Pre/Postoperative Patient Assessment and Diagnosis |
- Confirm patient identity with two (2) patient identifiers
- Confirm correct procedure, operative site, side/site marking with a completed appropriate consent (e.g., surgery, anesthesia, blood)
- Review relevant patient data
- Use age and culturally appropriate health assessment techniques (e.g., interview, observation)
- Review medication reconciliation A
- Conduct an individualized physical and psychosocial assessment
- Obtain a focused assessment relevantto the procedure
- Perform a pain assessment
- Identify nursing diagnoses
- Confirm advance directive status and/or DNR status
- Conduct patient and family teaching as appropriate for the procedure
| 15% |
Individualized Plan of Care Development and Expected Outcome Identification |
- Identify measurable patient outcomes acrossthe continuum of care
- Identify specific interventions for each nursing diagnosis to achieve expected outcomes
- Ensure care plan addresses specific patient considerations including physiological and behavioral responses, perioperative safety, age considerations, diversity, legal and ethical guidelines
- Evaluate patient responsesto plan of care
- Update plan of care as needed
- Utilize critical thinking skills to facilitate patient care
| 8% |
Patient Care and Safety |
- Maintain patient and personnel safety by monitoring environmental hazards (e.g., chemical, fire, smoke plumes, radiation, electrical, laser)
- Provide comfort measures to optimize behavioral responses to the surgical procedure (e.g., physiological, psychological, spiritual)
- Prepare the surgical site per procedure and surgeon preference
- Ensure the selection of appropriate procedure-specific barrier materials (e.g., lead aprons and drapes, eye goggles, laser shields)
- Evaluate patient response to pharmacological agents (e.g., pain management)
- Assist with anesthesia management
- Control environmental factors
- Maintain a sterile field utilizing aseptic technique
- Utilize equipment according to manufacturer’s recommendations
- Maintain the dignity and privacy of the patient
- Protect patients’ rights through advocacy
- Verify that specimens are prepared, labeled, and transported correctly
- Verify that the correct implants are available
- Verify that the implants are correctly prepared
- Prepare explants for final disposition
- Label solutions, medications, and medication containers
- Perform appropriate surgical counts
- Perform Universal Protocol
- Anticipate the need for intraoperative blood transfusion/salvage
- Utilize proper body mechanics
- Perform proper patient positioning appropriate for procedure
- Intervene with impaired/disruptive behavior in patients, family members, and/or the perioperative team in accordance with facility/institutional policy
- Identify wound classifications
- Maintain wound dressings, including tubes, lines, and drains
| 25% |
Management of Personnel, Services, and Materials |
- Acquire needed equipment, supplies, and personnel
- Assess expiration date and package integrity of products
- Implement cost containment measures
- Participate in product evaluation/selection
- Provide supervision of and education to healthcare team members
- Delegate tasks to appropriate personnel according to regulatory agencies and facility policies and procedures
- Supervise visitors
- Manage healthcare industry representative (HCIR) presence in the OR
- Practice environmental stewardship (e.g., go green, minimize waste)
| 9% |
Communication and Documentation |
- Maintain accurate patient records/documentation of all care provided (e.g., relevant facts, unusual occurrences, specimens, medications)
- Collaborate with the interdisciplinary healthcare team (e.g., nutrition, would class, social work, visiting nurse, referrals, transportation)
- Communicate current patient status to interdisciplinary healthcare providers (e.g., critical lab values, medical condition, medications, allergies, implants/implantable devices, specimen results)
- Communicate measurable patient outcomes across the continuumof care (e.g., hand offs)
- Document perioperative education provided to the patient and advocate where applicable
- Document post discharge follow up communication provided to patient
- Document preoperative and postoperative assessment
- Document transfer of care
- Document appropriate measures to prepare and track implantable tissue and other trackable items
- Evaluate patient status to facilitate transfer to the next level of care
- Implement effective solutions to identified patient communication barriers (e.g., translation services, hearing aids, assistive devices)
- Provide information about the patient according to HIPAA guidelines
- Utilize read-back for verbal orders
- Document surgical wound classification
| 11% |
Infection Prevention and Control of the Environment, Instrumentation, & Supplies |
- Ensure proper environmental cleaning forspills, room turnover, and/or terminal cleaning
- Ensure appropriate methods for cleaning, disinfecting, packaging, sterilizing, transporting and/or storage of instruments and reusable goods
- Ensure appropriate methods for transporting and storage of single-use items
- Maintain appropriate documentation for sterilization and disinfection
- Ensure proper handling and disposition of hazardous materials (e.g., chemo drugs, hazardous materials, radioactive materials)
- Ensure proper handling and disposition of biohazard materials (e.g., blood, CJD)
- Utilize appropriate Personal Protective Equipment (PPE)
- Adhere to appropriate procedures for sterilization, biological monitoring, and chemical monitoring
- Monitor environmental conditions of sterilization and storage areas
- Track materials and instruments brought in from outside the facility
- Adhere to guidelines regarding proper surgical attire based on restricted, semi-restricted, and non-restricted zones
- Adhere to proper hand hygiene guidelines, including surgical hand scrubbing
| 16% |
Emergency Situations |
- Identify emergency situations, including difficult airway, robotic
- Perform nursing interventions for malignant hyperthermia (MH)
- Perform nursing interventions for anaphylaxis
- Perform nursing interventions for cardiac arrest
- Perform nursing interventions for trauma
- Perform nursing interventions for hemorrhage
- Perform nursing interventions for local anesthetic systemic toxicity (LAST)
- Function as a member of the interdisciplinary healthcare team
- Safeguard patients and members of the healthcare team from environmental hazards and during disasters (e.g., fire, toxic fumes, natural disasters, terrorism, active shooter)
| 10% |
Professional Accountability |
- Function within scope of practice
- Seek assistance for recognized personal limitations
- Report impaired/disruptive behavior in interdisciplinary healthcare team
- Uphold ethical and professional standards
- Utilize resources for personal growth
- Participate in quality improvement activities
- Participate in interdisciplinary teams
- Participate in professional organizations
| 6% |
