Alexander's Care of The Patient in Surgery, 16th Edition - Rothrock, Jane C

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Alexander's Care
of the Patient in
Surgery
16TH EDITION
JANE C. ROTHROCK PhD, RN,

CNOR, FAAN
Adjunct Professor, Perioperative Programs
Delaware County Community College
Media, Pennsylvania
Associate Editor
Donna R. McEwen, RN, BSN,

CNOR(E)
Instructional Designer Consultant
Optum Operations Training
2
Optum/UnitedHealthCare
San Antonio, Texas
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3
Table of Contents
Cover image
Title Page
Copyright
Contributors
Clinical Consultants
Reviewers
About the Author
Preface
Unit I Foundations for Practice

Chapter 1 Concepts Basic to Perioperative Nursing
Overview of Perioperative Nursing Practice
4
Standards of Perioperative Nursing Practice
Evidence-Based Practice
Performance Improvement
Perioperative Nursing Roles
Key Points
Critical Thinking Question
References
Chapter 2 Patient Safety and Risk Management

Evolution of Perioperative Patient Safety
Major Professional Association and Government Regulatory Safety

Activities
Nonprovider Members of the Perioperative Patient Safety Team
Perioperative Nursing Safety Issues
Risk Management in the “Near” Future
Key Points
Critical Thinking Questions
References
Chapter 3 Workplace Issues and Staff Safety

Ergonomics
Safe Patient Handling and Movement

Slips, Trips, and Falls
Sharps Safety and Bloodborne Pathogens
Personal Protective Equipment
5
Responding to Exposure
A Culture of Safety
Waste Anesthetic Gases
Chemicals and Drugs
Standard Precautions
Cell Phone Hygiene
Immunizations and Infectious Disease Exposure
Radiation Safety
Latex Allergy
Fatigue and Burnout
Noise
Workplace Violence
Active Shooter
Key Points
References
Chapter 4 Infection Prevention and Control

Causes of Infection
Preventing Infection
Aseptic Practices to Prevent Infection
Key Points
References
6
Chapter 5 Anesthesia
Anesthesia Providers
Patient Safety
Environmental Noise
Awareness During Anesthesia
Preoperative Preparation
Types of Anesthesia Care
Perioperative Monitoring
Anesthesia Machines and Anesthetic Gases
General Anesthesia
Regional Anesthesia
Monitored Anesthesia Care
Moderate Sedation/Analgesia
Local Anesthesia
Pain Management
Temperature Control
Malignant Hyperthermia
Perioperative Nursing Considerations

Key Points
References
Chapter 6 Positioning the Patient for Surgery

7
References
Chapter 7 Sutures, Sharps, and Instruments

Suture Materials
Surgical Needles
Suturing Technique and Wound Closure Materials
Hemostasis
Instruments
Key Points
References
Chapter 8 Surgical Modalities

Minimally Invasive Surgery Overview
Video Technology
Practices and Potential Risks During Minimally Invasive Surgery
Energies Used During Surgery
Key Points
References
Chapter 9 Wound Healing, Dressings, and Drains

Anatomy
8
Etiology of Wounds
Types of Wound Closure
Phases of Wound Healing
Factors Affecting Wound Healing
Wound Classification
Antimicrobial Prophylaxis
Nursing Diagnoses
Patient, Family, and Caregiver Education and Discharge Planning
Wound Management
Dressings
Drains
Key Points
References
Chapter 10 Postoperative Patient Care and Pain Management
Perianesthesia Considerations
Perianesthesia Complications
Discharge From the Postanesthesia Care Unit
Admission to the Ambulatory Surgery Phase II Unit
Admission to the Surgical Unit
Postoperative Nursing Considerations
Patient, Family, and Caregiver Education and Discharge Planning
Key Points
9
References
Unit II Surgical Interventions
Chapter 11 Gastrointestinal Surgery

Surgical Anatomy
Surgical Interventions
Key Points
References
Chapter 12 Surgery of the Biliary Tract, Pancreas, Liver, and Spleen
Surgical Anatomy
Key Points
References
Chapter 13 Hernia Repair

Surgical Anatomy
10
Key Points
References
Chapter 14 Gynecologic and Obstetric Surgery

Surgical Anatomy
Key Points
References
Chapter 15 Genitourinary Surgery
Surgical Anatomy
References
Chapter 16 Thyroid and Parathyroid Surgery

Surgical Anatomy
Key Points
11
References
Chapter 17 Breast Surgery

Surgical Anatomy
Perioperative Nursing Considerations Surgical Interventions
Key Points
References
Chapter 18 Ophthalmic Surgery Surgical Anatomy

References
Chapter 19 Otorhinolaryngologic Surgery Surgical Anatomy
References
Chapter 20 Orthopedic Surgery 12
Surgical Anatomy
References
Chapter 21 Neurosurgery
Surgical Anatomy
References
Chapter 22 Reconstructive and Aesthetic Plastic Surgery

Surgical Anatomy
References
Chapter 23 Thoracic Surgery

Surgical Anatomy
13
References
Chapter 24 Vascular Surgery

Surgical Anatomy
References
Chapter 25 Cardiac Surgery

Surgical Anatomy
Key Points
References
Unit III Special Considerations
Chapter 26 Pediatric Surgery

Pediatric Surgical Anatomy
References
14
Chapter 27 Geriatric Surgery
References
Chapter 28 Trauma Surgery

References
Chapter 29 Interventional and Image-Guided Procedures
Interventional Radiology
Nursing Care of the Interventional Radiology Patient
Procedures
Key Points
References
Chapter 30 Integrative Health Practices

Energy Therapies History and Background
Major Categories of Integrative Health Practices and Complementary

and Alternative Medicine
Integrative Health Practices Use and Surgery
15
Key Points
References
Appendix A Laboratory Values
Illustration Credits
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
16
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Index
Special Features
Ambulatory Surgery Considerations
Enhanced Recovery After Surgery
Evidence for Practice
Patient Engagement Exemplar
Patient, Family, and Caregiver Education
Patient Safety
Research Highlight
Robotic-Assisted Surgery
Surgical Pharmacology
17
Copyright
3251 Riverport Lane

St. Louis, Missouri 63043
ALEXANDER'S CARE OF THE PATIENT IN SURGERY,

SIXTEENTH EDITION ISBN: 978-0-323-47914-1
Copyright © 2019 by Elsevier, Inc. All rights reserved. NANDA

International, Inc. Nursing Diagnoses: Definitions and
Classification 2018-2020, © 2017 NANDA International, ISBN 978-1-
62623-929-6. Used by arrangement with the Thieme Group,
Stuttgart/New York.
No part of this publication may be reproduced or transmitted in

any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details
on how to seek permission, further information about the
Publisher's permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are

protected under copyright by the Publisher (other than as may be
noted herein).
18
Notices
Knowledge and best practice in this field are constantly changing.
As new research and experience broaden our understanding,
changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own
experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described
herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility. With
respect to any drug or pharmaceutical products identified, readers
are advised to check the most current information provided (i) on
procedures featured or (ii) by the manufacturer of each product to
be administered, to verify the recommended dose or formula, the
method and duration of administration, and contraindications. It is
the responsibility of practitioners, relying on their own experience
and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions. To the fullest extent of the
law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise,
or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Previous editions copyrighted 2015, 2011, 2007, 2003, 1999, 1995,

1991, 1987, 1983, 1978, and 1972.
Library of Congress Cataloging-in-Publication Data
Names: Rothrock, Jane C., 1948- editor. | McEwen, Donna R.,

editor.
Title: Alexander's care of the patient in surgery / [edited by] Jane
Rothrock; associate editor, Donna McEwen.
Other titles: Care of the patient in surgery
19
Description: 16th edition. | St. Louis, Missouri : Elsevier, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2017051710 | ISBN 9780323479141 (pbk. : alk.
paper)
Subjects: | MESH: Perioperative Nursing–methods | Nursing Care–
methods | Surgical Procedures, Operative–nursing Classification:
LCC RD99.24 | NLM WY 161 | DDC 617/.0231–dc23 LC record
available at https://lccn.loc.gov/2017051710
Executive Content Strategist: Kellie White

