DUTIES OF THE CIRCULATING NURSE

CN must assist the sterile SN by providing the sterile supplies needed

A. After Scrub person/Nurse Scrubs 

     1. Fasten back of scrub persons gown.

     2. Open packages of sterile supplies like syringes, sutures, sponges gloves if a sterile package

         wrapped in porous material drops to the floor, DISCARD it. It can no longer be considered

         sterile. 

     3. Flip suture packets onto the instrument table or open overwraps for scrub person to take

         packets 

     4. Pour NSS into the round basin for sponges on instrument table 

     5. Count sponges, needles and instruments with the scrub nurse and record immediately 

B. After the patient arrives 

CN attends to the patient 

     1. Greets and identify patient. Check wristband 

     2. Heck NCP and patients chart for pertinent information including CONSENT 

     3. Be sure patients hair is covered with cap 

     4. Assist the patient in moving from the stretcher to the OR table. 

     5. Apply restraint straps over legs and arms. Keep patient covered with blanket for privacy and

         provide warmth. 

          a. Patients legs should not be crossed 

          b. Put arm board on L or R arm if IV is to be infused 

           6. Help anesthesiologist, surgeon or assistant as needed

C. During induction of General Anesthesia

     1. Stay in the room and near patient to provide comfort and assist anesthesiologist in the

        event that the patient gets excited. Patient must be guarded during induction to prevent

        possible injury or fall from OR table 

     2. Be quiet as much as possible 

• excitement may occur during induction from tactile or auditory stimulation

     D. After the patient is Anesthetized 

          1. Reposition patient only after the anesthesiologist say so 
          2. Attach anesthesia screen and other table attachments 
          3. Note patient’s position. All safety measures must be observed 
          4. If cautery is to be used, place inactive dispersive electrode plate in contact with patient’s
              skin to ground the patient properly. Avoid scar tissues, hairy or bony areas. 
          5. Expose appropriate area for skin prep 
          6. Turn overhead spotlight over site of incision 
          7. Arrange sterile prep 
          8. Cover the prep tray immediately after use

  

E. After Surgeon and Assistant scrub

     1. Be alert to anticipate needs of sterile team

• CN watches closely the operation and anticipate the needs without having the team ask for them
• Should know where all supplies are to facilitate time and get them quickly 

           2. Stay in the room. Inform SN if you must leave 

     3. Keep discarded sponges carefully collected, separated by sizes and counted. Sponges

         forceps or gloves never bare hands are used to handle and count sponges 

     4. Assist in monitoring blood loss. Weigh sponges if requested by surgeon. Measure blood

         volume from suction container 

     5. Obtain blood products for transfusion. 

     6. Know the condition of the patient at all times 

     7. Prepare and label specimens for transportation to lab 

     8. Complete the patient chart, permanent operating room records, and requisition for lab test,

         etc. 

     9. Be alert to any break in sterile technique 

F. During Closure 

     1. Count sponges, sharps and instruments with scrub nurse

• report counts as correct or incorrect to surgeon
• complete count records

          2. If another patient is scheduled to follow: 
               a. CN should call the ward for the next patient at least 45 min before the scheduled time of
                   operation to request that pre-op medication be given 

               b. Ask transport aide to get patient from the ward 30 min before OR

G. After the operation is completed 

     1. Open neck and back closures of gowns of surgeons and assistants so they can remove

         them without contaminating themselves  

     2. Assist with dressing. SN should roll drapes off patient before outer layer of dressing is

         applied 

     3. Connect all drainage system as indicated 

     4. See to it that the client is clean – wash off blood, feces. Put on a clean gown and blanket 

     5. Have transport aide bring a clean RR stretcher 

     6. Help move patient to stretcher or bed. Place pt to stretcher with a 4 man carry 

     7. Be sure chart and proper records including NCP accompany patient 

     8. Final completion of the client chart should include documentation of: 

          a. assessment of patients skin condition prior to and at completion of operation

              i.e. skin discoloration, rashes, pressure sores, burns

          b. urine output and blood loss – I and O

          c. type of dressing used

          d. time patient was discharged from OR 

     9. Have nursing assistant help transport pt to RR

  

