Assess for frailty (frail scale)
▫ Assess for functional status
 Assistance with ADLs?
▫ Cognitive impairment
 Increased risk for delirium

Moderate Sedation
• Same level of care and same equipment available if
moderate sedation done outside of the OR setting

• Assess for alcohol, cannabis and opioids

▫ Ask specifically
 Cannabis ointments and drops
 Prescription and legalized usage too

• Infant / Toddler Discharge

▫ 2nd responsible adult rides in back seat with child

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Moderate Sedation
• Know your scope of practice
▫ State Board of Nursing
▫ AORN Government affairs links to State BON

• RN can do moderate sedation for ASA 1,2 & 3

▫ No beards, dentures, or sleep apnea
 Difficult mask ventilation

• No competing responsibilities for monitoring RN

▫ 2 RNs in the room with the pt at all times
▫ Brief interruptible tasks ok for monitoring RN
 Tie gown, Open suture

Local Anesthesia
Ester or Amide Chain
binds the two halves

Depolarization creates action

potential on the nerve cells to
deliver pain signal to the brain

Local Anesthetic block the channels

and prevent depolarization

Local Anesthesia
• Esters - cocaine, procaine, tetracaine
▫ Metabolized by pseudocholinesterase
 Process releases para-aminobenzoic acid (PABA)
 Some people are allergic to that

• Amides - bupivacaine, lidocaine, mepivacaine,

▫ Metabolized in liver

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Local Anesthesia
• At baseline and every 5-15 minutes during case:
▫ Heart Rate/Rhythm, Pulse, BP
▫ Pulse oximetry
▫ Pain, anxiety and LOC

• The monitoring nurse for a straight local case

may also be the circulator

Local Anesthetic Systemic Toxicity

(LAST)
• High Serum levels of the local Anesthetic
▫ Use the lowest dose to achieve desired result

• Early signs usually appear around a minute after

injection but can be delayed for up to 30 min
• Frequent verbal communication with patient to
assess for S/S

Patients at highest risk for LAST

• Advanced age
• Heart failure, ischemic heart disease, conduction
abnormalities
• Liver disease
• Low Albumin Levels
• Metabolic or respiratory acidosis
• Medications that inhibit sodium channels

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Signs and Symptoms of LAST

1. Initial Phase: 2. Excitation Phase:
▫ Metallic Taste ▫ Shivering
▫ Numb tongue and lips ▫ Slurred speech
▫ Ringing in ears ▫ Confusion
▫ Light headedness ▫ Seizures
▫ Agitation ▫ Tachycardia/hypertension
3. Depression Phase:
▫ Coma
▫ Bradycardia/hypotension
(progression)
▫ Ventricular arrhythmias
▫ Respiratory/Cardiac arrest

Local Anesthetic Systemic Toxicity (LAST)

• Prevention! • Oxygen, Monitors, IV fluid
▫ Know + calculate maximum ▫ Hyperventilate with 100%
doses of local anesthetic O2
agent ▫ Establish IV access if not
▫ Always aspirate prior to already there
injection
• ACLS
▫ Ask patient about
symptoms after injection • 20% lipid emulsion
▫ Serial repairs of large or ▫ 1-1.5 ml/kg bolus over a
multiple wounds minute
 Can repeat bolus up to 3x
 Then infusion at 0.25
ml/kg/min

Regional Anesthesia
• Topical
▫ Drops or ointment

• Local infiltration
▫ Injected into incision site
▫ Epinephrine delays absorption for post op pain control
▫ 1% Lidocaine 4-5mg/kg per day (with epi 7mg/kg)

• Regional nerve blockade

▫ The injection onto or near nerves for temporary control
of pain

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Brachial Plexus 1. 2.
Block

1. Interscalene
2. Supraclavicular
3. Infraclavicular 3. 4.
4. Axillary

Brachial Plexus Block Complications

• Interscalene
▫ Horner’s syndrome
▫ Phrenic nerve paresis common
• Supraclavicular
▫ Pneumothorax
▫ Phrenic nerve paresis less common Horner’s syndrome
• Infraclavicular Signs on same side as the
block
▫ Short duration • Miosis
▫ Good pain control • Constricted pupil
• Ptosis
• Axillary • Droopy eyelid
▫ Hematoma • Anhidrosis
• Decreased sweating
▫ Accidental vascular injection
▫ Reliability improving with ultrasound technique

IV Regional Anesthesia – Bier Block

• Used in hand procedures
• 20 to 60 minute cases are ideal
• Bloodless field
• Rapid onset < 5 min
• Motor function returns rapidly then
sensation

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Femoral Block
• The femoral block is well-suited for surgery on the
anterior thigh and knee, quadriceps tendon repair
• Postoperative pain management after femur and knee
surgery

Neuraxial Anesthesia
Epidurals & Spinals

• Aspirate before injection

▫ Bupivacaine in the epidural vein = LAST
• Motor, sensory and autonomic block of nerve roots
and spinal cord
• Position and transfer patients with care due to lack of
motor/sensory function.
▫ Body alignment
▫ Too rapid a position change can cause severe hypotension

Peridural or Subdural or
Epidural/Caudal Spinal / Saddle
• Medication injected into • Medication injected into
epidural space the spinal fluid
• Can be used for • Lasts about two hours
postoperative pain • Injected below L2
• Longer Duration • Not for postoperative
• Larger dose pain
• Thoracic and Lumbar • Onset in 5 minutes
region
• Preferred for Obstetrics
• Onset in 15 – 30 minutes

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Neuraxial Anesthesia Considerations

• History of spinal malformation

• Previous spinal surgery

• Psychological status

• High skill level required in children

Neuraxial Anesthesia Contraindications

• Patient is anticoagulated • Pre-existing neurologic

▫ Bleeding disorders disorders
▫ Pharmacological ▫ Multiple sclerosis
• Increased ICP • Cancer of Brain/spinal
• Septicemia cord
• Skin infection at the • Patient refusal
insertion site

Neuraxial Anesthesia Complications

• Respiratory Depression
▫ Caused by sedatives used with Regional anesthesia or high
placement effecting phrenic nerve
▫ Treat the underlying cause and maintain respirations

• Bladder distention
▫ Sacral autonomic fibers are the last to recover
 Patient does not sense a full bladder

• Motor function returns before sensory function

▫ Offer bedpan or urinal for bladder distention

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Neuraxial Anesthesia Complications

• Hypotension
▫ Occurs in 1/3 of patients
▫ Decreased venous return and cardiac output
 GREATLY enhanced by hypovolemia
• Treatment
▫ IVF
▫ Vasopressors
▫ Slight head down position (5-10°)

Neuraxial Anesthesia Complications

• Post Dural Puncture Headache (PDPH)
▫ Spinal anesthesia
 Pencil point needles preferred over beveled
▫ Accidental Dural puncture in Epidural anesthesia

• Noninvasive treatments
▫ HOB flat, fluids, analgesics, caffeine, and Sumatriptan
• Invasive Treatment
▫ Epidural Blood patch

Anesthesia Emergence
• Hypoventilation
▫ Muscle relaxants not fully reversed
▫ CNS depressants
▫ Maintain respirations

• Emergence Delirium
▫ Adolescents
▫ Dream state
▫ Time and safety

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Upper Airway Obstruction

• Laryngospasm
▫ Drowning reflex
▫ Encourage coughing
▫ 100% O2
▫ Sedate and Paralyze if severe
• Trauma/Swelling
▫ 100% O2
▫ Vaporized Epinephrine
• Bronchospasm
▫ 100% o2
▫ Bronchodilators

General Anesthesia
• A state of being unaware and unresponsive to painful
stimuli
• Several aspects are involved:
▫ Lack of conscious awareness
 Unconsciousness
▫ Lack of perception of pain
 Analgesia
▫ Lack of movement
 Muscle relaxation
▫ Modification of autonomic responses
 HR / BP increase to painful stimuli

General Anesthesia Induction

• Quick onset, short acting medications
▫ Non-Barbiturate Hypnotics
• Laryngeal reflexes lost
• Induction agents Do NOT provide analgesia
• Inhalation induction
▫ Lack of patient cooperation or comprehension