Content Development Manager: Lisa Newton
Senior Content Development Specialist: Laura Selkirk
Publishing Services Manager: Catherine Jackson
Book Production Specialist: Kristine Feeherty
Design Direction: Amy Buxton
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
20
Contributors
Sheila L. Allen BSN, RN, CNOR, CRNFA(E)
Clinical Educator
Self-employed
Baton Rouge, Louisiana
Chapter 27: Geriatric Surgery
Jacqueline R. Bak MSN, RN, CNOR, RNFA
Allied Health and Nursing
Media, Pennsylvania;
Nursing, Paoli SurgiCenter
Paoli, Pennsylvania
Chapter 9: Wound Healing, Dressings, and Drains
Kay A. Ball PhD, RN, CNOR, CMLSO, FAAN
Professor, Nursing Department
Otterbein University
Perioperative Consultant
Lewis Center
Westerville, Ohio
Chapter 8: Surgical Modalities
Barbara A. Bowen BSN, MSN, CRNP, CRNFA
President
Perioperative Consulting and Surgical Services, LLC
Collegeville, Pennsylvania;
21
Consultant
Stryker Performance Solutions
Chicago, Illinois
Chapter 20: Orthopedic Surgery
Brian D. Campbell BS, BSN, CRNA, COL (USA Ret.)
Chief Nurse Anesthetist, Anesthesiology
Winchester Hospital
Winchester, Massachusetts;
Colonel, retired
USAR, 804th Med BDE
Devens, Massachusetts
Chapter 5: Anesthesia
Susan A. Carzo BSN, RN, CNOR, RNFA
Staff Nurse/RFNA, Operating Room
Winchester Hospital
Winchester, Massachusetts
Chapter 14: Gynecologic and Obstetric Surgery
Mary Michaela Cromb BSN
Retired
San Antonio, Texas
Chapter 7: Sutures, Sharps, and Instruments
Richard G. Cuming EdD, MSN, RN, NEA-BC, FAAN
Senior Vice President, Patient Care Services and Chief Nurse
Executive
Administration
Christiana Care Health System
Wilmington, Delaware
Chapter 1: Concepts Basic to Perioperative Nursing
Cateria Davis-Bruno MSN, CNOR
22
OR/CVOR Manager, Perioperative Services
Lakeland Regional Health Systems
Adjunct Clinical Instructor, Nursing
Polk State College
Lakeland, Florida
Chapter 25: Cardiac Surgery
Britta E. DeVolder BSN, MBA, RN, CNOR
Executive Director, Perioperative Services
University Health System
San Antonio, Texas
Chapter 11: Gastrointestinal Surgery
Carmencita Duffy BSN, RN, CNOR
Surgery
Highland Park Hospital
Northshore University Health System
Highland Park, Illinois
Chapter 16: Thyroid and Parathyroid Surgery
Debra L. Fawcett MS, PhD
Director of Infection Prevention
Infection Prevention and Control
Eskenazi Health
Indianapolis, Indiana
Chapter 6: Positioning the Patient for Surgery
Beth Fitzgerald MSN, RN, CNOR
Infection Preventionist
Newark, Delaware
Chapter 29: Interventional and Image-Guided
Procedures
Allison L. Flanagan MSN, RN, CNOR, RNFA
Specialty Team Coordinator, Operating Room
23
Paoli Hospital
Paoli, Pennsylvania
Chapter 19: Otorhinolaryngologic Surgery
David P. Gawronski MSN, RN, CNOR, CST Nurse
Manager, Operating Room, Sterile Processing Sisters
of Charity Hospital, St. Joseph Campus
Cheektowaga, New York
Chapter 28: Trauma Surgery
Cecil A. King MS, RN
RN Medical Case Manager
Infectious Disease Clinical Services
Cape Cod Healthcare
Hyannis, Massachusetts
Chapter 4: Infection Prevention and Control
Rachael Larner BSN, MSN, RN, Wexford, Pennsylvania
Chapter 30: Integrative Health Practices:
Complementary and Alternative Therapies
Helene P. Korey Marley, BSN, RN, CNOR, CRNFA
Clinical Service Coordinator, Operating Room
Pennsylvania Hospital
Philadelphia, Pennsylvania
Chapter 15: Genitourinary Surgery
Donna R. McEwen RN, BSN, CNOR(E)
Instructional Designer Consultant
San Antonio, Texas
Chapter 22: Reconstructive and Aesthetic Plastic
Surgery
Chapter 23: Thoracic Surgery
24
Eileen Dickson Mielcarek BSN, RNFA, COE
Practice Administrator, Owner
RNFA, Perioperative, Operating Room
Mielcarek Eye Center
Owner
Premier Medical Facial Aesthetics
Facial Rejuvenation at Mielcarek
Media, Pennsylvania
Chapter 18: Ophthalmic Surgery
Ellen Murphy BS, MS, JD
Professor Emerita, College of Nursing
University of Wisconsin-Milwaukee
Milwaukee, Wisconsin
Chapter 2: Patient Safety and Risk Management
Maureen P. Murphy MSN
Certified Registered Nurse Practitioner, Otolaryngology
Registered Nurse, Perioperative
Thomas Jefferson University Hospital
Chapter 21: Neurosurgery
Janice A. Neil PhD, RN, CNE
Associate Professor, College of Nursing
Department of Baccalaureate Education
East Carolina University
Greenville, North Carolina
Chapter 12: Surgery of the Biliary Tract, Pancreas,
Liver, and Spleen
Chapter 17: Breast Surgery
Jan Odom-Forren PhD, RN, CPAN, FAAN
Associate Professor, College of Nursing
University of Kentucky
Lexington, Kentucky
25
Chapter 10: Postoperative Patient Care and Pain
Management
Susan M. Scully MSN, RN, CNOR
Clinical Expert, Perioperative Complex
Children's Hospital of Philadelphia
Chapter 26: Pediatric Surgery
Patricia C. Seifert MSN, RN, CNOR, CRNF(E), FAAN
Independent Cardiac Consultant, Formerly Educator,
Cardiovascular Operating Room
Inova Heart and Vascular Institute
Former Editor-in-Chief, AORN Journal
Association of Perioperative Registered Nurses (AORN)
Denver, Colorado;
Cardiac Surgery
Seifert Consulting
Falls Church, Virginia
Chapter 25: Cardiac Surgery
Christine E. Smith MSN, RN, CNS, CNOR
Semi-retired, Perioperative CNS/Educator
Home Office/Perioperative Educator
Guerneville, California
Chapter 3: Workplace Issues and Staf Safety
James D. Smith Jr., BSN
RN First Assistant, Surgery
Missouri Baptist Medical Center
St. Louis, Missouri
Chapter 13: Hernia Repair
Michele Clemens Smith BSN
Clinical Nurse, Operating Room
Children's Hospital of Philadelphia
26
Chapter 26: Pediatric Surgery
Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN
Director, Evidence-Based Perioperative Practice
Nurse Practice
Association of Perioperative Registered Nurses (AORN)
Denver, Colorado
Patient Engagement Exemplar boxes
Cynthia Spry BS, BSN, MS, MA

Independent Consultant
New York, New York
Chapter 4: Infection Prevention and Control
Kathryn J. Trotter DNP
Associate Professor, School of Nursing
Duke University
Nurse Practitioner, Duke Breast Program
Duke Health
Durham, North Carolina
Chapter 17: Breast Surgery
Dana M. Whitmore BSN, RN, CNOR
Staff Development Nurse, Operating Room
Thomas Jefferson University Hospital
Chapter 21: Neurosurgery
Patricia Wieczorek MSN, RN, CNOR
Coordinator of Perioperative Nursing Programs
Perioperative Services
The Johns Hopkins Hospital
Baltimore, Maryland
Chapter 24: Vascular Surgery
27
Clinical Consultants
Chyna Davison BSN, RN
Staff Nurse, Operating Room
Glen Dixon Jr., MD

Chairman of Obstetrics and Gynecology
Winchester Hospital
Lorraine J. Foley MD, MBA

Clinical Assistant Professor
Tufts School of Medicine
Anesthesiologist, Winchester Anesthesia Associates
Winchester Hospital
President of the Society for Airway Management
Boston, Massachusetts
Arlan F. Fuller Jr., MD

Clinical Vice President for Oncology Services
Winchester Hospital
Charles L. Getz MD
Associate Professor
Thomas Jefferson University Hospitals
Rothman Institute
28
Sean P. Larner DO
Neurotology Fellow
Pittsburgh Ear Associates
Pittsburgh, Pennsylvania
Maureen Lewis MSN, CRNP, CNOR, CRNFA

RN First Assistant
Riddle Hospital
Media, Pennsylvania
Jess H. Lonner MD
Associate Professor of Orthopaedics
Thomas Jefferson University Hospitals
Rothman Institute
Elizabeth B. Pearsall BSN, RN, CNOR

Adjunct Faculty, Perioperative Programs
Media, Pennsylvania
Kim Russo
Riddle Memorial Hospital
Media, Pennsylvania
Inga Sinyangwe MSN, RN

Staff Development Specialist
Institute for Leadership, Education and Development
Christiana Hospital
Newark, Delaware
Ariana L. Smith MD
Assistant Professor of Urology
Director of Pelvic Medicine and Reconstructive Surgery
Joseph H. Viveiros RN, CNOR, RNFA

RN/RNFA Staff Nurse
29
Winchester Hospital
David L. Yarbrough RN, BS, MS, JD

COO, Senior Health Planner Aspen
Street Architects, Inc. Murphys,
California
Kathryn Yarbrough RN
Retired Healthcare Executive
Murphys, California
30
Reviewers
Sheila L. Allen BSN, RN, CNOR, CRNFA(E)
Clinical Educator
Self-employed
Baton Rouge, Louisiana
Andrea Bills BSN, RN, CNOR, RNFA, Dumont, New Jersey
Dee Anne Boner BSN, MSN, RN, CNOR

Clinical Staff Leader
Vanderbilt University Medical Center
Nashville, Tennessee
James Bowers BSN, RN, CNOR, TNCC

Clinical Educator
WVU Healthcare
Morgantown, West Virginia
Amy J. Broadhurst RN, BS, BSN, CNOR

Staff RN Operating Room
Newark, Delaware
Susan A. Carzo BSN, RN, CNOR, RNFA

Staff Nurse/RNFA, Operating Room
Winchester Hospital
Monica Y. Cisneros BSN, MSN, RN, ANP-BC, CRNFA
31
Advanced Practice Nurse, Registered Nurse First Assistant

Hackensack University Medical Center
Hackensack, New Jersey;
NYP Lawrence Hospital
Bronxville, New York
Marlene Craden BSN, RN, CNOR, CRNFA

Registered Nurse First Assistant
Kaleida Health
Millard Fillmore Suburban Hospital
Williamsville, New York
Theresa M. Criscitelli EdD, RN, CNOR

Assistant Vice President Administration
Perioperative/Procedural Services
Winthrop University Hospital
Mineola, New York
Helen M. Dickson MSN, RN, CNOR, RNFA

Registered Nurse First Assistant
Media, Pennsylvania
Joanne M. Epstein BSN, RN, CNOR

Educator, Surgical Services
St. Francis Hospital
Debra Eustace BSN, RN, CNOR, CRNFA

President
Surgifirst LLC
Annandale, New Jersey
Teresa M. Galanaugh-Scarpato BS
Coordinator, Perioperative Services
Main Line Health
Radnor, Pennsylvania
David P. Gawronski MSN, RN, CNOR, CST
32
Nurse Manager—Operating Room, Sterile Processing
Sisters of Charity Hospital, St. Joseph Campus
Cheektowaga, New York
Donna Ginsberg BSN, RN, CNOR, CRNFA

Owner, Surgical First Assistant Services LLC
Meridian and St. Barnabas Health
Asbury Park, New Jersey
Carol Hager BSN, RN, CRNFA, MSN, CRNP

Nurse Practitioner
UPMC Hamot—Bayview Breast Care at Hamot
Great Lakes Surgery Specialists
Erie, Pennsylvania
Mark Karasin BSN, BA, RN

Registered Nurse
New Jersey Spine Specialists LLC
Overlook Medical Center
Summit, New Jersey
Cynthia L. Kildgore RN, MSHA

Director of Perioperative Services
Andrew Kiskadden MSN, CRNA

Nurse Anesthetist, Anesthesia Consultants of Erie
Saint Vincent Health Center
Erie, Pennsylvania
Candice Kiskadden MSN, RN, CNOR

Instructor of Nursing
Mercyhurst University
Erie, Pennsylvania
Susan Lynch MSN, CSSM, CNOR, RNFA

Clinical Educator
Main Line Health
33
Media, Pennsylvania
M. Carolyn Malecka RN, CNOR, RNFA, Medford, New Jersey
Tanya Marandola MSN, RN, CNOR

Staff Nurse, Ophthalmology Coordinator
Roxana Cannon Arsht Surgicenter
Christiana Care Health Systems
Angela Mercer BSN, RN, CNOR

Perioperative Staff Nurse
Christiana Care Health Systems
Joseph K. Mollohan MSN, RN, CNOR, CSSM, RNFA

President
Perioperative Management Consultants
Springfield, Tennessee
Claudia Orsburn BSN, MSN, MS

Director of Surgical Services
Karen S. Pettit BSN, CRNFA, Phoenix, Arizona
Sharon S. Pomeroy BSN, MHA, BS, RN

Manager, Perioperative Services
Carol R. Ritchie MSN, RN, CNOR

Supervisor, Perioperative Services
Mayo Clinic
Phoenix, Arizona
Judy Roche RN, CNOR, CRNFA

Owner, CEO
Freelance Assistants, Inc.
34
Denver, Colorado
Billie Thomas BSN, RN, CNOR

Operating Room Staff Nurse
Christian Care Health Services
Cynthia Townsend MTHS, BSN, RN, CNOR

