The perioperative period is the time frame surrounding surgery. Every surgical procedure is broken down into three distinct categories to differentiate tasks and establish who is responsible for overseeing and delivering patient care in each category. These categories include:
- The preoperative phase
- The intraoperative phase
- The postoperative phase
The patient is the reason for the existence of the perioperative care team, and the purpose of this process is to deliver consistent, optimal care from the moment a surgery is ordered through the time a patient is fully recovered.
Each stage must fulfill specific actions to achieve this purpose. Perioperative nurses specialize in clinical pre-, intra-, and post-operative patient care to ultimately ensure safe and efficient surgeries.
The perioperative care team works closely with the patient throughout their perioperative experience. This team functions in various roles and areas, including preadmission testing (PAT), within the physical confines of the operating room (OR), the ambulatory services unit (ASU), and the postanesthesia care unit (PACU).
The Preoperative Phase
This initial phase, called the preoperative phase, is the time period from the decision to have the operation to the beginning of the surgical procedure. This phase can range from minutes to months, depending on the indication of the surgery. A trauma patient may only have minutes from decision to operation, whereas an elective case may be scheduled months in advance.
For patients with a surgery planned in advance, extensive testing during this preoperative period may be required and is very individualized. This is referred to as preadmission testing (PAT) and includes the various components:
- Medical history and physical examination
- Laboratory testing
- Blood type and crossmatch
- Chest x-ray
- Electrocardiogram (ECG)
- Diagnostic procedures
- Written instructions
- Informed consent
- Nurse interview
- Anesthesia assessment
Some of this testing may be done in the surgeon’s office; patients may also be referred to the preoperative testing center of the hospital or ambulatory care facility.
Scans may be necessary, such as magnetic resonance imaging (MRI), computed tomography (CT), x-rays or ultrasound. Pre-surgery heart testing may be required to determine the function of the heart, and the patient’s ability to tolerate surgery and anesthesia. These studies help the surgeon determine the nature or extent of the problem.
Anxiety is common during this time, and it is critical that the perioperative registered nurse (RN) is able to bring a sense of comfort, stability, and organization to the patient. Ongoing interaction helps reduce the anxiety many patients feel.
Another vital component of the preoperative phase is the visit by the perioperative RN. This involves an assessment of the patient, and is ideally done before the day of the surgical procedure to minimize the potential hazards of adverse psychosocial distress, and to alleviate anxiety and fears.
Factual information and clarification of misunderstandings is discussed during this time, and the patient is given the opportunity to express his or her feelings. Throughout this interview process, the RN learns about the patient, establishes rapport, and develops a plan of care before the patient is admitted to the hospital for surgery.
The Intraoperative Phase
The second phase, or intraoperative phase, involves the surgical procedure itself. It begins when the patient is taken to the OR suite (via a transport stretcher or wheelchair), and concludes when the patient is transported to the postanesthesia care unit (PACU).
During this phase, the patient is admitted to a presurgical holding area and prepped for surgery. A holding area nurse cares for the patient during this time and performs the following steps, documenting them on the surgical checklist:
- Has the patient put on a clean hospital gown and remove all jewelry, dentures, and removable prostheses (as applicable) for safekeeping
- Places a warm blanket over the patient and verifies patient identification
- Verifies surgical procedure, site, and surgeon verbally with patient and/or family. Site is validated by observing the indelible ink of the surgeon’s initials
- Reviews patient’s chart and electronic medical records (EMR) for completeness
- Takes vital signs and blood pressure
- Verifies allergies, sensitivities, and medication history
- Checks skin tone and integrity
- Verifies physical limitations and patient’s mental state
- Puts a cap on the patient to protect head, for purposes of asepsis, and to help minimize hypothermia
- Notifies the surgery control desk when the patient and surgical team is ready for transport to the OR
The holding area nurse performs a thorough patient assessment, formulates a nursing diagnosis with expected outcomes, and prepares an individualized plan of care (if this has not yet been completed by another member of the perioperative nursing team). Any antibiotics that are ordered prior to the surgical start time are given, and preanesthesia medications are administered as ordered. Their purpose is to eliminate anxiety by making the patient calm, drowsy, and comfortable.
A circulating nurse comes to the holding area for the patient when the OR is ready. A hand-over report is given by the holding room nurse to the circulator, using the surgical checklist. The circulating nurse fulfills the following duties before transporting the patient to the OR:
- Greets the patient and verifies patient identification
- Verifies anticipated surgical procedure, time, surgeon, and any allergies
- Verifies surgical site
- Checks IV infusions for accuracy, indwelling catheter is functioning properly
- Assesses for medication reactions and anxiety level
- Verifies history and physical data, laboratory tests, imaging reports, and consent forms are in patient’s chart
The circulating nurse then transports the patient to the OR and assists the anesthesia provider with induction. Prior to the initial incision, the entire perioperative team pauses for a “time out” as the surgical site listed on the consent form is read aloud and the team confirms all information is correct for the patient.
As surgery takes place, the circulating nurse and scrub nurse both monitor the patient’s vital signs. The scrub nurse assists the surgeon, and both nurses ensure the safety of the patient, preventing contamination and infection during the course of the surgery itself.
The intraoperative phase ends when the surgery has concluded and the patient is transported to the PACU.
The Postoperative Phase
The final phase, referred to as the postoperative period, is the time period immediately following surgery, when the patient is admitted to the PACU, until the patient is fully recovered. As with the preoperative phase, this period can be brief or require months of rehabilitation.