• Nursing Considerations
▫ Support ventilation, maintain open airway
▫ At risk for aspiration
▫ Suction ready

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Stages of Anesthesia
• Stage I - analgesia
▫ Analgesia and amnesia; drowsy
▫ Conscious, can follow simple commands

• Stage II – delirium/excitation
▫ Dream, excitement
▫ Unconscious
▫ Risk of laryngospasm
▫ Risk of cardiac arrest
▫ Pupils dilated

Stages of Anesthesia
• Stage III - Surgical stage / Unable to protect airway
▫ 1st plane-regular respirations
▫ 2nd plane-regular respirations, no longer moving
▫ 3rd plane-diaphragmatic respirations
 Optimal for surgeon
▫ 4th-irregular respirations

• Stage 4 – OVERDOSE!!
▫ Respiratory paralysis
▫ Deeper than necessary

Aldrete Score
• Activity:
▫ Moves extremities on command: 2 • Consciousness:
▫ Moves 2 extremities: 1 ▫ Fully awake: 2
▫ Cannot move extremities: 0 ▫ Arousable: 1
▫ Not responding: 0
• Breathing:
▫ Can breathe deeply/cough freely: 2 • Oxygen Saturation
▫ Dyspnea: 1 ▫ 92% on room air: 2
▫ Apnea: 0 ▫ Needs supplemental oxygen to
maintain saturation >90%: 1
• Circulation: ▫ 90% even with supplemental
▫ Systemic blood pressure 20% oxygen: 0
preanesthetic level: 2
▫ Systemic blood pressure 20% to
49% preanesthetic level: 1
▫ Systemic blood pressure 50%
preanesthetic level: 0

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Anesthesia Quiz
• 13 Questions
• 13 Minutes

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Anesthesia Quiz

1. What does th Aldrete score of indicate?

a. The pa�ent s oxygen satura�on is 2 on room air
b. The pa�ent s condition may be adequate for discharge
c. The pa�ent s blood pressure is within normal limits
d. The pa�ent s pain is well controlled

2. our pa�ent is about to undergo a carpal tunnel release. The anesthesia professional asks you to
assist him in applying a double tourniquet. e is going to perform a:
a. Brachial plexus nerve block
b. Bier block
c. Interscalene block
d. Intravenous catheter inser�on

. A pa�ent who is having a breast biopsy under local anesthesia of 1 Lidocaine with epinephrine.
Lidocaine anesthe�zes the area. What is the ra�onale for the Epinephrine?
a. To shorten the e ects of the lidocaine and improve post op recovery �mes
b. To increase the blood pressure and heart rate
c. or post opera�ve pain control
d. To counteract the cardioto ic e ect of Lidocaine

4. The femoral block is well-suited for which of the following surgeries?

a. Carpel tunnel release
b. Total ip
c. ORI of the ankle
d. uadriceps tendon repair

5. Which of the following events is the best indicator that a pa�ent is ready to be moved to the post
anesthesia care unit (PACU)?
a. The nursing documenta�on is completed
b. The anesthesia care provider indicates that the pa�ent is ready
c. The surgery is completed, and the dressing is in place
d. The surgeon indica�on that the pa�ent is ready

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6. Pa�ents with which of the following American Society of Anesthesiologists (ASA) Physical Status
Classifica�ons are considered appropriate for nurse-administered seda�on during a procedure?
a. All pa�ents in classifica�ons P1, P2, and P
b. Any classifica�on is appropriate
c. P1 and P2
d. edically stable pa�ents in classifica�on P1, P2, and P

. ow does the perioperative nurse immediately respond to a patient who is experienincing a

laryngospasm?
a. Positive pressure ventilation with 100 O2
b. Encouage the patient to cough
c. Administer a bronchdilator as ordered
d. Administer vaporized Epinephrine as ordered

8. During oderate seda�on the pa�ent s respiratory rate drops to 6-8 breaths per minute. The
monitoring nurse s first ac�on would be to:
a. Administer 1.5 L O2 per nasal cannula according to the physician s order
b. ive the pa�ent a dose of Romazicon
c. Perform a jaw thrust chin li�
d. Call anestheisa

. Mr. K. is a 78-year-old pa�ent with a history of heart disease arrives in the holding area. e has
received versed and local lidocaine injec�on for an axial block with bupivacaine. Upon injec�on,
the pa�ent begins to seize and rapidly decompensates. The Perianesthesia nurse
a. Understands the pa�ent is likely experiencing Local Anesthe�c Systemic Toxicity
b. Suspects the pa�ent is likely experiencing Central An�cholinergic Syndrome
c. Suspects and adverse reac�on to midazolam
d. Starts cardiopulmonary resuscita�on

10. To treat r. s condi�on in the previous ques�on the peranesthesia nurse prepares
a. Physos�gmine injec�on
b. Romazicon
c. 20 lipid emulsion for rapid infusion
d. Vasopressin

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11. Postoperatively the s/p shoulder arthoplasty patient's right eye is drooping. is pupil is
constricted on the right, and he has a hoarse voice. What id the possible cause?
a. This is a complication of the interscalene block
b. This is a possible stroke
c. This is an adverse reaction to a retrobulbar block
d. This is unrelated to a shoulder procedure

12. Mrs. M is a 50-year-old female with a history of hypertension scheduled for a le� total knee
arthroplasty under epidural anesthesia. Because this is an epidural you would expect the
anesthesiologist to administer than would be given if the case were done as a
spinal.
a. ore local anesthe�c
b. Less local anesthe�c
c. Lidocaine
d. The same amount of local anesthe�c

1 . All of the following are absolute contraindica�ons to spinal anesthesia except:

a. Pa�ent refusal
b. Infected inser�on site
c. Increased intracranial pressure
d. Previous spine surgery

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Complications
Objective: Identify the nurse’s role in caring for patients with
perioperative complications

• Hypothermia
• Post Op Complications
• DVT Prevention
• Fluid and Electrolyte Imbalances

Complications - Hypothermia
• Hypothermia is temp below 96.8° F (36° C)

• Prevention
▫ Core temps preferred (98.6°F/37.0°C)
▫ Patients lose 3-5 degrees under anesthesia
▫ Use approved warming devices according to
manufacturer’s instruction
▫ Intermittent use is safest
▫ Warm irrigation solutions and blood products
▫ Room temperature in procedure areas should be 68-75°;
humidity 20-60%

Complications - Hypothermia
• Post op shivering increases O2 consumption by 400%

• Myocardial ischemia

• Cardiac arrhythmias below 90° F (32° C)

• Increased Surgical Site Infections
• Acidosis
• Increased Bleeding

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Considerations
• Head and Neck procedures
▫ Keep trach tray nearby in case of swelling
▫ Wire cutters if jaw is wired closed
▫ Anticipate dizziness and N/V after ear surgery
▫ Send obturator with trach patients

Avoiding Complications
• Orthopedic procedures
▫ Casts should be removed outside of the OR
▫ Wet casts handled with palms only
▫ Elevate cast and keep open to air
▫ Cement (Methyl Methacrylate)
 Avoid vapors use scavenger system
 Let anesthesia know when placing cement into the
canal
 Dry time for cement effected by room temperature

Avoiding Complications
• Flap Procedure
▫ Vasoconstriction in graft areas biggest concern
▫ Monitor circulation with Doppler
▫ Protect site from shearing or pressure
▫ Keep warm

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Avoiding Complications
• Orthopedic procedures
▫ Fat emboli risk after long bone procedures
▫ Prevent DVT
 Sequential Compression Devices (SCDs)
 Coumadin / Heparin
 Early ambulation
▫ Monitor for Pulmonary Emboli
 Painful, Short of breath, sudden onset

Virchow’s Triad DVT formation

• Venous Stasis
▫ Immobility during surgery
 Sequential Compression
Device
• Endothelial injury
▫ Surgery interrupts vascular
endothelium

• Hypercoagulability
▫ Clotting cascade triggered

Fluid Imbalances - Patients at risk

• Burns
▫ Day 1&2 - fluid shifts cause hypovolemia
▫ Day 3 – fluid shifts back to vascular causing hemodilution