Manager, Perioperative Education and Research
Susanna S. Walsh RNFA, BSN, CNOR

Peri-Operative Manager
Marion Knapp Wardle MSM, BSN, RN, CNOR

Director of Nursing Programs/Perioperative Education
Quality and Patient Safety
Ann Bates Leach Eye Hospital/Bascom Palmer Eye Institute
University of Miami Health
Miami, Florida
35
About the Author

Jane C. Rothrock PhD, RN, CNOR, FAAN
To Brittany Anne Hutt—an incredible, loving niece who has energy,
motivation, sincere values, and a passion for creating a sustainable planet
we call home. You represent who we all should strive to be.
I love you and everything about you.
Dr. Jane Rothrock has practiced and taught perioperative nursing
since 1969. In 1979 she joined the faculty of Delaware County
Community College, where she is now an Adjunct Professor in the
36
college's Perioperative Programs. Her current responsibilities
include entry-level, postbasic RN education for perioperative
nursing. During her 40-year tenure at the college, Jane has helped to
educate more than 4500 registered nurses in the professional
practice of perioperative patient care.
Jane's decades of experience include not only being a faculty
member but also an author, editor, and speaker. She has taught at
the University of Pennsylvania, served as an OR director, and acted
as preceptor for many graduate students. She has authored five
perioperative nursing textbooks, published more than 50 articles,
and presented a host of topics to nursing audiences across the
United States and internationally. Jane is an AORN past president
and chaired AORN's Project Team on Professional Practice Issues,
its Project Team on a Professional Practice Model for Perioperative
Nursing, and its Perioperative Academic Curriculum Task Force.
She also served as an evidence reviewer for AORN's Evidence
based Recommended Practices for Perioperative Patient Care and is
currently a research reviewer for the AORN Journal.
Jane has received numerous professional awards and remains
very active in both nursing and community organizations. Jane is a
past vice chair of NOLF, a past member of the ANCC Magnet
Commission, a past president of the ASPAN Foundation, and a past
president of the AORN Foundation Board of Trustees. She served
on ASPAN's first National Clinical Guideline Panel to develop a
Guideline on Prevention of Unplanned Hypothermia in Adult
Surgical Patients. In 2000 Jane became a Fellow of the American
Academy of Nursing (FAAN). In 2016 she was elected Professor
Emerita at Delaware County Community College.
Jane began her nursing education with a diploma from Bryn
Mawr School of Nursing. She went on to earn her BSN and MSN
from the University of Pennsylvania and became the first recipient
of a doctoral degree from Widener University in suburban
Philadelphia, earning her PhD in nursing in 1987.
37
Preface
This updated sixteenth edition of Alexander's Care of the Patient in
Surgery reflects new and essential key concepts in perioperative
nursing practice and an increased sophistication and complexity in
surgical procedures. Its multimedia resource, first introduced in the
thirteenth edition, strongly enhances the elemental goal of this
textbook: to provide a comprehensive foundational reference that
will assist perioperative practitioners to meet the needs of patients
they care for safely, cost-effectively, and efficiently during surgical
interventions.
As the standard in perioperative nursing for more than 50 years,
Alexander's Care of the Patient in Surgery is written primarily for
professional perioperative nurses, but it is also useful for surgical
technologists, nursing students, healthcare industry representatives,
medical students, interns, residents, and government officials
concerned with healthcare issues. Perioperative nurses, RN first
assistants, clinical nurse specialists, nurse practitioners, surgeons,
and educators from many geographic areas of the United States
have served as contributors and reviewers for this text. In doing so,
they provide a vast range of perioperative patient care knowledge,
procedural information, and wisdom.
This thoroughly revised edition highlights current surgical
techniques and innovations. More than 1000 illustrations, including
many new photographs and drawings, help familiarize the reader
with contemporary procedures, methods, and equipment. Classic
illustrations, particularly of surgical anatomy, remain to enhance
the text. New to this edition are features highlighting patient
38
engagement and patient-centered communication, the addition of
Enhanced Recovery After Surgery protocols, and an expanded
emphasis on robotic-assisted surgery. Each chapter contains a
summary of Key Points and a Critical Thinking Question. There is a
thorough laboratory values appendix in which readers can review
normal lab values and ranges. Readers will again find Ambulatory
Surgery Considerations; Evidence for Practice; Patient, Family, and
Caregiver Education; Patient Safety; Research Highlights; Sample
Plan of Care; and Surgical Pharmacology features, updated to
reflect changes.
Enhanced in the sixteenth edition is the Evolve website. With its
learner resources, readers are able to access animations, The
Agency for Healthcare Research and Quality (AHRQ) case studies,
answers to the critical thinking questions, interactive study
questions, OR Live links, and scenario packets.
Also enhanced in the sixteenth edition are resources for
instructors and clinical educators. In addition to the learner
resources listed previously, instructor resources contain a lesson
plan for each chapter with the following elements: case studies,
answers to critical thinking questions, learning objectives,
suggested content for lectures and class activities, clinical learning
scenarios for each covered surgical procedure, PowerPoint lecture
slides with speaker notes, and an image collection of more than
1000 images to use in teaching. Instructors and clinical educators
will also find a test bank with more than 750 questions as well as
more than 50 customizable competency assessments for use in
clinical settings or simulation laboratories as learners practice new
perioperative nursing skills and techniques. Overall, this textbook
imparts state-of-the-art information and resources to reflect
contemporary practice and to promote delivery of comprehensive
perioperative patient care.
Unit I, Foundations for Practice, provides information on basic
principles and patient care requisites essential for all recipients of
perioperative patient care. The nursing process, a model for
developing therapeutic nursing interventional knowledge, reflects a
six-step method that includes the identification of desired patient
outcomes. Interest in patient outcomes and their improvement
continues to be an essential element of nursing. The collection of
39
health data requires clear identification of contributions to patient
outcomes and quantification of these contributions. Perioperative
nurses must continue to link their interventions to outcomes. This
relationship is presented in Chapter 1 and explicated in each
Sample Plan of Care throughout the text.
Research Highlights continue to be included in every chapter and
reflect the steady increase in the amount and quality of research
relevant to perioperative patient care. As current findings of new
research are important to use in clinical practice, the editors and
authors of Alexander's Care of the Patient in Surgery are committed to
supporting this research-practice relationship. The Research
Highlights will help perioperative nurses implement research
findings in their practice and patient care activities.
Chapter 1 also sets the stage for an emphasis on patient, family,
and caregiver education and discharge planning throughout the
text. Chapters in Units II and III address specific patient, family,
and caregiver education and discharge planning relevant for
patients undergoing one or more of the respective specialty surgical
procedures. As the responsibilities of perioperative nurses become
greater with regard to those important care components, it is
imperative that we effectively educate patients, their families, and
their caregivers. As length of stay in healthcare facilities continues
to decrease, patients, families, and caregivers need more and better
information to deal appropriately with postoperative needs after
discharge. Pain management, addressed in Chapter 10, also appears
in many of the chapters on surgical specialties because all
perioperative nurses recognize its importance in patient discharge
planning.
Chapter 2 focuses on patient safety and risk management,
including a review of the use of social media and patient privacy
issues. As members of the perioperative team face increasing
workloads and workplace stress, this sixteenth edition emphasizes
the need for workplace safety in Chapter 3. When pressure in the
surgical suite mounts, perioperative staff may feel the need to work
faster, even if it means taking shortcuts. The chapter on workplace
safety stresses the need for personal safety at work and explores
such issues as noise in the OR, active shooter situations, workplace
violence, and bullying. The remaining chapters in Unit I focus on
40
perioperative precepts guiding infection prevention; anesthesia;
patient positioning; sutures, sharps, and instruments; surgical
modalities; wound healing; and caring for the postoperative patient
in the PACU and on the transfer unit.
The chapters in Unit II, Surgical Interventions, include more than
400 contemporary and traditional specialty surgical interventions,
with descriptions of open approaches, minimally invasive surgical
procedures, and robotic-assisted surgery. Each chapter provides a
helpful review of pertinent anatomy and details the steps of
surgical procedures. Perioperative nursing considerations are again
presented within the nursing process framework. Current NANDA
International–approved nursing diagnoses and Sample Plans of
Care for each surgical specialty aim to help perioperative nurses
plan, implement, and evaluate individualized perioperative patient
care. Each of these chapters also provides an example of Evidence
for Practice related to the surgical specialty. In 2018 and beyond,
perioperative nurses can expect to find a continuing emphasis on
evidence-based nursing as a means to provide care that is effective
and yields improved outcomes. The integration of evidence-based
practice with the perioperative nurse's individual clinical expertise
leads to optimal care provision, the foundation of perioperative
patient care. Improving the quality of patient care and effecting safe
outcomes are at the heart of all our efforts to achieve excellence in
whatever setting we encounter the patient who is undergoing an
operative or other invasive procedure.
Incorporation of Surgical Pharmacology in the sixteenth edition
reflects the ongoing emphasis on medication safety in the United
States. Medication errors can occur anywhere in the medication-use
system, from prescribing to administering a drug. Alexander's Care
of the Patient in Surgery joins the nationwide health professional
education campaign that aims to reduce the number of common but
preventable sources of medication errors. Providing information
about select medications and dosages used in surgical specialties,
the Surgical Pharmacology feature is intended to promote safe
medication practices and to avoid serious, even potentially fatal,
consequences of medication errors by perioperative practitioners.
To further facilitate the perioperative nurse's focus on safe patient
care, Patient Safety features in each chapter succinctly review a
41
practice to assist perioperative practitioners in developing a core
body of knowledge about safe patient care. We intend for this
feature to raise awareness about patient safety applications. We also
intend simultaneously to foster communication and ongoing
dialogue in perioperative practice settings regarding application of
recommended patient safety strategies and use of robust process
improvement initiatives. In so doing, we hope to improve quality
and safety overall in perioperative patient care.
New to the sixteenth edition is information on Enhanced
Recovery After Surgery protocols. These protocols aim to increase
efficiency during all phases of perioperative patient care and
decrease length of stay for surgery patients and costs of care, while
improving outcomes. As applicable to the chapter content,
Enhanced Recovery After Surgery features address the evidence
based strategies and merits of such protocols.
The unique needs of pediatric, geriatric, and trauma surgery
patients are presented in Unit III, Special Considerations. The
“Interventional and Image-Guided Procedures” chapter reflects
processes of care in sophisticated hybrid OR suites, where
enhanced capabilities merge open and interventional surgery in a
multidisciplinary environment. The “Integrative Health Practices:
Complementary and Alternative Therapies” chapter was
introduced in the twelfth edition. Perioperative nurses frequently
encounter patients who use such therapies, some of which are
nonpharmacologic and some of which involve medications. This
chapter explores alternative medical systems, mind-body
interventions, biologically based therapies, manipulative and body
based methods, and energy therapies. Treatments and systems
within each category are discussed.
Many expert perioperative practitioners, RN first assistants,
clinical nurse specialists, and educators have contributed to this
sixteenth edition, and I owe a debt of gratitude to all of them for
sharing their expertise in the development of this text. I give
ongoing thanks to my partner, Alan Zulick, Esquire, for his help
during copyediting and page proofs. I also acknowledge the
valuable assistance of editors, reviewers, photographers, and
illustrators who have contributed their time and expertise to the
revision of this text. The team I had the privilege of working with at
42
Elsevier is talented and eager to support perioperative practitioners
in their commitment to excellence in patient care. Laura Selkirk, I
would clone you and give you as a gift to all of my nurse editor
colleagues if I could—you walk the entire journey with each edition
of this book with supreme aplomb! Donna McEwen, my Associate
Editor, is not only a masterful editor but also an instructional
design expert. The Evolve website is the elegant and robust feature
that it is due to her acumen and talent. Christine Smith is a clinical
nurse specialist who developed the competencies. Mickey Cromb is
a registered nurse and instructional designer who developed the
test bank. Clearly, I work with a team to be admired and esteemed
for their contributions to this edition.
Alexander's Care of the Patient in Surgery is written by and for
perioperative nurses. Its premise is underscored by the clear
understanding that perioperative nursing is a caring and
intellectual endeavor, requiring critical thinking, technical acumen,
and clinical reasoning and decision-making to improving patient
outcomes. With the multimedia package accompanying this
sixteenth edition, Alexander's Care of the Patient in Surgery invites
you to journey with us as we meet the challenges and opportunities
of perioperative nursing in the twenty-first century. Jane C. Rothrock
43
UNIT I
Foundations for
Practice
OUTLINE
Chapter 1 Concepts Basic to Perioperative Nursing

