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Perioperative role in three dimensions
Elaine Patterson, RN, an operating room nurse at St Joseph’s Hospital, Denver, illustrates nursing practice at three points on the perioperative role continuum.
Perioperative role in three dimensions Julia A Kneedler, RN Do nurses realize the extent to which they are practicing in the perioperative role? Interviews with nurses about the role, published in the Journal during the past year led us to believe they do not. In the February issue, Sharon McFarland was asked if she sees surgical patients before they come to the OR. She replied that she rarely sees patients in the unit due to staffing and time. She went on to say she arranges to do a short preoperative assessment in the holding area with almost every patient, talking with him about his illness, checking for allergies, looking for skin problems, and making sure he is warm and comfortable. She gave examples of how she does assessment, planning, implementation, and evaluation-the four components of the nursing process. But she seemed to believe that t o be practicing i n the AORN Journal, November 1979, V o l 3 0 , N O 5
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Fig 1. The model illustrates that the perioperative role is like the bellows on an old-fashioned camera. At the center are the four components of the nursing process. The “Standards of Nursing Practice: OR” and the perioperative role are merely extensions of the nursing process.
perioperative role, she had to go to the patient unit preoperative1y.l We would like to emphasize that the application of the four components may differ from nurse to nurse and from operating room to operating room. Application may vary during the three phases of surgery and may take place in different geographic areas of the hospital. But that doesn’t mean the perioperative role isn’t being practiced. Contrary to the view of many, the perioperative role statement was not in-
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tended to be new and different. It was intended to be a clear, concise statement of actual practice. AORN has accepted the nursing process as a definition of nursing and used it as the basis for specifically delineating practice i n the operating room. The model of t h e perioperative role depicts the components of the nursing process as its core or base (Fig 1). We believe these four components of the nursing process are the basis for the “Standards of Nursing Practice: OR.”2
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The perioperative role: A continuum /
preoperative assessment homeiclinic preoperative assessment /surgical unit preoperative assessment preoperative surgical suite phase Fig 2
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i ntraoperative basic competency phase
excellence
postoperative phase recovery room
1 postoperative evaluation surgical unit
\ postoperative evaluation homeiclinicl
As you can see, the Standards reflect the nursing process, but some of the four components have additional parts. For example, assessment has two parts: collecting data and then identifying a nursing diagnosidpatient problem. Planning involves establishing patient goals and an individualized plan of care. The perioperative role uses the same theoretical framework. It involves the same four components as the nursing process. According to the perioperative role statement by the Project 25 Task Force, “The perioperative role of the operating room nurse consists of nursing activities performed by the professional operating room nurse during the preoperative, intraoperative, and postoperative phases of the patient’s surgical e~perience.”~ As the shows,the perioperative role is merely an extension of the nursing Process. Like the bellows of an oldfashioned camera, it expands. Applying the nursing process to the operating room, you still use all the compo-
nents-assessment, planning, implementation, and evaluation. You also have three time periods during which you provide patient care-preoperative, intraoperative, and postoperative. Then you add the environ-
Julia A Kneedler, RN, EdD, is assistant director of education at AORN Headquarters, Denver, She received a BSN from Walls Walls College,College place, Wash, a n MS i n medical-surgical nursing from Loma Linda University, Loma Linda, Calif, and an EdD in adult continuing education from the University of Northern Colorado, Greeley.
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ment where nursing activities occurthe operating room, holding area, surgical unit, and clinic or home. Last, but no less important, are the specific nursing activities, such as positioning patients; doing sponge, needle, and instrument counts; providing emotional support; maintaining an aseptic, controlled environment; identifying the patient, and evaluating the effectiveness of care given in the operating room. (These are examples from the perioperative role ~tatement.~) These many facets have been put together and described succinctly as the perioperative role. You continue t o apply the same principles. But because the scope of your practice has expanded, and you have performed a preoperative assessment, you can individualize care. As a demonstration of the perioperative role in action, the Project 26 Task Force presented a slide program at the 1979 AORN Congress in St Louis. This article is based on that presentation. Focus862
ing on Elaine Patterson, an operating room nurse at St Joseph’s Hospital, Denver, it depicts the perioperative role at three points on a continuum (Fig 2). A staff nurse when this article was written, she is now a cardiovascular team leader. The patient is Mrs Dexter, admitted with a diagnosis of a mass in the right breast. She is scheduled for a right breast biopsy with frozen section and possible mastectomy. This situation illustrates the perioperative role at the first level. When Mrs Dexter arrives in the holding area, Elaine is there to greet her. She has reviewed the chart, making sure the laboratory information and operative consent are present and in order. The patient has her head turned away. Elaine touches her shoulder, and when Mrs Dexter turns toward her, she can see tears in her eyes. “I’m sorry,’’ she says. “I tried not to cry. It’s difficult enough to go under
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Elaine becomes more involved with the patient and family as the geographic boundaries of herpractice expand. At the first level (left), Elaine assesses Mrs Dexter in the holding area. She compares the identification band with the hospital admission form. She expands her practice by going to the unit to perform her assessment (center), where she answers Mrs Dexter’s questions about recovery. Expanding her practice to the clinic (right), Elaine conducts her initial assessment by gathering more data about the patient‘s background and health history. Photographs by Elinor S Schrader. The Journal thanks the staff at St Joseph’s Hospital for their assistance in preparing this article.