• Congestive heart failure

▫ Prone to fluid overload
▫ Tend to become vasodilated under anesthesia

• Pediatrics
▫ Small volumes = small margin of error

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Fluid Imbalances
• Neuro patients
▫ Fluid overload will increase ICP
▫ Dehydration decreases cerebral perfusion
▫ Autonomic dysfunction from cord injury causes loss of
vasomotor tone

• Liposuction
▫ Prone to hypovolemia

Fluid Imbalances
• Diabetes Insipidus
▫ Trauma/surgery to pituitary gland or hypothalamus
causes decrease in antidiuretic hormone
▫ Treat with Vasopressin or DDAVP

• Renal Patients
▫ Prone to fluid overload

Fluid Imbalances
Signs of Fluid Overload
• Edema
• Dyspnea
• Rales
• Weight gain
• Neck vein distention
• Increased CVP and BP
• Bulging fontanelle

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Fluid Imbalances
Signs of hypovolemia

• Postural hypotension
• Decreased BP
• Increased pulse
• Dry mucous membranes
• Decreased urine output
• Dizziness or fainting
• Sunken fontanelle

Electrolytes – Sodium
Normal value 135 - 145
• Causes of Hyponatremia:
▫ Irrigation fluid absorbed into venous sinuses.
▫ Results from fluid overload
▫ Hysteroscopies and TUR procedures
 Monitor I&O of irrigation on these cases
 Report to anesthesia and surgeon if deficiency occurs
▫ Glycine and Sorbitol leave behind free water after
metabolism
• Hyponatremia Causes fluid to shift into tissues

Electrolytes – Sodium
Normal value 135 - 145

Hyponatremia Hyponatremia
Signs and Symptoms: Treatment:
• N/V, irritability • Restrict fluids
• Slowed breathing • Diuretic
• Headache, blurred vision • Hypertonic Saline
• Edema solution
• Muscle twitching,
cramping

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Electrolytes – Sodium
Normal value 135 - 145

Hypernatremia: S/S and Treatment:

• Causes: • S/S: Thirst, concentrated
▫ Hypovolemia – Dialysis, urine, muscle weakness,
dehydration, burns, seizures, coma
diuretics, DI
• Hypernatremia cases • Treat with fluid
the fluid to shift out of
tissues and into the
vascular system

Electrolytes – Potassium
Normal value is 3.5 – 5.0

Hypokalemia: S/S and Treatment

• Causes: • Symptoms include
▫ Lost by diuretics ▫ Abdominal distention
▫ Bowel prep ▫ Loss of bowel sounds
▫ Vomiting or diarrhea ▫ Weakness or paralysis
▫ Laxative abuse ▫ Hypotension
▫ Alkalosis
• Treat with potassium
replacement

Electrolytes – Potassium
Normal value is 3.5 – 5.0

Hyperkalemia S/S and Treatment:

• Causes: • Symptoms
▫ Too much in IV fluid ▫ Intestinal cramping,
▫ Intracellular Potassium ▫ Elevated T wave,
▫ Hypertension
• Potassium, Hydrogen Ion ▫ Spastic paralysis
and glucose are Pals ▫ Cardiac standstill
▫ Diabetic Ketoacidosis
▫ Burns • Kayexalate
▫ Addison disease ▫ Takes several hours
• D50 followed by insulin
• Correction of acidosis

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Electrolytes – Calcium
Normal value is 8.5 – 10.5
Normal Ionized Value is 4.5 – 5.6

Hypocalcemia: S/S and Treatment

• Causes: • Twitching
▫ Multiple banked blood • Laryngospasm
transfusions
 Citrate • Cramping
▫ Hypoparathyroidism • Arrhythmias
▫ Parathyroid regulates Ca • Positive Chvostek’s sign
and Phos levels
and Trousseau’s sign
▫ Diuretics
• Treat with replacement

Electrolytes – Calcium
Normal value is 8.5 – 10.5
Normal Ionized Value is 4.5 – 5.6

Hypercalcemia: S/S and Treatment

• Causes: • Symptoms include
▫ Medically neuromuscular
▫ Hyperparathyroidism depression, arrhythmias
▫ Bone cancer/multiple
myeloma
• Treatment:
▫ Sarcoidosis
▫ Mithramycin
 Increases GI
absorption of dietary ▫ Phosphate replacement
Ca++

Phosphorus - Hypophosphatemia
Normal value is 1-2mEq/L

Hypophosphatemia: S/S and Treatment

• Causes: • Symptoms include
▫ Hypercalcemia neuromuscular
▫ Hyperparathyroidism depression, arrhythmias
▫ Bone cancer/multiple
myeloma
• Treatment:
▫ Sarcoidosis
▫ Mithramycin
 Increases GI
absorption of dietary ▫ Phosphate replacement
Ca++

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Phosphorus - Hyperphosphatemia
Normal value is 1-2mEq/L

Hyperphosphatemia: S/S and Treatment

• Causes: • Twitching
▫ Hypocalcemia • Laryngospasm
▫ Hypoparathyroidism
▫ Parathyroid regulates Ca • Cramping
and Phos levels • Arrhythmias
▫ Diuretics • Positive Chvostek’s sign
and Trousseau’s sign
• Treat with replacement

Electrolytes – Magnesium
Normal value is 1.5 to 2.5

• Magnesium deficiency (hypomagnesemia):

▫ Poor nutrition, alcoholism, pancreatitis, diuretics
▫ Muscle spasms and twitching

• Magnesium excess (hypermagnesemia):

▫ Sedative effect on the CNS
▫ Used for premature labor, Preeclampsia,
 Monitor mom
 Monitor baby
▫ Treatment of V-fib and Torsade's de Pointes

Complete Blood Count

• RBC’s • Hemoglobin
▫ Normal range ▫ Normal range
 Men: 4.3 to 5.9  Men: 13.2 to 17.5
 Women: 3.5 to 5.5  Women: 11.5 to 16
▫ Contains Hemoglobin ▫ Carries Oxygen
▫ Can be low even with a
normal RBC

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Complete Blood Count

• Anemia – Low Hematocrit
▫ Normal range:
 Men 42-52
 Women 37-47

• Ideally treat low H&H with iron preoperatively

Complete Blood Count

• Thrombocytopenia – Low platelet count
▫ Normal range 150,000-450,000 µL
▫ Not a problem for most surgeries if above 50,000 µL

• White Blood Cell

▫ Normal Value: 5000 – 10,000 cells/mm3
• Increase • Decrease
▫ Infection ▫ Prolonged infection
▫ Autoimmune Disease ▫ Bone Marrow suppression
▫ Leukemia ▫ Chemotherapy
▫ Radiation

Prothrombin Time (PT)

Normal Value: 11-12.5 sec

What it measures What it means

• A PT test evaluates the • Bleeding or Clotting
coagulation factors: disorder
▫ Extrinsic: VII • Liver Disease
▫ Common: X, V, II, and I • Warfarin Therapy

• May cancel case if

unsuspected

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Partial Thromboplastin Time (PTT)

Normal Value: 30-40 seconds

What it Measures What it means

• Evaluates coagulation • Bleeding or Clotting
factors: disorder
▫ Intrinsic: XII, XI, IX, VIII, • Heparin Therapy
▫ Common: X, V, II and I • Hemophilia
• Shortened in early
stage DIC

• May cancel case if

unsuspected

Complications Quiz
• 10 Questions
• 10 Minutes

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Complica�ons Quiz

1. A 74-year-old pa�ent is scheduled for an exploratory laparotomy. The nursing diagnosis

poten�al for hypothermia is made. In developing a periopera�ve care plan for the pa�ent, which
of the following ac�ons would be most appropriate?
a. Provide the anesthesia provider with a blood/fluid warmer
b. Increase the opera�ng room s ambient temperature to 26. ° C -2 .4° (80° F - 85° F)
c. Provide the surgeon with extra drape sheets for thermal insula�on
d. Place a sequen�al compression device and stockings on the pa�ent s legs to improve
circula�on