Chapter 2 Patient Safety and Risk Management
Chapter 3 Workplace Issues and Staff Safety
Chapter 4 Infection Prevention and Control
Chapter 5 Anesthesia
Chapter 6 Positioning the Patient for Surgery
Chapter 7 Sutures, Sharps, and Instruments
Chapter 8 Surgical Modalities
Chapter 9 Wound Healing, Dressings, and Drains
Chapter 10 Postoperative Patient Care and Pain
Management
44
CHAPTER 1
Concepts Basic to
Perioperative
Nursing
Richard G. Cuming
Overview of Perioperative Nursing

Practice
Perioperative nursing is the nursing care provided to patients before,
during, and after surgical and invasive procedures. Nurses practice
this specialty in surgical suites, ambulatory surgery centers,
endoscopy suites, laser centers, interventional radiology
departments, mobile surgical units, and physicians' offices across
the United States and the world. Perioperative nursing includes a
broad array of cutting-edge innovations, such as remote surgery,
virtual endoscopy, robotics, computerized navigation systems,
transplanted tissue and organs, biologic materials that are absorbed
to replace worn-out body parts, radiofrequency identification
(RFID), transoral approaches (natural orifice surgery), and
electronic health records (EHRs). In this high-tech era, perioperative
patient care is very different from the way it was in the past.
In the past, the term operating room (OR) nursing was used to
describe the care of patients in the immediate preoperative,
45
intraoperative, and postoperative phases of the surgical experience
(Fig. 1.1). This term implied that nursing care activities were limited
to the physical confines of the OR. The term may have contributed
to stereotypic images of the OR nurse who took care of the OR and
its equipment but had little, if any, interaction or nursing
responsibility for medicated and anesthetized patients in the
surgical suite. With such an image, nurses practicing outside the OR
had difficulty crediting important elements of the nursing process
and patient care accountability to the nurse who practiced “behind
the double doors” of the surgical suite.
FIG. 1.1 The Agnew Clinic, by Thomas Eakins, 1889.

In this painting, reforms and advancements in surgical
techniques and procedures are apparent. Surgeons
wear gowns, instruments are sterilized, ether is used,
and the patient is covered. An operating room nurse is
a prominent member of the team.
Today, perioperative nursing implies the delivery of

comprehensive patient care within the preoperative, intraoperative,
and postoperative periods of the patient's experience during
operative and other invasive procedures by using the framework of
46
the nursing process. In doing so, the perioperative nurse assesses
the patient by collecting, organizing, and prioritizing patient data;
establishes nursing diagnoses; identifies desired patient outcomes;
develops and implements a plan of nursing care; and evaluates that
care in terms of outcomes achieved by and for the patient.
Throughout the process, the perioperative nurse functions both
independently and interdependently. As with nurses in other
specialties, the perioperative nurse collaborates with other
healthcare professionals, makes appropriate nursing referrals, and
delegates and supervises other personnel in providing safe and
efficient patient care.
When nurses practice perioperative nursing in its broadest sense,
care may begin in the patient's home, a clinic, a physician's office,
the patient care unit, the presurgical care unit, or the holding area.
After the surgical or invasive procedure, care may continue in the
postanesthesia care unit (PACU), and evaluation of patient
outcomes may extend onto the patient care unit, in the physician's
office, in the patient's home, in a clinic, or through written or
telephone patient surveys.
When nurses practice perioperative nursing in its more limited
sense, patient care activities may be confined to the common areas
of the surgical suite. Assessment and data collection may take place
in the holding area, whereas evaluation may take place on
discharge from the OR. Regardless of the way nurses practice
perioperative nursing in a healthcare setting, it is based on the
nursing process and professional nursing practice.
The perioperative nurse functions as a patient advocate during
times of vulnerability. This specialty requires a broad knowledge
base, instant recall of nursing science, an intuitive ability to be
guided by nursing experience, diversity of thought and action, and
great stamina and flexibility. Whether a generalist or a specialist,
the perioperative nurse depends on knowledge of surgical
anatomy, physiologic alterations and their consequences for the
patient, intraoperative risk factors, potentials for and prevention of
patient injury, and psychosocial implications of surgery for the
patient, family, and caregiver. This knowledge enables the
perioperative nurse to anticipate needs of the patient and surgical
team and to rapidly initiate safe and appropriate nursing
47
interventions. This too is part of patient advocacy, that is, doing for
the patient what needs to be done to provide a safe and caring
environment. The Association of periOperative Registered Nurses
(AORN) has asserted the significance of such safety by reaffirming
that staffing of healthcare personnel must ensure that patients
undergoing surgical and invasive procedures have a perioperative
nurse as circulator in the OR, and that the core activities of
perioperative nursing care (assessment, diagnosis, outcome
identification, planning, and evaluation) be completed by a
perioperative nurse (AORN, 2014a).
A significant part of perioperative nursing is the delivery of
scientifically based care. Such care implies understanding the
rationale for certain activities and interventions; knowledge of how
and when to implement them; and the skills to evaluate safety, cost
effectiveness, and outcomes of the care delivered. This knowledge
empowers the perioperative nurse to anticipate and prepare for
steps of the surgical procedure and understand their concomitant
implications for the patient and for the surgical team. Scientific
nursing interventions; critical thinking and clinical reasoning; and
caring, comforting behaviors are at the heart of perioperative
nursing. Unit II of this book focuses on surgical procedures
common to inpatient and ambulatory settings. Each chapter in Unit
II contains a Sample Plan of Care with suggested nursing
interventions. A fundamental assumption throughout this textbook
is that perioperative nursing is a blend of technical and behavioral
care and that critical thinking underpins caring for patients
professionally. Quality nursing care is dependent on nurses' ability
to think critically (Helzer Doroh and Monahan, 2016). Critical
thinking requires purposeful, outcome-directed thought and is
driven by patient need. It is based on the nursing process and
nursing science. Further, critical thinking requires knowledge,
skills, and experience guided by professional standards and ethics
and grounded in constant reevaluation, self-correction, and
continual striving to improve.
Perioperative Patient Focused Model

AORN has developed a model to describe the important
48
relationship between the patient and the perioperative nursing care
provided. The Perioperative Patient Focused Model (AORN, 2015)
consists of domains or areas of nursing concern including nursing
diagnoses, nursing interventions, and patient outcomes. These
domains are in continuous interaction with the health system that
encircles the focus of perioperative nursing practice—the patient
(AORN, 2015).
Three of these domains (behavioral responses, patient safety, and
physiologic responses) reflect phenomena of concern to
perioperative nurses and comprise the nursing diagnoses,
interventions, and outcomes that surgical patients or their families
experience. The fourth domain, the health system, comprises
structural data elements and focuses on clinical processes and
outcomes.
The model illustrates the dynamic nature of the perioperative
patient experience and the nursing presence throughout that
process. Working in a collaborative relationship with other
members of the healthcare team and the patient, the nurse
establishes outcomes, identifies nursing diagnoses, and provides
nursing care. The nurse intervenes within the context of the
healthcare system to help the patient achieve the highest attainable
health outcomes (physiologic, behavioral, and safety) throughout
the perioperative experience.
The model emphasizes the outcome-driven nature of
perioperative patient care. Perioperative nurses possess a unique
understanding of desired outcomes that apply to all surgical
patients. In contrast to some nursing specialties in which nursing
diagnoses are derived from signs and symptoms of a condition,
much of perioperative nursing care is preventive in nature and
based on knowledge of risks inherent to patients undergoing
surgical and invasive procedures. Perioperative nurses identify
these risks and potential problems in advance and direct nursing
interventions toward prevention of undesirable outcomes, such as
injury and infection. Based on an individual patient assessment, the
perioperative nurse identifies risks and relevant nursing diagnoses.
This information guides nursing interventions for each patient.
From admission through discharge and home follow-up, the
perioperative nurse plays a major role in managing the patient's
49
care. Research based on AORN's Perioperative Patient Focused
Model continues to test and validate the contributions of
perioperative nurses to patient outcomes in the variety of settings in
which this nursing specialty is practiced.
Standards of Perioperative Nursing

Practice
Perioperative nursing is a systematic, planned process in a series of
integrated steps. For professional nursing, national standards
establish the full expectations of the professional role within which
the nurse practices. In the 1960s, the American Nurses Association
(ANA) engaged in standards development. First published in 1973,
these standards helped to shape nursing practice. Specialty nursing
organizations, including AORN, have worked with the ANA to
develop their own standards and guidelines using the ANA
framework. This collaboration has resulted in the use of common
language and a consistent format for the profession.
Perioperative Nursing Practice Standards