During this phase, the following should be of primary focus and importance in nursing care:
- Reestablishing the patient’s physiologic balance
- Pain management
- Prevention of postoperative complications
- Promotion of adequate discharge planning and health teaching
The recovery room, or postanesthesia, nurse must perform thorough assessments and intervene immediately when indicated. Once the patient is fully awake and alert and ready to be discharged from the recovery room or the PACU, the postanesthesia nurse will transfer the responsibility of care to a surgical floor nurse, where the patient will stay until discharged to home. If the surgery was done at a same-day surgical facility, the patient will be discharged from the PACU/recovery room directly home.
Postoperative care is focused mainly on managing and monitoring the patient’s physiologic health and assisting in postsurgical recovery. Ensuring hydration and appropriate nutrition, preventing infection, monitoring urination and bowel movements, assisting with mobility, managing pain and discomfort, and administering appropriate medications are some of the primary responsibilities included in postanesthesia/recovery room nursing care.
Perioperative Patient Care Team
Each member of this team is an integral entity, and must work in harmony with one another to accomplish the expected outcomes of the patient’s surgical experience. Utilizing a comprehensive surgical checklist, along with briefing, can provide a seamless interface between patient care areas and minimize the risk for errors.
Here’s a recap:
Preoperatively, the perioperative nurse initiates this surgical checklist and performs the preoperative assessment. The surgeon marks the surgical site and the patient is transferred to the care of the surgical team. Hand-over report, including the patient’s condition, is communicated verbally and in writing.
In the OR, the patient is surrounded by the surgeon, the surgical assistant, the scrub person, the anesthesia provider, and the circulating nurse. The entire surgical team pauses for a “time out” before the procedure begins, reaffirming the correct patient is having the correct procedure on the correct body part. The circulating nurse documents this collaboration.
Postoperatively, the perianesthesia nurse receives a hand-over report from the circulating nurse and the anesthesia provider regarding the surgical procedure and the patient’s current condition. The patient remains in the PACU until his or her physiologic status is deemed stable by the anesthesia provider.
U.S. Medicare and Medicaid regulations state that the OR must be supervised by an experienced RN and that the circulator must be an RN. Licensed practical nurses (LPNs) and surgical technologists (STs) may serve as scrub nurses or assist with circulating responsibilities under the supervision of the qualified RN.
CNOR: The Certified Perioperative Nurse
The operating room certification is a way for perioperative nurses to demonstrate their knowledge and professional achievement for specialized skills required of OR nurses.
A perioperative nurse has been in clinical perioperative practice for 24 months or more and has successfully passed the national examination is certified by the Competency & Credentialing Institute (CCI) as a certified perioperative nurse, which is credentialed as CNOR. Recertification must take place every 5 years to remain active.
Eligibility and exam details
- Licensed RN in state of practice and currently employed full or part time in administrative, teaching, research, or general staff capacity in perioperative nursing
- Bachelor of science in nursing (BSN) or related degree (BA or BS) is not required for CNOR
- Two years of perioperative nursing experience (2400 hours)
Once eligibility requirements have been met, you can apply for and take the CNOR examination. The exam fee is $295 for members of the Association of periOperative Registered Nurses (AORN) and $375 for non-members.
It is a computer-based exam that includes 200 multiple choice questions, 15 of which are not scored. Three hours and 45 minutes are given to complete the exam, and it consists of the following seven content areas, containing both knowledge and task-oriented questions:
- Pre/Postoperative Patient Assessment and Diagnosis
- Individualized Plan of Care Development and Expected Outcome Identification
- Intraoperative Activities
- Communication and Documentation
- Infection Prevention and Control
- Emergency Situations
- Professional Accountabilities
Due to the complexity of the exam, at least three months should be allotted for studying and preparing for the CNOR exam.
Some of the roles eligible for CNOR Certification include:
- OR staff nurse, RN first assistant, or private RN scrub nurse
- Surgical services administrative nurse manager or nursing coordinator
- Assistant surgical services supervisor
- Surgical services director
- Surgical services head nurse, charge nurse, assistant head nurse, or team leader
- Perioperative educator or staff development director
- Perioperative clinical nurse specialist or nurse clinician
- Nurse case manager
Salary and Outlook
As with any specialty nursing field, compensation depends on years of experience and educational level, in addition to geographical location and your employer. The U.S. Bureau of Labor Statistics reports that RNs with their BSN made a median annual salary of $77,600 in May 2021. The bottom 10 percent earned less than $59,450, and the top 10 percent earned more than $120,250. This is well above the average for many other U.S. occupations.
Considering our current nursing shortage, the growing healthcare needs of our aging population, and the need to replace those who have left or retired from nursing over the last several years, there is a high demand today for qualified perioperative nurses.
Employment opportunities in this field can be enticing depending on the industry or type of facility that you work at. For instance, hospitals and ambulatory surgical centers are predicted to offer the highest levels of current and future employment.
Perioperative nursing is a diverse field that encompasses patient care in a variety of settings, with the primary goal of providing competent, efficient care to patients and their families who are experiencing a surgical event.
Perioperative nurses must be trained to manage general to intensive nursing care, and provide a spectrum of care, from neonatal to geriatric, and from outpatient or same-day surgery to inpatient surgery. Perioperative nursing is an exciting and fulfilling specialty that’s challenging, constantly evolving, and sure to keep you on your toes!