2. A pa�ent undergoing a transurethral resec�on of the prostrate (TURP) under spinal anesthesia
starts to have trouble breathing and has a bounding pulse. The electrolyte panel shows a sodium
of 1 0 mEq/L. The most likely cause is:
a. Anesthesia overdose
b. An adverse reac�on to the bladder s being filled and emp�ed rapidly during surgery
c. emorrhage
d. Absorp�on of irriga�on fluid into the vascular system

. During the preopera�ve assessment of a pt, the periopera�ve nurse notes a current electrolyte
report of sodium 1 6 mEq/L potassium 2.8 mEq/L chloride 101 mEq/L. On the basis of
these data, the nurse should:
a. Inform the anesthesia provider of a low potassium value
b. Send a sample to the laboratory for repeat electrolyte analysis
c. Check the complete blood count to correlate the hematocrit with these electrolyte
results
d. Recognize that these electrolyte values are normal

4. During the preopera�ve assessment for a pa�ent scheduled for an emergency Caesarean
sec�on, the periopera�ve nurse notes that the pa�ent s magnesium level is 6mg/L. This places
the pa�ent at risk for:
a. Seizures
b. ypertensive episode
c. Tachycardia
d. ypotensive episode

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. The patient is coming for an Av fistula from the floor. eparin was stopped three days ago. The
preoperative labs showed an INR of 2. and a PTT of 5 seconds. What is the response of the
perioperative nurse?
a. This is a normal finding three days after eparin is discontinued. Continue preparing
the patient for surgery
b. Inform anesthesia and the surgeon. Tell the surgical team to hold opening the room
c. Repeat the lab. These numbers are obviously inaccurate
d. Call the scheduling office to cancel the procedure

. Understanding Virchow s triad, the periopera�ve nurse does which of the following?
a. Places sequen�al compression device on the pa�ent
b. Places the grounding pad over a large muscle mass
c. Provides a blood fluid warmer and forced air warmer to the anesthesia provider
d. Ensures blood products are available for the pa�ent

. Which of the following be t contribute to preven�ng inadvertent hypothermia in a surgical

pa�ent:
a. Use of room temperature irriga�ng solu�ons
b. Adjustment of room temperature between 68- 0 degrees
c. Decrea e �me between prepping of the skin and draping
d. Use of forced air warmer during the procedure

. What is the most common type of emboli after a long bone procedure?
a. yocarial Infarction
b. Drug error
c. at emboli
d. Blood clot

. ou are caring for a parathyroidectomy pa�ent post opera�vely. The pa�ent begins to
experience muscle twitching, cramping, and paresthesia. Which electrolyte imbalance do you
suspect?
a. Calcium
b. agnesium
c. Potassium
d. Sodium

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10. r. Smith is undergoing a small bowel resec�on. Which preopera�ve lab result is of most
concern?
a. Platelets 00,000/mcL
b. Sodium 1 mEq/L
c. ematocrit 22
d. White blood cell count 8,000/mcL

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Surgical Emergencies
Objective: Identify the nurse’s role in caring for patients with surgical
emergencies

• DIC
• Air Embolism
• Cardiac Arrest during surgery
• ABG Interpretation

Disseminated Intravascular
Coagulation (DIC)
• Inappropriate clotting followed by hemorrhaging
• Two causes:
▫ Systemic response
 Trauma
 Sepsis
 Obstetrics – amniotic fluid

▫ Release of procoagulant into the blood stream

 Boney tumor

Disseminated Intravascular
Coagulation (DIC)
Complications Treatment
• Severe Bleeding • Correct the cause
• Stroke • Treat with FFP and
• Reduced blood flow to Cryoprecipitates
organs • Heparin sometimes
• Overload of liver and used in the beginning
kidneys • Volume / blood
replacement

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Air Embolism Risk

Venous Arterial
• Pressure in the right • Bypass
atrium is less than
• Dialysis
atmospheric pressure
• Neuro procedures
where the patient is
sitting
• Hysteroscopy and TUR
procedures

Air Embolism Signs and Symptoms

• Rapid onset pulmonary edema

• Drop in ETCO2
• Hypoxia
• Hypotension
• Arrhythmias
• Neurologic damage

Treating Air Embolism

Venous Arterial
• 1stidentify and occlude the • Deep Trendelenburg
sites of air entry position
• Sloppy wet sponges, • Aspirate air from
irrigation syringe circuit
• Bone wax
• Discontinue Nitrous Oxide
• Place patient in left lateral
position (Durant’s maneuver)
• Aspirate RA catheter

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Cardiac Arrest = Compressions

• Medical reasons
▫ MI, arrhythmias, anaphylactic reactions, emboli, vagal
stimulation, malignant hyperthermia, anesthesia
overdose, hypoxia, laryngospasm, aspiration,
hypothermia, electrolyte imbalances

• Surgical reasons
▫ Hypovolemic shock related to blood loss

Cardiac Arrest
• The RN’s Job
▫ 1st Get help in your room
▫ Get the defibrillator
▫ Document
 meds, time and dose
 rhythms
 time start and stop CPR
▫ Know who is running the code

Cardiac Emergencies
• OMI (Oh My)
▫ Oxygenation, Monitors, IV fluid

• Inadequate HR / BP • Adequate HR
▫ CPR ▫ Epinephrine
▫ Defibrillator ▫ Amiodarone
▫ Epinephrine ▫ Dopamine
▫ Amiodarone ▫ ICU monitored bed
▫ Cardioversion

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PVC Premature Ventricular Contraction

• A relatively common event where the heartbeat is
initiated by the ventricles rather than by the Sino
atrial (SA) node

Ventricular Arrhythmias
• Ventricular Tachycardia – Tachycardia with beats
initiated in the ventricles

• Ventricular Fibrillation - uncoordinated

contraction of the ventricles

Ventricular Arrhythmias
• Bigeminy – PVC every other beat

• Couplet – Pair of PVCs

• Run – Several PVCs in a row. Think of it as
unsustained V-Tach

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Another Arrhythmia
• Supraventricular Tachycardia (SVT) - tachycardia
caused by an electrical impulse originating above
the ventricles
▫ Not a ventricular arrhythmia so Amiodarone is not going
to work
▫ Vagal Stim, Adenosine, Sync Cardioversion

Narrow complex QRS HR >170

Cardiac Emergencies
• Treating Bradycardia
▫ Atropine
▫ Dopamine drip
▫ Pacer

Cardiac Emergencies
Pulseless Electrical Activity - PEA
Causes – 6 H’s and 6 T’s Treatment
• Hypovolemia • CPR
• Hypoxia • Treat the underlying cause
• Hydrogen ions (Acidosis) ▫ Stuff to the left
• Hyper / Hypokalemia
• Hypoglycemia
• Hypothermia
• Toxins (Drug overdose)
• Cardiac Tamponade
• Tension pneumothorax
• Thrombosis (MI / PE)
• Tachycardia
• Trauma

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ABG Interpretation
• Normal Values
pH 7.35 to 7.45
pO2 80 to 100
O2 Sat 98
pCO2 35 to 45 (Respiratory Acid)
HCO3 22 to 26 (Metabolic Base)
Base Excess +2 to -2 (buffer to base ratio)

R.O.M.E
• Respiratory Opposite
▫ Respiratory gas (CO2) and pH going in Opposite
directions.
▫ Indicates a Respiratory problem
• Metabolic Equal
▫ Metabolic Gas (HCO3) and pH going in Equal or same
direction
▫ Indicates a metabolic problem

ABG Interpretation
Is it a Respiratory or Metabolic Problem?