AORN (2015) has developed a set of standards for perioperative
nursing (Box 1.1). These standards are authoritative statements that
define and enumerate the responsibilities for which perioperative
nurses are accountable. The standards represent a comprehensive
approach to meeting the healthcare needs of surgical patients and
relate to nursing activities, interventions, and interactions. They are
used to explicate clinical, professional, and quality objectives in
perioperative nursing. The Guidelines for Perioperative Practice
contain recommendations for implementing perioperative patient
care based on a comprehensive appraisal of both research and
nonresearch evidence (AORN, 2016). They complement the
Standards of Perioperative Nursing, which are based on and describe
the application of the nursing process in perioperative nursing. The
guidelines include the collection and analysis of health data,
identification of expected outcomes, planning and implementation
of patient care, and evaluation of the effects of this care on patient
50
outcomes.
Box 1.1
Standards of Perioperative Nursing
• Focus: providing perioperative patient care and performing

professional role responsibilities
• Responsibility: each perioperative nurse, with appropriate
working conditions and resource support
• Underlying themes:
• Perioperative nursing care is individualized to unique
patient needs and situations.
• Care is provided in the broad context of injury
prevention.
• Cultural, racial, and ethnic diversity, along with the
patient's preferences and goals, is always taken into
account when planning and providing perioperative
nursing care.
• Conceptual framework for practice: The Perioperative Patient
Focused Model
• Nursing process underpinning: assessment, diagnosis,
planning, implementing the plan of care, and evaluating the
patient's progress toward outcomes
• Quality and appropriateness of practice emphasis: systematically
evaluated
• Evaluation of own practice: in the context of current professional
standards, rules, and regulations
• Collegiality: demonstrated when interacting with
peers, colleagues, and others
• Collaboration: takes place with the patient and other designated
personnel when practicing professional nursing
Modified from the Association of periOperative Registered Nurses: Guidelines for

perioperative practice, Denver, 2015, The Association.
51
AORN (2015) Standards of Perioperative Nursing require, in part,
that the perioperative nurse evaluates the effectiveness of nursing
practice and the quality of that practice. These standards also
require perioperative nurses to evaluate their own practice.
Achieving certification (certified nurse, operating room [CNOR]),
pursuing lifelong learning, and maintaining competency and
current knowledge in perioperative nursing are hallmarks of the
professional. The guidelines focus on the importance of evidence
based practice (EBP) and participation in the generation of new
knowledge through research. The pace and complexity of advances
in surgical procedures, minimally invasive surgery, robotics, new
technologies, professional nursing issues, ongoing healthcare
reform measures, continuing changes in evidence-based
recommendations for practice, and the burgeoning body of nursing
research demand constant professional education and development.
Perioperative professionals must continue to research patient
outcomes, to link nursing interventions to outcomes, and to develop
methods that conserve resources when implementing interventions.
Nursing Process
Looking at nursing as a process brings it into perspective as a
system of critical thinking that provides the foundation for nursing
actions (Fig. 1.2). The focus of the nursing process is the patient,
and prescribed nursing interventions are those that meet patient
needs. Using the nursing process directs the perioperative nurse's
focus on the patient by using clinical skills and knowledge to care
for patients and to make independent judgments and clinical
decisions. Use of the nursing process, nursing plans of care, clinical
pathways, and best practices (discussed later in this chapter) is an
integral part of patient care.
52
FIG. 1.2 The steps of the nursing process are
interrelated, forming a continuous cycle of thought and
action. OR, Operating room; PACU, postanesthesia
care unit.
53
In its simplest form, the nursing process consists of the following
six steps: assessment, nursing diagnosis, outcome identification,
planning, implementation, and evaluation. The process is dynamic
and continual. Certain responsibilities are inherent in the nursing
process: (1) providing culturally and ethnically sensitive, age
appropriate care; (2) maintaining a safe environment; (3) educating
patients and their families; (4) ensuring continuity and coordination
of care through discharge planning and referrals; and (5)
communicating information.
Assessment
Assessment is the collection and analysis of relevant health data
about the patient. Sources of data may be a preoperative interview
with the patient and the patient's family; review of the planned
surgical or invasive procedure; review of the patient's medical
record; examination of the results of diagnostic tests; and
consultation with the surgeon and anesthesia provider, unit nurses,
or other personnel. Data collection focuses on these major elements:
(1) the patient's current diagnosis, physical status, and psychosocial
status (including literacy, language skills, and spiritual, ethnic,
cultural, and lifestyle information relevant to the delivery of
patient-specific care); (2) previous hospitalizations or surgical
interventions and serious illnesses; and (3) the planned surgical or
invasive procedure and the patient's understanding of this plan.
Implementing patient-centered care requires the perioperative
nurse to encourage the patient's active involvement in his or her
care as part of patient safety. Of primary importance are the
understanding of the scheduled procedure by the patient and
patient's family and the patient's participation in activities such as
marking the surgical site (Patient Safety) (the Universal Protocol for
correct site surgery, along with other National Patient Safety Goals,
is discussed in Chapter 2) (TJC, 2016a). The perioperative nurse also
assesses risk factors that may contribute to negative outcomes.
Patient Safety
54
Involving Patients in Marking the Surgical Site
Perioperative nurses value the goal of patient safety. One way to
facilitate this goal is to improve involvement of patients in their
care through information and education. TJC NPSGs and its Speak
Up campaigns are safety initiatives that encourage patients to take
an active role in their health care. Help Avoid Mistakes in Your
Surgery offers a patient the following information about marking
the surgical site and the time-out:
• A healthcare professional will mark the spot on your body on

which the surgeon will operate. Make sure that only the correct
part and nowhere else is marked. This helps avoid mistakes.
• Marking usually happens when you are awake. Sometimes
you cannot be awake for the marking. If this happens, a family
member or friend or another healthcare worker can watch the
marking. They can make sure that your correct body part is
marked.
• Your neck, upper back, or lower back will be marked if you are
having spine surgery. The surgeon will check the exact place
on your spine in the OR after you are asleep.
• Ask your surgeon if he or she will take a “time-out” just before
your surgery. This is done to make sure the surgeon does the
right surgery on the right body part on the right person.
NPSG, National Patient Safety Goals; OR, operating room; TJC,

The Joint Commission.
Modified from The Joint Commission: 2017 hospital national patient safety goals (website),
2016. https://www.jointcommission.org/hap_2017_npsgs/. (Accessed 26 December 2016).
The perioperative nurse proactively reports any concerns (e.g.,

abnormal laboratory values, or issues related to the patient's lack of
understanding of the planned procedure) to the surgeon,
documents all data collected, and notes any referrals that he or she
makes.
Assessment formats vary from institution to institution but
always include the physiologic and psychosocial aspects of the
55
patient. In some settings the assessment is done in stages by one or
more perioperative nurses. A perioperative nurse may perform an
assessment in the presurgical care unit or by telephone before the
day of surgical admission. In such cases the nurse in the OR verifies
parts of the assessment previously done and completes the
remainder. For a perioperative nurse caring for a healthy patient,
assessment may mean only a thoughtful, brief review of the
assessments previously done; a short patient interview; review of
the medical record and surgical procedure; and a mental rehearsal
of the resources and knowledge necessary to support the patient
successfully through an operative procedure or any other invasive
procedure. At other times, the perioperative nurse assesses all
aspects of the patient and the patient's condition thoroughly.
When developing guidelines for preoperative assessment;
patient, family, and caregiver education; and discharge planning,
the perioperative nurse considers the following:
• What is the best EBP?

• Is relevant, concise patient information already
available to the perioperative nursing staff? • Is
enough information available for
perioperative nurses to consider patient care
needs when preparing the OR room (e.g., special
equipment, accessory items, instruments,
sutures)?
• Is sufficient time available to initiate a
meaningful perioperative nurse–patient
interaction?
• Are surgical patients satisfied with their
perioperative nursing care (do they express
feelings of comfort and satisfaction regarding their
care in the surgical setting)? Do they have
knowledge of the perioperative nurse's role? • Is
there continuity of care between the
56
perioperative unit and other nursing care units?
Being able to exchange information about patients in face-to-face

meetings, by telephone, or by written messages is helpful for unit
and perioperative nurses. A thorough assessment made and
recorded by the preoperative nurse can accompany patients to the
OR and serve as a guide for the perioperative nurse, who then
completes a more focused preoperative patient assessment. With
the burgeoning number of ambulatory surgery procedures,
preoperative assessment is often integrated with preadmission
testing. Some institutions hold group preoperative sessions. These
not only help nurses get to know the patients, but also permit
nurses to impart information on common routines, reactions,
sensations, and nursing procedures that will take place
preoperatively, intraoperatively, and postoperatively. The
perioperative setting determines the type of interaction that occurs.
The use of preoperative phone calls and online questionnaires has
gained wide acceptance. The important point is that some form of
assessment; patient, family, and caregiver education; and discharge
planning is done. The particular facility and nursing staff determine
how to accomplish it.
Assessment requires that the nurse know and understand the
patient as a feeling, thinking, and responsible individual who is a
candidate for a surgical or invasive procedure. Data identified
through assessment help the perioperative nurse meet unique
patient needs throughout the surgical intervention. Based on data
collected, recorded, and interpreted during patient assessment, the
perioperative nurse then formulates a nursing diagnosis.
Nursing Diagnosis
Nursing diagnosis is the process of identifying and classifying data
collected in the assessment in a way that provides a focus for
planning nursing care. Nursing diagnoses have evolved since they
were first introduced in the 1950s. Today they are identified,
named, and classified according to human response patterns and
functional health patterns. The authoritative organization
responsible for delineating the accepted list of nursing diagnoses is
the North American Nursing Diagnosis Association International
57
(NANDA-I) (Box 1.2). Each NANDA-I–approved nursing diagnosis
has a set of components including a definition of the diagnostic
term, its defining characteristics (i.e., the pattern of signs and
symptoms or cues that make the meaning of the diagnosis clear),
and its related or risk factors (i.e., causative or contributing factors
that are useful in determining whether the diagnosis applies to a
particular patient). For perioperative patients, many nursing
diagnoses are “risk” diagnoses, which means they are not
evidenced by signs or symptoms because the problem has yet to
occur. Nursing interventions are directed at preventing the
problem, vulnerability, or risk.
Box 1.2
Selected Perioperative Nursing Diagnoses
• Ineffective airway clearance