SCRUBBING, GOWNING and GLOVING

     1. Washes hands, forearms and upper arms 

     2. Picks up brush and forceps 

     3. Rinses brush 

     4. Gets soap solution 

     5. Scrubs hand for 1 ½ minutes starting from fingertips 

     6. Scrubs forearms for 1 minute 

     7. Scrub upper arms for ½ minutes 

     8. Scrub other hands, forearms and arm for the prescribed time 

     9. Rinses brush hands, forearms and upper arms 

     10. Repeats scrubbing

           Hands – 1 minute each

           Forearms – ½ minute each 

     11. Rinses brush, hands and forearms 

     12. Repeat scrubbing

           Hands – ½ minute each 

     13. Discards brush 

     14. Rinses hands 

     15. Keeps hands higher than the arms through steps 5-15 

     16. Dries hands and arms on hem and gown 

     17. Lets hem face below table level 

     18. Grasps gown at armhole 

     19. Puts arms through sleeves of gown 

     20. Allows assistant to tie laces at the back; bends sideward allow assistant to grasp belt of

           gown

     21. Opens packages of glove, transfers powder to the hand, and discard paper package of

           powder 

     22. Powders hands seeing to it that the powder does not fall on gloves 

     23. Grasps one glove by the cuff and puts glove on 

     24. Inserts gloved fingers into the cuff of the other glove; puts on the other glove 

     25. Folds sleeve of gown to fit wrist and unfolds cuff of glove over sleeve 

     26. Repeats step 25 with the other sleeve 

     27. Inserts gloved hands into pouch of gown 

     28. Maintain asepsis throughout gloving and gowning 

          a. keeps hands above table level 

          b. does not turn back towards sterile field

PREVENTING INTRAOPERATIVE POSITIONING INJURY

The patient’s position on the operating table depends on the surgical procedure to be performed as well as on his or her physical condition.

• The patient should be in as comfortable a position as possible, whether asleep or awake.

• The operative field must be adequately exposed.

• An awkward position, undue pressure on a body part, or use of stirrups or traction should not

   obstruct the vascular supply.

• Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts
   the neck or chest.

• Nerves must be protected from undue pressure. Improper positioning of the arms, hands, legs, or
   feet may cause serious injury or paralysis. Shoulder braces must be well padded
   to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary.

• Precautions for patient safety must be observed, particularly with thin, elderly, or obese patients, or
   those with a physical deformity.

• The patient needs gentle restraint before induction in case of excitement.

POST OPERATIVE PERIOD

POST OPERATIVE CARE

RECOVERY ROOM (Immediate Postoperative Care)

1. Assess for and maintain patent airway. 
     1. Position unconscious or semiconscious client on side (unless contraindicated) or on back with
         head to side and chin extended forward. 
     2. Check for presence/absence of gag reflex. 
     3. Maintain artificial airway in place until gag and swallow reflex have returned.

2. Administer oxygen as ordered.
3. Assess rate, depth, and quality of respirations. 
4. Check vital signs every 15 minutes until stable, then every 30 minutes.
5. Note level of consciousness; reorient client to time, place, and situation.
6. Assess color and temperature of skin, color of nailbeds, and lips.
7. Monitor IV infusions: condition of site, type, and amount of fluid being infused and flow rate.
8. Check all drainage tubes and connect to suction or gravity drainage as ordered; note color,
    amount, and odor of drainage.

  

9. Assess dressings for intactness, drainage, hemorrhage.
10. Monitor and maintain client's temperature; may need extra blankets.
11. Encourage client to cough and deep breathe after airway is removed.
12. If spinal anesthesia used, maintain flat position and check for sensation and movement in lower
      extremities.

CARE ON SURGICAL FLOOR

1. Monitor respiratory status and promote optimal functioning. 
     1. Encourage client to cough (if not contraindicated) and deep breathe every 1-2 hours. 
     2. Instruct client to splint incision while coughing. 
     3. Assist client to turn in bed every 2 hours. 
     4. Encourage early ambulation. 
     5. Encourage use of incentive spirometer every 2 hours: causes sustained, maximal inspiration
         that inflates the alveoli. 
     6. Assess respiratory status and auscultate lungs every 4 hours; be alert for any signs of
         respiratory complications.

2. Monitor cardiovascular status and avoid post-op complications. 
     1. Encourage leg exercises every 2 hours while in bed. 
     2. Encourage early ambulation. 
     3. Apply antiembolism stockings as ordered. 
     4. Assess vital signs, color and temperature of skin every 4 hours.

3. Promote adequate fluid and electrolyte balance. 
     1. Monitor IV and ensure adequate intake. 
     2. Measure I&O. 
     3. Irrigate NG tube properly, using normal saline solution. 
     4. Observe for signs of fluid and electrolyte imbalances.

4. Promote optimum nutrition. 
     1. Maintain IV infusion as ordered. 
     2. Assess for return of peristalsis (presence of bowel sounds and flatus). 
     3. Add progressively to diet as ordered and note tolerance.

5. Monitor and promote return of urinary function. 
     1. Measure I&O. 
     2. Assess client's ability to void. 
     3. Report to surgeon if client has not voided within 8 hours after surgery. 
     4. Check for bladder distention. 
     5. Use measures to promote urination (e.g., assist male to sit on side of bed, pour warm water
         over female's perineum).

6. Promote bowel elimination. 
     1. Encourage ambulation. 
     2. Provide adequate food and fluid intake when tolerated. 
     3. Keep stool record and note any difficulties with bowel elimination.

7. Administer post-op analgesics as ordered; provide additional comfort measures.
8. Encourage optimal activity, turning in bed every 2 hours, early ambulation if allowed (generally
    client will be out of bed within 24 hours; have client dangle legs before getting out of bed).
9. Provide wound care.

1. Check dressings frequently to ensure they are clean, dry, and intact.  
2. Observe aseptic technique when changing dressings.  
3. Encourage diet high in protein and vitamin C.  
4. Report any signs of infection: redness, drainage, odor, fever.