PH
7.35 - 7.45
Acidosis Alkalosis

CO2
Respiratory
35 - 45

HCO3
Metabolic
22 - 26

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ABG Interpretation
• Respiratory Acidosis
▫ Caused by decreased ventilation
▫ Treat with ventilation

• Respiratory Alkalosis
▫ Caused by hyperventilation
▫ Treat with sedation or decreased ventilation

ABG Interpretation
• Metabolic Acidosis • Metabolic Alkalosis
▫ Excess production of ▫ Acid loss
metabolic acids ▫ Upper GI loss
 Cardiac arrest ▫ Diuretics (Potassium
 Sepsis loss = Hydrogen Ion
 Ketoacidosis loss)
 Renal failure ▫ Over administration of
▫ Treat with Bicarb Alkali
▫ Treat the cause

Some Examples
#1 #3
• pH 7.30 • pH 7.25
• pCO2 70 • pCO2 40
• HCO3 30 • HCO3 12

• #2 #4
• pH 7.48 • pH 7.50
• pCO2 20 • pCO2 45
• HCO3 15 • HCO3 35

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Compensation
• Compensated • Partially Compensated
▫ pH = WNL ▫ pH = Not WNL
▫ CO2 = Not WNL ▫ CO2 = Not WNL
▫ HCO3 = Not WNL ▫ HCO3 = Not WNL

• Uncompensated
▫ pH = Not WNL

▫ CO2
One Not WNL & One is WNL
▫ HCO3

Surgical Emergencies Quiz

• 12 Questions
• 12 Minutes

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Surgical Emergencies Quiz

1. The pa�ent with increased ICP is in surgery for burr holes and is in a si ng posi�on with a skull
pin headrest. This pa�ent is at risk for:

a. oot drop
b. Venous air embolism
c. Creutzfeldt akob Disease
d. Pulmonary embolism

2. Interpret the AB for your trauma pa�ent:

p .25, PCO2 40, CO 12

a. etabolic alkalosis
b. etabolic Acidosis
c. Respiratory alkalosis
d. Respiratory acidosis

. During an outpa�ent procedure under local anesthesia, the pa�ent suddenly becomes restless.
The immediate response of the periopera�ve nurse monitoring the pa�ent should be to:

a. increase the rate of the intravenous fluids

b. request addi�onal seda�on for the pa�ent
c. check for signs of allergic reac�on
d. check the pa�ent's airway

4. Interpret the AB for your 2 hrs. postopera�ve pa�ent: p .48, PCO2 50, CO 4

a. etabolic alkalosis
b. etabolic Acidosis
c. Respiratory alkalosis
d. Respiratory acidosis

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5. A�er transferring to the OR bed, the AAA pa�ent experiences di culty breathing, upper back
shoulder pain and profuse swea�ng. In response, the circula�ng nurse s first ac�on would be to

a. Assist with rapid sequence intuba�on and call for the pa�ent s blood products to be
brought to the room
b. Provide a quiet unhurried environment to decrease anxiety in the pa�ent.
c. Assess the pulses in the pa�ent s lower extremi�es
d. Provides the anesthesia provider with a rapid transfuser

6. The EC shows every other beat is a PVC. What is this rhythm called:

a. Run of V-tach
b. Bigeminy
c. 1st degree heart block
d. Pulseless Electrical Ac�vity

7. A moderately obese male pa�ent, recently extubated a�er a thoracotomy, con�nues to be

sedated and has oxygen desatura�ons despite s�mula�ng the pa�ent to cough and deep
breathe. e is wearing a simple facemask with 8L O2. AB s are drawn. p . 2, PaCO2 50,
CO 25, PaO2 65. These results indicate what acid base imbalance?

a. etabolic acidosis
b. etabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

8. The periopera�ve nurse would expect labs for the pa�ent with Disseminated Intravascular
Coagula�on (DIC) to look like:

a. Low PT/PTT, fibrinogen and platelets

b. Elevated platelets, low fibrinogen, low PT/PTT
c. Prolonged PT/PTT, nega�ve D-dimer, elevated platelets
d. Prolonged PT/PTT, low fibrinogen, and low platelets

9. Interpret the AB for the intraopera�ve pa�ent: p .55, PCO2 20, CO 18

a. etabolic alkalosis
b. etabolic Acidosis
c. Respiratory alkalosis
d. Respiratory acidosis

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10. The anesthesiologist suspects the trauma pa�ent for exploratory laparotomy may be developing
Disseminated Intravascular Coagula�on. What clinical finding causes her to suspect DIC?

a. The pa�ent s b ood pre ure i e e ated

b. The ETCO2 is creeping up and the oxygen satura�on is falling.
c. The pa�ent is experiencing epistaxis and bleeding from an old venipuncture wound.
d. The pa�ent has developed a respiratory acidosis

11. Where should fire blankets be located?

a. They should not be used in the OR
b. They should be near Anesthesia at the head of the bed
c. They should be on the wall in the sterile core between rooms
d. They should be within easy reach of the circulator

12. The patient is in a sitting position with a skull pin headrest when an air embolism occurs, The
most important measure the perioperative nurse can take is to:
a. Contact the intensive care unit and ask if the unit can arrange to have a bed ready
posoperatively
b. Lower the head of the patient to reduce the angle of the position
c. Ensure that the scrub nurse has saline for the surgeon to irrigate, detect, and occlude
the vessel
d. Advise the laboratory that blood gases will be sent soon and order a central venous
pressure (CVP) tray

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Trauma Surgery
Objective: Summarize the nurse’s role in caring for surgical trauma
patients

• Trauma surgery
• Mass Casualties
• Blood products

Trauma Triage Order

• 1st Cervical Spine
▫ C-spine immobilization top priority - immediately above
airway

2nd Airway obstruction

• Anticipate tracheostomy for facial injury or
upper airway edema. Trach tray
• Rapid sequence intubation:
▫ Pre-oxygenation,
▫ Paralysis with induction,
▫ Placement with proof

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3rd Hemorrhage
• Surgery is not hemodynamically stabilizing to a
trauma patient
▫ Unless the purpose is to stop the bleeding

• Staged procedure
▫ Large procedure divided into smaller surgeries

Hemorrhage leads to Acidosis

• Uncorrected hemorrhagic shock in trauma
patients leads to profound metabolic acidosis
▫ Interferes with blood clotting mechanisms
▫ Promotes coagulopathy & blood loss

Acidosis is bad for you

• Vasodilatation
• Myocardial depression
• Hyperkalemia
• Shift of oxyhemoglobin dissociation curve to
the right
• Confusion, stupor

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Metabolic Acidosis
Treatment Options
• Identify cause of bleeding: mechanical vs. non-
mechanical bleeding
• Warm patient to reverse coagulopathies
• Blood, FFP, and Platelet replacement
• Bicarb should not be used to treat severe metabolic
acidosis unless the ventilation is adequate to remove
the increased CO2 that is formed.

4th Cardiac Tamponade

• Fluid around heart prevents cardiac
adequate output
▫ Jugular vein distention
▫ Narrowing pulse pressures

• Emergent treatment
▫ Pericardiocentesis - Spinal
needle and 60cc syringe
▫ Prepare for a chest tube,
sternotomy or
thoracotomy according
to direction

5th Pneumothorax (Tension)

• All mediastinal
physiology is shifted
▫ Life threatening
• Closed Chest injury to
the lung

• Needle the chest

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5th Pneumothorax
• Sucking
chest wound

• Chest tube
▫ Set up
▫ Secure
▫ Transport

Trauma
• 6th Increased ICP
▫ Cushing’s triad
 Increase in BP, drop in HR, Neuro repiratory pattern
▫ Hyperventilate
▫ Evacuate fluid/blood
 Prepare for Burr Hole

Neuro assessment

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7th Massive burns

• Fluid deficit biggest issue:
▫ Days 1&2 - fluid shifts cause hypovolemia
 Intravascular to interstitial shift
 Hyperkalemia

▫ Day 3 – fluid shifts back to vascular causing hemodilution

 Interstitial to intravascular shift
 Hypokalemia

7th Massive burns

• Hypothermia

• Excision of tissue within 72 hours of burn

▫ Very bloody, prepare for transfusion

• Additional trauma commonly accompanies burns

8th Spinal cord Injury

• Stabilizing the fracture
• Log roll
• Team effort to remove cervical collar

 Loss of vascular tone

 Vasodilatation and peripheral pooling
 Neurogenic shock
 Place in trendelenburg,
 Vasopressors,
 fluid replacement

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9th Extremity Injury

• Repair the injury: supplies and equipment
▫ Monitor for compartment syndrome
 Check for cap refill and pulses of injured extremities
under drapes
▫ Fasciotomy if swelling impedes
blood flow