• Anxiety
• Risk for allergy reaction
• Risk for aspiration
• Readiness for enhanced comfort
• Ineffective coping
• Risk for electrolyte imbalance
• Impaired urinary elimination
• Risk for imbalanced fluid volume
• Impaired gas exchange
• Hyperthermia
• Risk for hypothermia
• Risk for infection
• Risk for injury
• Risk for perioperative positioning injury
• Deficient knowledge
• Acute pain
• Risk for impaired skin integrity
58
• Risk for delayed surgical recovery
• Ineffective peripheral tissue perfusion
From NANDA International, Inc: Nursing Diagnoses: Definitions and Classification 2018-
2020, © 2017 NANDA International. Used by arrangement with the Thieme Group,
Stuttgart/New York.
Not all patient problems encountered in the perioperative setting

can be described by the list of accepted NANDA-I nursing
diagnoses. Perioperative nurses can participate in describing and
naming new nursing diagnoses that characterize unique
perioperative patient problems. NANDA-I has established a “to be
developed” category to designate nursing diagnoses that are
partially developed and deemed useful to the nursing profession.
Perioperative nurses may develop unique diagnostic labels and
definitions and work to develop and validate them further through
this process.
Outcome Identification
Outcome identification describes the desired or favorable patient
condition that can be achieved through nursing interventions (Box
1.3). To be useful for assessing the effectiveness of nursing care,
patient outcomes should be “nursing-sensitive”; they should be
influenced by nursing and describe a patient state that can be
measured and quantified. Nursing-sensitive patient outcomes
derive from nursing diagnoses and direct the interventions that
resolve the nursing diagnoses. They are the standards or criteria by
which the effectiveness of interventions is measured. Outcomes are
stated in terms of expected or desired patient behavior and must be
specific and measurable. The appropriate time to measure
perioperative nursing-sensitive outcomes varies.
Box 1.3
Selected Perioperative Nursing Data Set
Desired Patient Outcomes
59
• O.10 Patient is free from signs and symptoms of injury related
to thermal sources.
• O.20 Patient is free from signs and symptoms of unintended
retained objects.
• O.30 Patient's procedure is performed on the correct site, side,
and level.
• O.40 Patient's specimen(s) is managed in the appropriate
manner.
• O.50 Patient's current status is communicated throughout the
continuum of care.
• O.60 Patient is free from signs and symptoms of injury caused
by extraneous objects.
• O.80 Patient is free from signs and symptoms of injury related
to positioning.
• O.130 Patient receives appropriately administered
medication(s).
• O.280 Patient is free from signs and symptoms of infection.
• O.290 Patient is at or returning to normothermia at the
conclusion of the immediate postoperative period. • O.300
Patient's fluids, electrolyte, and acid-base balances are
maintained at or improved from baseline levels. • O.310
Patient's respiratory status is consistent with or improved
from baseline levels established preoperatively. • O.320
Patient's cardiovascular status is maintained at or improved
from baseline levels.
• O.500 Patient or designated support person demonstrates
knowledge of the expected psychosocial responses to the
procedure.
• O.550 Patient or designated support person demonstrates
knowledge of the expected responses to the operative or
invasive procedure.
• O.700 Patient or designated support person participates in
decisions affecting his or her perioperative plan of care. •
O.720 Patient's value system, lifestyle, ethnicity, and culture
are considered, respected, and incorporated in the
perioperative plan of care.
60
• O.740 Patient's right to privacy is maintained.
Modified from Association of periOperative Registered Nurses (AORN): PNDS—

perioperative nursing data set, ed 3, Denver, 2011, The Association.
Some outcomes from intraoperative nursing interventions can be

measured or evaluated immediately. Others occur over a longer
period. In this textbook, the use of the phrase “the patient will”
indicates an outcome that is expected to occur over time.
Identification of expected and desired outcomes unique to the
surgical patient provides the opportunity to prioritize care,
becomes a basis for continuity of care, and directs evaluation
(outcomes research). In this type of research, the relationship
between patient characteristics, the processes of care (i.e., what the
perioperative nurse does, which is described later in the
Implementation section), and the outcomes of that care are studied,
enhancing the perioperative nurse's ability to improve care. By
using EBP, patient care can be standardized and perioperative
nurses can support their choice of interventions that result in
improved patient outcomes (Spruce, 2015).
Planning
After collecting and interpreting patient data, identifying
appropriate nursing diagnoses, and establishing desired outcomes,
the perioperative nurse begins planning the nursing care for the
patient. Planning requires use of nursing knowledge and
information about the patient and the intended surgical or invasive
procedure to prepare the surgical environment and to plan patient
care. Perioperative nurses check equipment for proper functioning;
ensure that requisite supplies and positioning devices are available;
and use their knowledge of anatomy to have proper instruments,
sutures, accessory items, and surgical supplies on hand for the
procedure to be performed. They also modify routines based on
unique patient information such as allergies, transmissible
infections, risk for perioperative hypothermia, deep vein
thrombosis (DVT), infection, or pressure injury. They know the
sequence of steps in the operative or other invasive procedure and
use surgeons' preference cards, nursing care guides, and other
61
resources, such as computerized data sheets, to prepare the room
and equipment for the patient and surgical team.
Planning is preparing in advance for what will or may happen and
determining the priorities for care. Planning based on patient
assessment results in knowing the patient and the patient's unique
needs so that alterations in events, such as positioning requirements
or the surgical process, are anticipated and readily accommodated.
Planning also requires knowledge of the patient's psychosocial state
and feelings about the proposed operation so that the perioperative
nurse can provide explanation, comfort, and emotional support.
Effective communication with other members of the healthcare
team is essential, and improving communication among team
members improves patient safety (Cabral et al., 2016). Briefings
before the procedure allow for opportunities to improve safety and
efficiency of care by ensuring that team members understand the
plan of care, are prepared for potential changes, and discuss any
safety concerns (Fig. 1.3). Debriefings at the end of the procedure
provide an opportunity to discuss changes that should be made
based on lessons learned. Coaching the surgical team has been
shown to improve the quality of briefings and debriefings
(Research Highlight).
FIG. 1.3 A surgical team at Christiana Care Health
System's Christiana Hospital (Newark, Delaware)
conducts a briefing before surgery. This briefing allows
team members to finalize the plan for the patient's
62
care, anticipate potential changes in the patient's
needs, and discuss potential safety concerns
effectively.
Research Highlight
Coaching to Improve Quality of Surgery Briefings and
Debriefings
Communication failures are identified as a root cause of many
sentinel events occurring during surgery, including such failures as
wrong-patient, wrong-site, and wrong-procedure events. To reduce
communication failures and make the surgical environment safer
for patients, many teams have adopted CRM training. CRM has
been shown to improve communication and teamwork in the
aviation industry and has been successfully applied to healthcare in
many settings. The OR is thought to be an ideal setting for CRM
training because effective communication of each team member is
essential to improve safety and teamwork.
The purpose of this research was to determine whether or not
communication in the OR was improved through coaching.
Specifically, the researchers sought to leverage a coaching
intervention to improve the quality and quantity of OR briefings
and debriefings.
Using a preintervention/postintervention evaluation design,
researchers in a large Midwestern hospital used trained observers
to evaluate the frequency and quality of communication before and
after surgical procedures. On completion of preintervention
observations, a retired orthopedic surgeon, highly skilled in the use
of CRM techniques, conducted coaching over a 4-week period. This
particular surgeon was well known to the OR team, having
developed strong relationships with them during the previous 5
years when he participated in their initial CRM training.
Postintervention observations were then conducted using the same
trained observers and tools with documented reliability and
validity.
63
The frequency of briefings and debriefings was 100% both
preintervention and postintervention. The authors, although
pleased with these results, suspect that the finding may be
attributable to the Hawthorne effect (i.e., staff knew that briefings
and debriefings were being observed). When examining the quality
of the communication that occurred during briefings and
debriefings, there was a significant difference in briefing
preintervention scores (mean [M] = 3.478, standard deviation [SD] =
0.70) and postintervention scores (M = 3.644; SD = 0.76; t = −2.01; p =
.044). Likewise, there was a significant difference in the scores for
debriefings preintervention (M = 2.377, SD = 1.10) and
postintervention (M = 2.991, SD = 1.18; t = −4.608; p < .0001).
Although there was no difference in the frequency of briefings
and debriefings observed in this study, there were significant
differences in the quality of the communication observed.
Coaching appeared to be an effective intervention, improving the
quality of communication among team members.
CRM, Crew resource management; OR, operating room.
Modified from Kleiner C et al: Coaching to improve the quality of communication during
briefings and debriefings, AORN J 100(4):358–368, 2014.
Implementation
Implementation is performing nursing care activities and
interventions that were planned as well as responding with critical
thinking and orderly action to changes in the surgical procedure,
patient's condition, or emergencies (Box 1.4). Implementation uses
established standards of nursing care, recommendations for
practice, clinical practice guidelines, and best practices. During this
phase of the nursing process the perioperative nurse continues to
assess the patient to determine the appropriateness of selected
interventions and to alter interventions as necessary to achieve
desired outcomes of care. Interventions are the “work of nursing.”
Many interventions used in perioperative nursing address patient
safety issues (Patient Safety). The study of nursing interventions
links nursing diagnoses with interventions and outcomes, and leads
to validation of selected interventions or the development of new
ones. Likewise, clinical practice, decision-making, and EBP are
enhanced by their study. The study of nursing interventions also
64
helps deliver cost-effective care by quantifying resource allocation.
Box 1.4
Selected Perioperative Nursing Data Set
Perioperative Nursing Interventions
• A.10 Confirms patient identity.

• A.20 Verifies operative procedure, surgical site, and laterality.
• Im.60 Uses supplies and equipment within safe parameters. •
E.10 Evaluates for signs and symptoms of physical injury to
skin and tissue.
• Im.20 Performs required counts.
• E.50 Evaluates results of the surgical count.
• Im.330 Manages specimen handling and disposition. •
E.40 Evaluates correct processes have been performed for
specimen handling and disposition.
• Im.500 Provides status reports to designated support
person. • E.800 Ensures continuity of care.
• Im.10 Implements protective measures prior to operative or
invasive procedure.
• Im.80 Applies safety devices.
• Im.160 Maintains continuous surveillance.
• A.280.1 Identifies physical alterations that require additional
precautions for procedure-specific positioning.
• Im.120 Implements protective measures to prevent skin/tissue
injury due to mechanical sources.
• Im.210 Administers prescribed solutions.
• Im.220 Administers prescribed medications.
• Im.300 Implements aseptic technique.
• Im.300.1 Protects from cross-contamination.
• Im.270 Performs skin preparations.
• Im.280 Implements thermoregulation measures.
65
• Im.370 Monitors physiologic parameters.
• E.260 Evaluates response to thermoregulation measures. •
A.520.1 Preserves and protects the patient's autonomy, dignity,
and human rights.
Modified from Association of periOperative Registered Nurses (AORN): PNDS—

perioperative nursing data set, ed 3, Denver, 2011, The Association.
Patient Safety
Perioperative Patient Safety Issues
Much of the work of perioperative nursing involves patient safety
including protecting patients from risks and vulnerabilities related
to the procedure, positioning, equipment, and the environment. It
is essential that perioperative nurses proactively assess risks to
their patients and implement interventions to minimize those risks.
Steelman and colleagues (2013) surveyed perioperative nurses to
identify what safety issues they considered their highest priority.
They obtained 3137 usable responses. The majority of nurses
considered preventing wrong site, procedure, or patient surgery
(69%) and preventing retained surgical items (61%) to be high
priority safety issues in need of heightened attention. More than
one-third of respondents identified preventing medication errors,
failures in instrument reprocessing, pressure injuries, and surgical
fires to be high-priority issues as well.
The top rated issues include the following:
1. Preventing wrong site/procedure/patient surgery

2. Preventing retained surgical items
3. Preventing medication errors
4. Preventing failures in instrument reprocessing
5. Preventing pressure injuries
6. Preventing specimen management errors
7. Preventing surgical fires
8. Preventing perioperative hypothermia
9. Preventing burns from energy devices
66
10. Responding to difficult intubation/airway emergencies
From Steelman VM et al: Priority patient safety issues identified by perioperative nurses,
AORN J 97(4):402–418, 2013.
Finally, implementation also means being the patient's advocate

by recognition of patient concerns and unmet needs. Advocacy, a
part of nurse caring, encompasses caring behaviors that promote
emotional and physical comfort. Caring behaviors include
establishing a “connection” with the patient, responding to each
patient's individuality, and meeting patient, family, and caregiver
expectations (Patient Engagement Exemplar). The role of patient
advocate is especially important in surgical settings when patients
are sedated or unconscious and unable to speak for themselves. As
caring patient advocates, perioperative nurses advance the best
interests of their patients.
Patient Engagement Exemplar