10. Provide adequate psychologic support to client/significant others.
11. Provide appropriate discharge teaching: dietary restrictions, medication regimen, activity
      limitations, wound care, and possible complications.

POSTOPERATIVE COMPLICATIONS

RESPIRATORY SYSTEM

Common post-op complications of respiratory tract are atelectasis and pneumonia (for additional information on these disorders see Atelectasis and Pneumonia). 

1. Predisposing factors 
     1. Type of surgery (e.g., thoracic or high abdomen surgery) 
     2. Previous history of respiratory problems 
     3. Age: greater risk over age 40 
     4. Obesity 
     5. Smoking 
     6. Respiratory depression caused by narcotics
     7. Severe post-op pain 
     8. Prolonged post-op immobility 

2. Prevention: see Care on Surgical Floor, above.

CARDIOVASCULAR SYSTEM

Common post-op complications of the cardiovascular system are deep vein thrombosis, pulmonary embolism, and shock (for additional information on these disorders see Thrombophlebitis or Shock. 

1. Predisposing factors to deep vein thrombosis (DVT)

1. Lower abdominal surgery or septic diseases (e.g., peritonitis) 
2. Injury to vein by tight leg straps during surgery 
3. Previous history of venous problems 
4. Increased blood coagulability due to dehydration, fluid loss 
5. Venous stasis in the extremity due to decreased movement during surgery 
6. Prolonged post-op immobilization

2. Predisposing factors to pulmonary embolism: may occur as a complication of DVT.
3. Most common causes of shock during post-op period 
     1. Hemorrhage 
     2. Sepsis 
     3. Myocardial infarction and cardiac arrest 
     4. Drug reactions 
     5. Transfusion reactions 
     6. Pulmonary embolism 
     7. Adrenal failure

4. Prevention of DVT, pulmonary embolism, and shock: see Care on Surgical Floor.

GENITOURINARY SYSTEM

Post-op complications of the genitourinary system often include urinary retention and urinary tract infection (for additional information on these disorders see Nephrolithiasis and Pyelonephritis). 

1. Predisposing factors to urinary retention include 
     1. Anxiety 
     2. Pain 
     3. Lack of privacy 
     4. Narcotics and certain anesthetics that diminish client's sense of a full bladder 

2. Prevention and nursing interventions for urinary retention: see Care on Surgical Floor. 
3. Post-op urinary tract infections are most commonly caused by catheterization; prevention consists
    of using strict sterile technique when inserting a catheter, and appropriate catheter care (every 8
    hours or according to agency protocol).

GASTROINTESTINAL SYSTEM

An important GI post-op complication is paralytic ileus (paralysis of intestinal peristalsis). 

1. Predisposing factors 
     1. Temporary: anesthesia, manipulation of bowel during abdominal surgery 
     2. Prolonged: electrolyte imbalance, wound infection, pneumonia

2. Assessment findings 
     1. Absent bowel sounds 
     2. No passage of flatus 
     3. Abdominal distention

3. Nursing interventions 
     1. Assist with insertion of nasogastric or intestinal tube with application of suction as ordered. 
     2. Keep client NPO. 
     3. Maintain IV therapy as ordered. 
     4. Assess for bowel sounds every 4 hours; check for abdominal distention, passage of flatus. 
     5. Encourage ambulation if appropriate.

WOUND COMPLICATIONS

1. Wound infection 
     1. Predisposing factors 
          1. Obesity 
          2. Diabetes mellitus 
          3. Malnutrition 
          4. Elderly clients 
          5. Steroids and immunosuppressive agents 
          6. Lowered resistance to infection, as found in clients with cancer 

     2. Assessment findings: redness, tenderness, drainage, heat in incisional area; fever; usually
         occurs 3-5 days after surgery. 
     3. Prevention: see Care on Surgical Floor
     4. Nursing interventions 
          1. Obtain culture and sensitivity of wound drainage (S. aureus most frequently cultured). 
          2. Perform cleansing and irrigation of wound as ordered. 
          3. Administer antibiotic therapy as ordered. 

2. Wound dehiscence and evisceration

     1. Dehiscence: opening of wound edges 
     2. Evisceration: protrusion of loops of bowel through incision; usually accompanied by sudden
         escape of profuse, pink serous drainage 
     3. Predisposing factors to wound dehiscence and evisceration 
          1. Wound infection 
          2. Faulty wound closure 
          3. Severe abdominal stretching (e.g., coughing, retching) 

     4. Nursing interventions for wound dehiscence 
          1. Apply Steri-Strips to incision. 
          2. Notify physician. 
          3. Promote wound healing.

     5.  Nursing interventions for wound evisceration 
          1. Place client in supine position. 
          2. Cover protruding intestinal loops with moist normal saline soaks. 
          3. Notify physician. 
          4. Check vital signs. 
          5. Observe for signs of shock. 
          6. Start IV line. 
          7. Prepare client for OR for surgical closure of wound.