Mass Casualty
• Disaster Drills are held at least twice a year
• Upon receiving word of disaster
• Notify hospital departments
• Call in off duty staff
• Set up command center and triage

• Each injury is
evaluated
• Red tagged patients
to surgery first

Blood Administration
• Blood conservation is first priority

• Low Hct are tolerated more now than in the past

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Estimating blood loss

Dry sponges
4x4 hold ~ 10 mL blood
Ray-techs ~ 10-20 mL blood
Lap sponges ~ 100 mL blood

Pediatric cases should have sponges & gauze

weighed for blood loss

Risks of Blood Transfusions

• Transmission of Hep B, Hep C, and HIV

• TRIM(transfusion-associated immunomodulation)

• Increased SSI risk with Banked Blood

• TRALI (transfusion-related acute lung injury)

• Incompatibility reaction

Blood Administration
• Type and screen
▫ Quick (usually within 15 minutes)
▫ ABO and Rh factors only

• Type and Crossmatch

▫ Test for several common antibody reactions between
donor and recipient
▫ Takes longer (as long as 45 min.)
▫ Takes 1cc of pt blood per unit requested to do the cross-
match

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ABO compatibility
• Pts. who are Rh+ can receive both Rh+ and Rh-
blood.
• Pts. who are Rh- cannot receive Rh+ blood
▫ Ro Gham
• Type O
▫ No antigens
• Type A
▫ A antigens
• Type B
▫ B antigens
• Type AB
▫ A and B antigens

Autologous and Directed Donor

• Autologous transfusions
▫ Patients own blood
▫ Preoperative donation
▫ Eliminates risk of blood borne pathogens

• Directed Donor transfusions

▫ Friends and family can donate for a patient
▫ Still goes through all steps of public donation
▫ No statistically significant decrease in risks

Blood Salvage
• Autotransfusion is the quickest form of blood
replacement in the case of an emergency

• Contraindications:
▫ Dirty Bowel
▫ Clotting agents
▫ Amniotic Fluid
▫ Bone Cement
▫ Malignancy

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Normovolemic hemodilution
• 1-2 units of blood removed preoperatively

• Volume replacement with Crystalloids

• Surgical bleeding happens with diluted blood

• Units reinfused with intact clotting factors

Acute Hemolytic Reaction

• Reaction to antigen or antibody

• Symptoms
▫ Lumbar pain, tightness in chest, fever, chills,
hemoglobinuria, shock

• Difficult to assess in surgery

▫ Sudden onset of uncontrolled surgical bleeding that is
unexplained.
▫ Bleeding from non-surgical sites

Other Transfusion Reactions

• Delayed Hemolytic Reaction
▫ More mild reaction to antigens or antibodies
▫ Jaundice
▫ Anemia
• Non-Hemolytic (Febrile reaction)
▫ Reaction to antigen, WBCs or Platelets
▫ Fever, chills, headache, back pain
• Transfusion associated Circulatory Overload (TACO)
▫ Noncardiac pulmonary edema
 Reaction to antigen
 Hives, cough, fever, chills, cyanosis, shock

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Uncross matched Blood

• Emergency Release Blood

• Only in life-threatening bleeding situations

• Draw type and cross from patient early

• Universal donor
▫ O negative

Massive Transfusion
• ARDS (acute respiratory distress syndrome)
▫ Microaggregates lodge in the pulmonary bed
▫ Use a microaggregate filter
• Coagulopathy
▫ Replace clotting factors after 4 units
• Hypothermia
▫ Banked blood is refrigerated
▫ Use warming devices
• Hypocalcemia
▫ Citrate binds patient’s circulating calcium

Trauma Surgery Quiz

• 11 Questions
• 11 Minutes

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Trauma Quiz

1. Concerning the inten�on to combat fluid volume deficit intraopera�vely in a pa�ent who
professes to be a ehovah's witness, which of the following interven�ons would be permited by
this pa�ent's religion?

a. Intraopera�ve administra�on of autologous blood

b. Directed donor transfusion
c. Blood from the blood bank
d. Autotransfusion

2. During an abdominal hysterectomy on a pa�ent with a hemoglobin reading of 10 and a

hematocrit reading of 0, the periopera�ve nurse no�ces 600 cc of bloody fluid in the suc�on
canister. In this case, the periopera�ve nurse would first:

a. Weigh the soiled sponges and add this weight to the 600-cc suc�on loss to calculate the
blood loss
b. Alert the anesthesia provider and the surgeon to the presence of the 600 cc in the
suc�on canister
c. Ask the scrub nurse how much irriga�on has been used and subtract this amount from
the 600 cc to es�mate the par�al blood loss.
d. Prepare paperwork for type and cross-match

3. During the emergency induc�on of anesthesia, the periopera�ve nurse may be requested to use
the Selleck's maneuver (cricoid pressure) to:

a. Displace the larynx anteriorly for beter endotracheal tube placement

b. Suppress the cough reflex
c. acilitate the opening of the trachea or intuba�on
d. Control regurgita�on of stomach contents

4. The pa�ent condi�on necessitates rapid sequence intuba�on. The periopera�ve nurse
an�cipates the order of ac�vity will be and assists
accordingly

a. Paralysis with induc�on, pre-oxygena�on, placement with proof

b. Pre-oxygena�on, paralysis with induc�on, placement with proof
c. Pre oxygenation, paralysis with induction, second oxygenation, placement with proof
d. Posi�on, paralysis with induc�on, placement with proof

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Zander Perioperative Education, LLC

5. A 25-year-old male arrives to the trauma room a�er a high-speed rollover VA. The abdomen is
distended and tender. e has a closed �b-fib fracture and mul�ple lacera�ons to his face, chest
and arms. The periopera�ve nurse is prepping the abdomen for an exploratory laparotomy. She
asks another nurse in the room to locate and mark the pulse distal to the fracture in the lower
extremity. Why?

a. Post-opera�ve nurses will need to know where the peripheral pulse used to be
b. Bounding pulses secondary to high blood pressure should be noted
c. Poor perfusion will cool the extremity necessita�ng warming measures
d. This pa�ent is at risk for compartment syndrome, and she will use the mark to check for
a pulse periodically during the procedure

6. A pa�ent admited through the emergency department has a deep scalp lacera�on and maxillary
and cervical fractures. A�er evalua�ng the pa�ent, the periopera�ve nurse's next ac�on should
be to:

a. Prepare the fiberop�c laryngoscope

b. Apply pressure to stop bleeding from the lacera�on
c. aintain head immobiliza�on
d. Prepare for adequate suc�on

7. or a pa�ent with a ruptured abdominal aor�c aneurysm, which method would provide for the
safest and most immediate blood replacement?

a. Type-specific replacement
b. Directed dona�on
c. Autologous replacement
d. Autotransfusion

8. The periopera�ve nurse receives a pa�ent from the emergency room. The opera�ve consent was
signed for a craniotomy by the pa�ent's husband, who is no longer immediately available. The
pa�ent is unstable and disoriented. To iden�fy the opera�ve site, the nurse's most appropriate
ac�on in this situa�on would be to:

a. Confirm the diagnosis from the emergency room physician's notes

b. Consult the surgeon for confirma�on of the opera�ve site
c. Evaluate the computerized axial tomography (CAT) scan
d. Request advice from the manager

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Zander Perioperative Education, LLC

9. During an exploratory laparotomy on a blunt force trauma pa�ent the pa�ent s BP is /40, R
122, RR, 16 on the ven�lator. The pa�ent s AB is as follows: p . 2, CO2 5, CO 1 . The
circula�ng nurse understands the appropriate treatment for this AB is to:

a. Increase the respiratory ven�la�on rate

b. Stop the bleeding and treat with sodium bicarbonate IV
c. Decrease the respiratory ven�la�on rate
d. Perform cardiopulmonary resuscita�on

10. During a mass casualty situa�on which pa�ents will you treat in surgery first?

e. Red Tagged pa�ents

f. Only pa�ents who require surgical procedures
g. Orthopedic trauma pa�ents
h. Black tagged pa�ents