Basic Concepts for Engaging Patients
An important aspect of perioperative nursing is actively engaging
patients and families in their own care. Patient-centered care and
patient engagement is a key strategy for improving safety and
efficacy in health care systems.
The NAQC defines patient engagement as “the involvement in
their own care by individuals (and others they designate to engage
on their behalf) with the goal that they make competent, well
informed decisions about their health and health care and take
action to support those decisions” (Sofaer and Schumann, 2013).
NAQC has highlighted major assumptions about patient
engagement that every nurse should know and practice. First and
foremost of these is that nurses establish a relationship with
patients and families to form a partnership with them so they are
able to participate in decisions about their care. Perioperative
nurses form this relationship at the first meeting of the patient; it is
based on ethical behavior and respecting patient's privacy.
67
Partnerships with surgical patients should begin at the time a
patient decides on surgery, and at that time they should be
informed of the risks, benefits, and alternatives to having surgery.
Education is offered regarding strategies to optimize surgical
outcomes such as smoking cessation, nutrition, preoperative
bathing, and exercise. NAQC guiding principles are used
throughout this book as important patient-centered care concepts
and exemplars are highlighted.
NAQC, Nursing Alliance for Quality Care.
Modified from Sofaer S, Schumann MJ: NAQC guiding principles. Nursing Alliance for
Quality Care. Fostering successful patient and family engagement: nursing's critical role
(website), 2013. http://www.naqc.org/WhitePaper-PatientEngagement. (Accessed 26
December 2016).
Delegation.
A team delivers perioperative patient care, and different categories
of team members assist in a host of direct and indirect patient care
activities. The surgical team usually consists of a surgeon and
assistants at surgery (e.g., residents, interns, physician assistants
[PAs], registered nurse first assistants [RNFAs], certified nurse
practitioners [NP-Cs], or certified first assistants [CFAs]); an
anesthesia provider; a circulating nurse; and a scrub person, who
may be either a surgical technologist (ST) or an RN. Other members
of the healthcare team, such as nursing assistants, orderlies,
environmental services personnel, and patient care technicians,
support the surgical team. During implementation of patient care
the perioperative nurse may delegate certain nursing activities to
these personnel, which are often called unlicensed assistive personnel
(UAP). As the use of UAP grows, questions and concerns arise
about the proper scope of delegated activities. Each state's board of
nursing defines the scope of practice for registered nurses, based on
the nursing process. Further, each state's nurse practice act (a state
law that protects the health and safety of the public) establishes
legal qualifications for who can practice nursing. Implementation of
the plan of care and the interventions to accomplish it are part of
the nursing process. Therefore guidelines for proper delegation of
some of these interventions are necessary. Delegation transfers to a
competent person the authority to perform a selected nursing task
68
in a selected situation according to the “five rights” of delegation
(Box 1.5). The perioperative nurse who delegates a task retains
accountability for that delegation. Nursing functions of performing
assessments, determining nursing diagnoses, establishing patient
outcomes, developing the plan of care, and evaluating patient
outcomes, as well as nursing interventions that require independent
nursing knowledge, skills, or judgment, cannot be delegated
(ANA/NCSBN, 2016). Perioperative nurses need to understand that
institutional policy cannot contradict the nurse practice act of their
state. Although tasks and procedures may be delegated to UAP
members of the surgical team, the perioperative nurse remains
responsible for supervising care because supervision cannot be
delegated. Accordingly, the perioperative nurse assesses the patient
and the competency level of personnel to determine which team
member has the skill to provide the necessary care. Using UAP
appropriately assists the profession of perioperative nursing to
maintain high-quality patient care services.
Box 1.5
The Five Rights of Delegation
• The Right task. The perioperative nurse determines that this

task is delegable for a specific patient, taking into
consideration such factors as potential for harm, complexity of
the task, necessary problem-solving, and predictability of the
outcome. Routine tasks performed according to a standardized
procedure and which have predictable outcomes are safest to
delegate.
• The Right circumstances. The perioperative nurse considers
the patient care setting, resources available, and other relevant
factors. Tasks delegated must not require independent nursing
judgment.
• The Right person. The perioperative nurse is the right person
to delegate the right task to the right person to be performed on
the right patient. The perioperative nurse must be familiar with
institutional and state board policies on delegation, along
69
with the job description of the UAP; the person's capabilities,
knowledge, and skill level; and learning needs to ensure that
safe, quality patient care is provided. In this way the nurse
matches tasks to the UAP's skills, qualifications, and
competence.
• The Right communication and direction. The perioperative
nurse provides a clear, specific, and concise description of the
task, with key information relating to its objectives, rationale,
limits, and expectations. There should be an opportunity for
questions and clarifying instructions. Information that the
perioperative nurse needs to know from the person
performing the task must be identified. Communication
should be direct and not provided through others.
• The Right supervision and evaluation. The perioperative
nurse appropriately monitors the task or person performing it,
evaluates results or patient outcomes or both, intervenes if
necessary, and provides feedback. Providing immediate
feedback or identifying a problem with performance as it
occurs is essential to upholding standards of care and
performance expectations.
Perioperative nurses must be involved actively in providing the

assessment, evaluation, and judgment needed to coordinate and
supervise perioperative patient care. When delegating care
activities, perioperative nurses retain accountability for analyzing
and evaluating the outcomes of delegated tasks. Activities that rely
on the nursing process, such as performing assessments; making
nursing diagnoses; establishing plans of care; providing extensive
patient, family, and caregiver education; and planning for patient
discharge, cannot be delegated.
UAP, Unlicensed assistive personnel.
Modified from the National Council of State Boards of Nursing response to the PEW taskforce
principles and vision for health care workforce regulation, Chicago, 1996, The Council; Cherry B,
Jacob SR: Contemporary nursing: issues, trends and management, ed 7, St Louis, 2016, Elsevier;
Taylor C et al: Fundamentals of nursing: the art and science of person-centered nursing care, ed 8,
Philadelphia, 2015, Wolters Kluwer.
Documenting Interventions.
70
Accurate documentation of nursing care is integral to all phases of
the nursing process, especially implementation of the plan of care.
A description of the patient, nursing diagnoses and desired patient
outcomes, nursing care given, and the patient's response to care
(outcomes) should be included in the patient record.
Documentation of the nursing care given should include more than
technical aspects of care, such as counts or application of the
electrosurgical unit (ESU) dispersive pad. Nursing care
documentation should be associated with assessment and nursing
diagnoses, with preestablished outcomes against which
appropriateness and effectiveness of care may be judged. The form
for this documentation may include standardized protocols and
interventions; space should be provided to add interventions that
are unique to individual patients or to describe variances in care.
Documentation should require little time to complete, be specific to
the perioperative setting, and provide continuity across the various
areas in surgery, from presurgical holding areas to the PACU. Most
facilities incorporate computerized documentation systems to
enhance retrievability of data for evaluation of care and patient
outcomes.
Syntegrity.
In 1993 AORN recognized the need to describe and define the
unique contributions of perioperative nurses to patient outcomes.
After 6 years of research and validation, the Perioperative Nursing
Data Set (PNDS) was recognized as a specialty nursing language,
which provided a uniform and systematic method to document the
basic elements of perioperative nursing care (AORN, 2011). The
third edition of the PNDS has since been incorporated into an
electronic framework called Syntegrity. Similar to the Perioperative
Patient Focused Model, the PNDS begins with desired patient
outcomes. Each outcome is defined and interpreted and presents
criteria by which to measure outcome achievement. Subsequently,
nursing interventions to achieve the desired patient outcomes are
noted, along with suggested nursing activities to support the
interventions. Of special import is the opportunity for perioperative
nurses to use Syntegrity to document assessments, interventions,
and outcomes electronically, enabling Syntegrity to compare
71
clinical outcomes from large patient populations within an
institution and even across institutions. Syntegrity can be used to
guide research, develop best practices, and support EBP.
Evaluation
Evaluation is checking, observing, and appraising the results of what
was done. Although evaluation is traditionally listed as the last
phase of the nursing process, it is an integral, systematic, and
ongoing component of providing safe, effective, and good
perioperative patient care. Evaluation focuses on the patient's
progress in attaining identified outcomes. When feasible and
appropriate, the patient, family, and caregiver should participate in
the evaluation process. The attainment of outcomes, any revisions to
nursing diagnoses or desired outcomes, and the plan of care are
documented. Because perioperative patient care processes and
interventions often are interdisciplinary, healthcare facilities may
need to use additional evaluation methods.
Evaluation of the patient's progress toward desired outcomes
extends throughout the postoperative period and beyond. It is
essential that critical information be shared with nurses responsible
for care postoperatively. Communication during this transition of
care, referred to as a handoff or handover, is critical to patient
safety and continuity of care (Research Highlight).
Research Highlight
Transitions in Care
Transitions in care (patient handoffs) should be considered high

risk activities. During a single surgical intervention there are
numerous transitions in care, with the first occurring in the
preoperative area. Using a qualitative descriptive design, this
study aimed to identify the role of the preoperative assessment in
the patient's transition and to identify the contributions nursing
made in the surgical patient's first transition of care.
Researchers in a large medical center in the northeastern United
States used a semistructured interview guide to conduct focus
72
groups with a total of 24 nurses. Four themes emerged:
1. Understanding vulnerabilities
2. Multidimensional communication
3. Managing expectations
4. Connecting the disconnected
The authors conclude that the role of the nurse in the

preoperative assessment and transition of care is one of advocate.
As an advocate, nurses identify risk factors, vulnerabilities, and
patient needs that may be significant during the surgical
experience. Additionally, results from this study suggest that the
nursing preoperative assessment may be a valid tool to help define
and identify risk factors potentially affecting the patient during the
entire perioperative experience.
Modified from Malley A et al: The role of the nurse and the preoperative assessment in
patient transitions, AORN J 102(2):181.e1–181.e9, 2015.
Performance improvement (PI) activities, notably by monitoring

important aspects of care, problem identification, problem-solving,
and peer review, may be part of the overall system evaluation.
Often referred to as quality improvement (QI) programs, overall
system evaluations by interdisciplinary teams address areas for
improvement in patient care, identify problems, propose solutions,
and monitor and evaluate the effectiveness of improvements. This
topic is discussed in more detail later in the chapter.
Institutional Standards of Care

Healthcare facilities have developed additional standards to
communicate expectations of performance. Perioperative
departments have the responsibility, delegated through
administrative governance of the institution, to develop policies
and procedures, which is often called the surgical services standards
of care. Policies are written statements that outline responsibilities
and appropriate actions in specific circumstances. To be effective, a
policy should be consistent with national and state practice
standards, be realistic and achievable, be consistently followed
73
except where prior approval of deviation has been obtained, and be
based on evidence and reasoned and rational thinking. Procedures
are written guides to implementing policies. They describe detailed
chronologic sequences of activities as they relate to particular
policies. Policies and procedures are usually combined in the
department's Standards of Care Manual, which is kept readily
available as a perioperative care resource. Many facilities have
moved to an online manual as well to provide easy access in
multiple patient care locations. Participation of staff members in
policy and procedure development increases their knowledge of the
subject matter and generates a sense of ownership. This results in
meaningful and authoritative interpretation of approved policy and
procedure to peers and furthers successful implementation.
Evidence-Based Practice
Perioperative nursing relies on a strong foundation of traditions
designed to provide excellent patient care. These traditions include
many aspects of direct patient care as well as control of the
environment in which care is provided. Perioperative nurses have
an ethical responsibility to review practices and to modify them,
based on the best available scientific evidence (Evidence for
Practice). This process can be used proactively to evaluate
alternative ways of providing care, such as using different patient
positioning surfaces or developing patient education materials. EBP
can also be used to problem-solve, such as when investigating a
serious adverse event or other clinical problems including
perioperative hypothermia, a pressure injury, or a retained surgical
item. EBP allows the perioperative nurse to base care decisions on
the best available research rather than tradition (Spruce, 2015).
Evidence for Practice

Evidence-Based Practice and Association of
periOperative Registered Nurse's Guidelines for
Perioperative Practice
74
Patient care decisions based on scientifically sound evidence rather
than the opinion of healthcare providers are known as evidence
based practice (EBP). At times, staff nurses base practice decisions
on what they were taught in nursing school or from other nurses
rather than on what has been scientifically validated. AORN's
Guidelines for Perioperative Practice are a collection of evidence-based
recommendations to promote patient safety during operative and
invasive procedures. These guidelines represent one way that
AORN supports perioperative RNs, advances the nursing
profession, and promotes excellence in perioperative nursing
practice. The guidelines illustrate how the perioperative RN
ensures a safe work environment, provides safe perioperative
patient care, and reflects the RN's scope of practice. Illustrating
optimal levels of workplace safety and patient care, the guidelines
are achievable, evidence-based statements of professional practice,
which are meant to serve as foundational documents in the
development of policies, procedures, and competency validation
tools.
Representing AORN's official position on perioperative practice,
the guidelines are created by AORN's perioperative nursing
specialists in collaboration with the AORN Guidelines Advisory
Board and liaisons from a number of related professional
organizations such as the American College of Surgeons and the
Association for Professionals in Infection Control and
Epidemiology. The guidelines help perioperative nurse leaders
synthesize and translate a large amount of literature into
manageable recommendations. AORN's guidelines meet the
National Academy of Medicine's (formerly the Institute of
Medicine [IOM]) definition of clinical practice guidelines and are
based on a thorough review of both research and nonresearch
evidence. Each recommendation is rated based on the quality and
strength of the evidence supporting it. Through the application of
EBP, the guidelines support cost-effective, scientifically sound, and
safe approaches to patient care.
For perioperative nurses to implement an evidence-based
approach to problem-solving, it is most useful to adopt a model
that helps focus clinical decision-making and solution
implementation. Evidence-based models generally include step-by
75
step direction for addressing clinical problems and pairing them
with research-based interventions so that practice changes,
supported by the best evidence, occur. There are a number of
widely used models, such as the Johns Hopkins Nurse Evidence
Based Practice Model, the Stetler Model of Research Utilization, the
ACE Star Model of Knowledge Transformation, and the Iowa
Model of Evidence-Based Practice to Improve Quality of Care (see
Fig. 1.4). Regardless of the model selected and implemented,
communication is essential to ensure that practice changes are
understood and adopted.
Providing care that is patient centered, evidence based, and data
driven is the responsibility of all nurses. Evidence-based
perioperative nursing care results in improved patient outcomes
and increases the patient's satisfaction with care delivered.
Through the adoption and implementation of an evidence-based
model, practice changes are grounded in science.
AORN, Association of periOperative Registered Nurses; RN,
registered nurse.
Modified from the Association of periOperative Registered Nurses (AORN): Guidelines for
perioperative practice, Denver, 2016, The Association; White S, Spruce L: Perioperative
nursing leaders implement clinical practice guidelines using the Iowa Model of Evidence
Based Practice, AORN J 102(1):51–56, 2015.
EBP, a systematic process, identifies clinical issues and collects

and then evaluates the best evidence. It is frequently used to design
and implement clinical practice changes after thoroughly
evaluating the practice of interest. Early and important changes that
were implemented through the EBP process and the work of nurses
are double-gloving to reduce sharps injuries (Stebral and Steelman,
2006), asking patients to shower preoperatively twice with
chlorhexidine gluconate (Pottinger et al., 2006), administering
antibiotics within 60 minutes before the surgical incision (Spalter
and Wyatt, 2006), and administering a combination of blood
products (massive transfusion protocol) for control of hemorrhage
(Enticott et al., 2012).
When there is not enough evidence to guide practice,
perioperative nurses can collaborate with a nurse researcher in a
research study to address the practice issue or to identify, review,
76
and evaluate evidence about it. One model used in many healthcare
facilities is the Iowa Model of Evidence-Based Practice to Promote
Quality Patient Care (Fig. 1.4).
77
FIG. 1.4 The Iowa Model of Evidence-Based Practice
to Promote Quality Patient Care is used in many
healthcare settings to identify opportunities to improve
care; evaluate evidence; and design, implement, and
evaluate evidence-based practice changes.
78
EBP has become an integral part of many national quality
initiatives. The Surgical Care Improvement Project (SCIP) began as
a national quality partnership endorsed by many organizations and
focused on improving care of surgical patients by using EBP to
significantly reduce surgical complications. SCIP measures address,
among other important care aspects, timely administration of
preoperative prophylactic antibiotics and the expeditious removal
of urinary catheters postoperatively (TJC, 2016b).
Performance Improvement
Continuing trends in health care have seen increased control of
costs, more efficient use of resources and supplies, decreased length
of stay for surgical patients, and a shift of many surgical procedures
from inpatient to ambulatory surgery settings (Ambulatory Surgery
Considerations). Concomitantly, there is a keener awareness of the
need for continued improvement in delivery of perioperative
patient care. TJC has taken a strong position on the need to monitor
and evaluate the quality and appropriateness of care delivery
continually to resolve any identified problems while striving
constantly to improve delivery systems and processes. In 1994 TJC
instituted performance assessment, measurement, and
improvement as the core of its standards. This represented an
evolution from quality assurance to continuous QI, and finally to PI.
Such a transition underscored the belief that measuring outcomes
and improving care are essential elements of effective healthcare
delivery. PI efforts encompass improvements in quality and
effectiveness based on ethical and economic perspectives.
Ambulatory Surgery Considerations

Timely Patient Discharge
Approximately 70% of all surgeries are now performed as

ambulatory procedures. This shift from inpatient to outpatient has
been facilitated by the development of minimally invasive surgical
79
techniques and the improvement of anesthesia techniques and
medications. Performing procedures on an ambulatory basis
provides cost efficiencies to the facility and improves patients'
experiences, allowing them to recover in their own home.
Ambulatory surgery also places additional pressures on the
perioperative team, which must ensure that quality care and
patient safety are maintained while preparing the patient for a
timely discharge.
To ensure that patients are best prepared for a timely discharge
after their procedure, a number of strategies are required, and
coordinated perioperative team efforts are essential. Preparing for a
safe, efficient discharge begins at the time the surgery is planned.
Enhanced recovery after surgery (ERAS) protocols are often
implemented. Preoperative patient preparation includes nutritional
assessment and optimization, smoking cessation, and improved
physical fitness. Patient education related to the postoperative
course and expected recovery take into account the patient's health
literacy level. Because low levels of health literacy are increasingly
common, patient education is important. In addition to appropriate
thromboprophylaxis and antibiotic prophylaxis, ERAS protocols
minimize prolonged fasting and often eliminate routine bowel
preparation.
During the intraoperative phase, ambulatory surgical procedures
require close attention to a number of surgical and anesthetic
issues. The use of minimally invasive techniques is preferable, and
close attention to ensuring hemostasis is important. Early
ambulation is facilitated if drains and nasogastric tubes are not
used. Opiates are avoided for pain management, perioperative
hypothermia is prevented, and any intraoperative vascular volume
loss is replaced.
Postoperatively early mobilization, early oral intake, and
avoidance of opiate analgesics all contribute to a safe and efficient
recovery period. The overall aim of performing procedures on an
ambulatory surgery basis is to return patients to their optimal state
of health, in their natural environment, as quickly as possible. This
can be accomplished by a coordinated interprofessional team effort
when careful planning and attention are focused around a shared
goal.
80

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JANE C. ROTHROCK PhD, RN,

Donna R. McEwen, RN, BSN,

About the Author

Unit I Foundations for Practice

Perioperative Nursing Roles

Critical Thinking Question

Chapter 2 Patient Safety and Risk Management

Major Professional Association and Government Regulatory Safety

Nonprovider Members of the Perioperative Patient Safety Team

Perioperative Nursing Safety Issues

Risk Management in the “Near” Future

Critical Thinking Questions

Chapter 3 Workplace Issues and Staff Safety

Safe Patient Handling and Movement

Sharps Safety and Bloodborne Pathogens

Personal Protective Equipment

Waste Anesthetic Gases

Chemicals and Drugs

Cell Phone Hygiene

Immunizations and Infectious Disease Exposure

Fatigue and Burnout

Critical Thinking Question

Chapter 4 Infection Prevention and Control

Critical Thinking Questions

Awareness During Anesthesia

Types of Anesthesia Care

Anesthesia Machines and Anesthetic Gases

Monitored Anesthesia Care

Perioperative Nursing Considerations

Critical Thinking Questions

Chapter 6 Positioning the Patient for Surgery

Chapter 7 Sutures, Sharps, and Instruments

Suturing Technique and Wound Closure Materials

Perioperative Nursing Considerations

Critical Thinking Question

Chapter 8 Surgical Modalities

Energies Used During Surgery

Critical Thinking Questions

Chapter 9 Wound Healing, Dressings, and Drains

Types of Wound Closure

Phases of Wound Healing

Factors Affecting Wound Healing

Patient, Family, and Caregiver Education and Discharge Planning

Critical Thinking Questions

Discharge From the Postanesthesia Care Unit

Admission to the Ambulatory Surgery Phase II Unit

Admission to the Surgical Unit

Postoperative Nursing Considerations

Patient, Family, and Caregiver Education and Discharge Planning

Unit II Surgical Interventions

Chapter 11 Gastrointestinal Surgery

Perioperative Nursing Considerations

Critical Thinking Question

Perioperative Nursing Considerations

Critical Thinking Question

Chapter 13 Hernia Repair

Perioperative Nursing Considerations

Critical Thinking Questions

Chapter 14 Gynecologic and Obstetric Surgery

Perioperative Nursing Considerations

Critical Thinking Questions

Perioperative Nursing Considerations