11. The trauma pa�ent needs emergency released uncross matched blood. What blood type will the
trauma pa�ent receive?

a. AB posi�ve
b. O nega�ve
c. A nega�ve
d. O posi�ve

[Link] 177
Zander Perioperative Education, LLC

Complete your evaluation to receive

your 16.0 ANCC contact hours

803-271-0744

[Link] 178
 Type of Sterilizer Type of testing

Steam – Gravity Displacement and Prevacuum Geobacillus Stearothermophilus spore testin

preferably daily

[Link]
Prevacuum An air removal test like Bowie Dick should be
chamber. For new, renovated or moved equip
successful air removal tests should be done b

Ethylene oxide Bacillus atrophaeus spore testing should be d

Plasma Bacillus Atrophaeus spore testing done at the

other sterilizers in the facility

Ozone Geobacillus Stearothermophilus spore testin

Peracetic acid Geobacillus Stearothermophilus spore testin

Dry Heat Bacillus atrophaeus indicators upon installati

repair. (Table top type monitored weekly)

179
[Link] 180
Zander Perioperative Education, LLC

[Link] 181
 Feature Sea le Responses

[Link]
Eye Spontaneous
Opening To Speech
To Pain
None

Verbal Orientated
Response Confused Conversation
Words (inappropriate)
Sounds (incomprehensible)
None

Obey Commands
Best Motor Localise Pain
Response
Flexion - Normal
Flexion - Abnormal
Extend
None

182
Total Coma Score
 Zander Perioperative Education, LLC

AVK
You need to talk to learn. Reading out loud and reading along are very effective ways to retain information.
What you need
1. A study group.
2. A handheld recorder
3. The recordings of class, Zander Study Group Questions and Practice Exam on your Zander account page
4. A Perioperative nursing textbook (Alexanders 17th ed, Berry and Kohn 15th ed.)
5. Secondarily, access to the 2024 AORN Guidelines and Drain’s Perianesthesia Nursing: A Critical Care
Approach 8th edition.
6. Blank Notebook

What to do
1. Schedule your exam. Everyone works better with a deadline.
2. This learning style does well with a study group. If you have the opportunity to belong to one, make an
effort to attend.
3. You should have marked your slides to identify your areas of weakness as you took notes. You may want
to listen through the recordings again with no other thought than to mark the slides with content that
you think you may answer incorrectly.
4. Next look those things up in the Perioperative textbook that you have chosen to use. Take notes in a
separate notebook on the topics you marked.
5. Make sure you check each topic with the Guidelines to make sure your information from the text is
current. This takes a long time. It is work. And it's very effective.
6. Once you have worked through the whole class. You have looked up every topic you mark as an area of
weakness and taken notes on the information. Now it is time to record. Read your notes from your
notebook into the recorder. This takes a little time but not nearly as laborious as writing it.
7. Once you have the notes and the recordings you will listen to them over and over. Preferably you will be
reading the notes at the same time you are listening. This will engage both your auditory and visual
learning at the same time. Also, listen to the recordings from class but remember your own notes are
more important.
8. Study for about an hour a day for 6 weeks before your exam.
9. Use the apps with practice questions. My favorites are the study group questions or the additional 200
questions on your account page. Check out the Zander CNOR Prep Facebook page. The other apps
mentioned in class are good too.
10. Email me at Wendy@[Link] if you have any questions. I am here to help you. Remember I can
share a copy of the recorded class with you one final time. I ask that you have scheduled your exam
before I send you this final set.

[Link] 183
 Zander Perioperative Education, LLC

AKV

For an AKV the worst thing you can do is review written notes and read books... You're not a visual learner
so that's the most ineffective way to retain information. A study partner that will get up and move with you
is okay but not a study group.

What you need

1. A handheld recorder
2. The recordings of class
3. The recordings of class, Zander Study Group Questions and Practice Exam on your Zander account
page
4. A Perioperative nursing textbook (Alexanders 17th ed, Berry and Kohn 15th ed.)
5. Secondarily, access to the 2024 AORN Guidelines and Drain’s Perianesthesia Nursing: A Critical Care
Approach 8th edition.
What to do
1. Schedule your exam. Everyone works better with a deadline.
2. You should have marked your slides to identify your areas of weakness as you took notes. You may
want to listen through the recordings again with no other thought than to mark the slides with
content that you think you may answer incorrectly.
3. Next look those things up in the Perioperative textbook that you've chosen to use. Record those
things you look up into your hand-held recorder.
4. Make sure you check each topic with the Guidelines to make sure your information from the text is
current. If you see something different or new than what was in the textbook read that information
into your hand-held recorder too.
5. You'll have the recordings I'll send to you and now you have your focused recordings too. Now listen
to these at least an hour a day while you are doing something physical. Clean the house, walk the
dog, or do some laundry. I also like to listen while I am driving. It can be anything as long as you’re
not lying down or curled up resting.
6. Listen to the Zander study group summaries in the same manner
7. Study for about an hour a day for 6 weeks before your exam.
8. Use the apps with practice questions. My favorites are the study group questions or the additional
200 questions on your account page. Check out the Zander CNOR Prep Facebook page. The other
apps mentioned in class are good too.
9. Email me at Wendy@[Link] if you have any questions. I am here to help you. Remember I
can share a copy of the recorded class with you one final time. I ask that you have scheduled your
exam before I send you this final set.

[Link] 184
 Zander Perioperative Education, LLC

KVA
A study partner that will get up and move with you is okay but not a study group. You need physical activity,
but written books and notes work better than an audio version.
What you need
1. A handheld recorder
2. The recordings of class, Zander Study Group Questions and Practice Exam on your Zander account
page
3. A Perioperative nursing textbook (Alexanders 17th ed, Berry and Kohn 15th ed.)
4. Secondarily, access to the 2024 AORN Guidelines and Drain’s Perianesthesia Nursing: A Critical Care
Approach 8th edition.
5. Laptop or computer

What to do
1. Schedule your exam. Everyone works better with a deadline.
2. You should have marked your slides to identify your areas of weakness as you took notes. You may
want to listen through the recordings again with no other thought than to mark the slides with
content that you think you may answer incorrectly.
3. Next look those things up in the Perioperative textbook that you've chosen to use. Take notes in a
separate notebook on the topics you marked.
4. Make sure you check each topic with the Guidelines to make sure your information from the text is
current. This takes a long time. It's work. And it's very effective.
5. Once you have worked through the whole class. You've looked up every topic you mark as an area of
weakness and taken notes on the information. Now, copy those notes onto flashcards.
6. Set your notebook up on a treadmill and program it to a slow walk while you review your notes.
7. Divide the flashcards into stacks that you estimate you can learn in an hour of time. Choose a stack
each day to carry with you. Read through some of them if you get a minute.
8. You may want to retype them into a word document. Copying the information will help you retain it.
9. If you want to review your notes while sitting, it’s okay but only in short bursts. Sit and study for no
more than 15-20 minutes and then get up and be active at least that long. Then sit down and study
for another 15-20 minutes.
10. Make sure to review the written summaries at the bottom of each of the Zander Study group posts
as well.
11. Study for about an hour a day for 6 weeks before your exam.
12. Use the apps with practice questions. My favorites are the study group questions or the additional
200 questions on your account page. Check out the Zander CNOR Prep Facebook page. The other
apps mentioned in class are good too.
13. Email me at Wendy@[Link] if you have any questions. I am here to help you. Remember I
can share a copy of the recorded class with you one final time. I ask that you have scheduled your
exam before I send you this final set.

[Link] 185
 Zander Perioperative Education, LLC

KAV

For a KAV the worst thing you can do is review written notes and read books... You're not a visual learner so
that's the most ineffective way to retain information. You can do it, it's just harder. A study partner that will
get up and move with you is okay but not a study group.

What you need

1. A handheld recorder
2. The recordings of class, Zander Study Group Questions and Practice Exam on your Zander account
page
3. A Perioperative nursing textbook (Alexanders 17th ed, Berry and Kohn 15th ed.)
4. Secondarily, access to the 2024 AORN Guidelines and Drain’s Perianesthesia Nursing: A Critical Care
Approach 8th edition.
What to do
1. Schedule your exam. Everyone works better with a deadline.
2. You should have marked your slides to identify your areas of weakness as you took notes. You may
want to listen through the recordings again with no other thought than to mark the slides with
content that you think you may answer incorrectly.
3. Next look those things up in the Perioperative textbook that you've chosen to use. Record those
things you look up into your hand-held recorder. Read directly from the text book.
4. Make sure you check each topic with the Guidelines to make sure your information from the text is
current. If you see something different or new than what was in the textbook read that information
into your hand-held recorder too.
5. You'll have the recordings I'll send to you and you have your focused recordings too. Now listen to
these at least an hour a day while you are doing something physical. Clean the house, walk the dog,
or do some laundry. It can be anything as long as you’re not sitting down or lying down. KAV’s retain
information most readily during mild physical activity.
6. Listen to the recorded study group summaries too.
7. Study for about an hour a day for 6 weeks before your exam.
8. Use the apps with practice questions. My favorites are the study group questions or the additional
200 questions on your account page. Check out the Zander CNOR Prep Facebook page. The other
apps mentioned in class are good too.
9. Email me at Wendy@[Link] if you have any questions. I am here to help you. Remember I can
share a copy of the recorded class with you one final time. I ask that you have scheduled your exam
before I send you this final set.

[Link] 186
 Zander Perioperative Education, LLC

VAK
Must teach to learn. You are high visual learners, so clutter doesn’t work well for you. You are the people that
go into the OR and have to clean and straighten it before you start the day. Study in a place with minimal visual
clutter.
What you need
1. A video camera or smartphone with video recording capability
2. The recordings of class, Zander Study Group Questions and Practice Exam on your Zander account page
3. A Perioperative nursing textbook (Alexanders 17th ed, Berry and Kohn 15th ed.)
4. Secondarily, access to the 2024 AORN Guidelines and Drain’s Perianesthesia Nursing: A Critical Care
Approach 8th edition.
5. Blank Notebook and flashcards

What to do
1. Schedule your exam. Everyone works better with a deadline.
2. You should have marked your slides to identify your areas of weakness as you took notes. You may want
to listen through the recordings again with no other thought than to mark the slides with content that
you think you may answer incorrectly.
3. Next look those things up in the Perioperative textbook that you've chosen to use. Take notes and
create an outline for yourself so you can record a short presentation for each topic.
4. Make sure you check each topic with the Guidelines to make sure your information from the text is
current. This takes a long time. It's work. And it's very effective.
5. Once you have worked through the whole class. You've looked up every topic you mark as an area of
weakness and taken notes on the information.
6. Divide your notes by topic and pick a topic. Read through and rehears until you can present this topic to
your video camera. Record yourself presenting. Work your way through each topic.
7. By doing this you are dividing up the material into smaller chunks and then absorbing them one at a
time.
8. Once you get through recording all the topics. You study by watching them. You can also watch the
recordings I will send to you. Your own recordings are more useful though.
9. Watch the study group summaries from your account page.
10. Study for about an hour a day for 6 weeks before your exam.
11. Use the apps with practice questions. My favorites are the study group questions or the additional 200
questions on your account page. Check out the Zander CNOR Prep Facebook page. The other apps
mentioned in class are good too.
12. Email me at Wendy@[Link] if you have any questions. I am here to help you. Remember I can
share a copy of the recorded class with you one final time. I ask that you have scheduled your exam
before I send you this final set.

[Link] 187
 Zander Perioperative Education, LLC

VKA
You are a traditional learner so reviewing your notes is the best way to study. What is most important for you is
to have the RIGHT information. The best thing you can do is to focus your study on your personal areas of
opportunity.
What you need
1. A study group.
2. The recordings of class, Zander Study Group Questions and Practice Exam on your Zander account page
3. A Perioperative nursing textbook (Alexanders 17th ed, Berry and Kohn 15th ed.)
4. Secondarily, access to the 2024 AORN Guidelines and Drain’s Perianesthesia Nursing: A Critical Care
Approach 8th edition.
5. Blank Notebook

What to do
1. Schedule your exam. Everyone works better with a deadline.
2. This learning style does well with a study group. If you have the opportunity to belong to one, make an
effort to attend.
3. You should have marked your slides to identify your areas of weakness as you took notes. You may want
to listen through the recordings again with no other thought than to mark the slides with content that
you think you may answer incorrectly.
4. Next look those things up in the Perioperative textbook that you've chosen to use. Take notes in a
separate notebook on the topics you marked.
5. Make sure you check each topic with the Guidelines to make sure your information from the text is
current. This takes a long time. It's work. And It's very effective.
6. Once you have worked through the whole class. You've looked up every topic you mark as an area of
weakness and taken notes on the information. Now, copy those notes onto flashcards.
7. Divide the flashcards into stacks that you estimate you can learn in an hour of time. Choose a stack each
day to carry with you. Read through some of them if you get a minute.
8. Flash cards work really well for you. Reading while pacing about works for you to and is easy to do with
flashcards.
9. You may want to retype them into a word document. Copying the information will help you retain it.
10. If you want to review your notes while sitting, it’s okay but only in short bursts. Sit and study for no
more than 20 minutes and then get up and be active at least that long. Then sit down and study for
another 20 minutes. You can do long study sessions, but you are most efficient for the first 20 minutes.
11. Study for about an hour a day for 6 weeks before your exam.
12. Use the apps with practice questions. My favorites are the study group questions or the additional 200
questions on your account page. Check out the Zander CNOR Prep Facebook page. The other apps
mentioned in class are good too.
13. Email me at Wendy@[Link] if you have any questions. I am here to help you. Remember I can
share a copy of the recorded class with you one final time. I ask that you have scheduled your exam
before I send you this final set.

[Link] 188
Zander Perioperative Education, LLC

Quiz Answer Key

[Link] 189
Zander Perioperative Education, LLC

Answer Key
Test Taking Strategies Surgical Field
1-B 1-B
2-B 2-C
3-D 3-D
4-C 4-A
5-A 5-B
6-C 6-B
7-B 7-D
8-B 8-D
9-A 9-A
10-B 10-B
11-D 11-B

Sterile Processing Operative Suite

1-A 1-A
2-B 2-D
3-A 3-A
4-A 4-C
5-B 5-A
6-C 6-B
7-B 7-C
8-B 8-B
9-C 9-D
10-A 10-C
11-A
12-B
13C
14-A
15-B

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Zander Perioperative Education, LLC

Regulatory Compliance Safe Use of Equipment

1-B 1-A
2-A 2-D
3-A 3-A
4-A 4-A
5-A 5-D
6-D 7-D
7-B 8-C
8-A 9-A
9-A 10-C
10-B 11-D
11-B 12-B
12-C 13-D
14-C
Legal Integrity 15-A
1-D 16-D
2-B
3-A Patient Safety
4-B 1-D
5-D 2-D
6-B 3-B
7-A 4-C
8-B 5-D
9-B 6-B
10-D 7-A
11-B 8-A
9-D
10-C
11-D
12-C
13-C
14-B
15-A

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Zander Perioperative Education, LLC

Preparing for Anesthesia Safe Administration of Anesthesia

1-C 1-B
2-A 2-B
3-C 3-C
4-B 4-D
5-A 5-B
6-C 6-D
7-A 7-B
8-B 8-C
9-D 9-A
10-A 10-A
11-C 11-A
12-A 12-D
13-A
14-A Complications
15-C 1-A
16-B 2-D
17-B 3-A
4-D
Pharmacology 5-B
1-A 6-A
2-B 7-D
3-C 8-C
4-C 9-A
5-B 10-C
6-A
7-C
8-B
9-B
10-C
11-A
12-A

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Zander Perioperative Education, LLC

Surgical Emergencies Trauma Surgery

1-B 1-D
2-B 2-C
3-D 3-D
4-A 4-B
5-A 5-D
6-B 6-C
7-C 7-D
8-D 8-B
9-C 9-B
10-C 10-A
11-A 11-B
12-C

[Link] 193
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All rights reserved. No part of this document may be reproduced or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission
of Zander Perioperative Education.

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