anesthesia the first time. But I’ll also be the last to know what is happening to me.” ‘‘It’sall right if you cry,” Elaine says. “It’s understandable that you’re upset. I understand your apprehension about being the last to know. Unfortunately, that is unavoidable. But you can trust that we will do our best for you.” With this brief conversation, Mrs Dexter seems to relax, so Elaine goes on to verify the surgical site. Mrs Dexter nods when Elaine asks if it is the right breast that will be operated on. She also explains that her leR elbow is arthritic and cannot be straightened. Elaine assesses the amount of extension in the joint by observing how far Mrs Dexter can move it comfortably. A preoperative assessment has been done. You may question its depth and the environment where i t occurred. Nevertheless, Elaine has performed an assessment at the beginning level on the perioperative continuum. She is
practicing nursing i n the operating room within the perioperative role definition. The planning phase begins when Elaine assesses Mrs Dexter and starts to individualize her care. For example, Elaine realizes she will need to plan for special padding and extra protection of the arthritic elbow. In the OR, the case is opened and supplies and equipment made ready. In the intraoperative period, the implementation component of the perioperative role begins. Elaine transfers Mrs Dexter to the operating bed. As she works, she explains briefly what is happening to help reduce Mrs Dexter’s anxiety. A warm blanket is placed over her and the safety straps applied to maintain her safety during the procedure. Elaine alerts the patient as she places the electrocardiograph (ECG) leads and the electrosurgical grounding pad. Noticing the armband is on the arm on the operative side of the body, Elaine
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The intraoperative phase. Elaine’s practice increases in scope and depth. At the first level (left), she individualizes care with extra elbow padding. As her practice advances (center), she is aware of the patient‘s needs during the excitement phase, and she anticipates the anesthesiologist’s need for assistance. Elaine has increasing patient contact as her practice progresses. At right, she comforts Mr Dexter in the waiting area after informing him of his wife’s mastectomy.
removes it to the nonoperative arm. Elaine applies protective padding to the arthritic arm before placing it in a functional position for the procedure. Prior to induction, she tells the anesthesiologist about Mrs Dexter’s level of apprehension and her arthritic left arm. Then she stands near Mrs Dexter during induction, providing emotional support and assisting the anesthesiologist. A biopsy is done, and a specimen is sent to the pathology laboratory. When it comes back, the result is positive for malignancy, and the surgeon makes the decision to perform a mastectomy. As the procedure progresses, Elaine monitors the patient’s physiological status by calculating blood loss as she counts sponges. When blood replacement is necessary, Elaine sends other personnel to obtain it. She also controls and maintains an aseptic environment by telling the scrub nurses that a lap sponge hanging off the table is contaminated. At the end of the procedure, Elaine removes the electrosurgical
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grounding pad and assesses the integrity of the patient’s skin in that area. During the intraoperative period, Elaine performed many nursing activities included in the examples in the perioperative role statement. (See AORN Journal, May 1978,1164-1165.) 0 telling the patient what is happening 0 determining psychological status 0 giving prior warning of noxious stimuli 0 standing near or touching the patient during procedures or induction 0 communicating emotional status to other appropriate members of the health care team providing physical safety for the patient maintaining a n aseptic, controlled environment effectively managing human resources Elaine did not have to relearn these functions. She drew on her already ac-
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quired knowledge and skills. For the perioperative role, the only difference is the application of knowledge and skills-in other words, performance. Immediately after the procedure, Elaine accompanies Mrs Dexter to the recovery room. She tells the nurse Mrs Dexter’s name and the type of surgery performed and shows her the wound suction. At this point, Elaine does an immediate evaluation of Mrs Dexter’s arthritic arm to determine if the positioning procedure used in the operating room was effective in protecting her arm from injury. The side rails are raised to maintain safety during the recovery period. Do you perform nursing activities reflecting the scope of the perioperative role (preoperative, intraoperative, and postoperative)? I believe most operating room nurses perform these types of functions daily. You assess the patient before, during, and after surgery. You plan, implement, and evaluate. Do you think you practice the perioperative
role at the level just described? Think about your practice as the next level is described. Make your own decision. At this level, we expand the geographic boundaries. Elaine begins her preoperative assessment on the surgical unit. Reviewing the chart, she learns about the patient’s health history and family background. Mrs Dexter, who is 45, has sons age 17 and 14 and a daughter age 12.Her husband is a bank vicepresident, and she is not employed outside the home. Under family history, Elaine notes that Mrs Dexter’s mother died ten years ago from metastatic cancer originating in the breast. Talking with the unit nurse, she learns that the patient is anxious but wants to be informed about the procedure. She has discussed the disease process with her physician. After being informed of the types of treatment for breast cancer, Mrs Dexter has decided she would prefer the surgeon t o perform a total mastectomy with axillary dissection if a malignancy is found. Active in
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Elaine’s perioperative nursing practice expands during the postoperative phase. At the first level, Elaine’s postoperative evaluation takes place in the recoveryroomwhere she and the recovery room nurse check the wound suction (left). As she progresses, Elaine goes to the unit one day postoperatively to conduct her evaluation with the unit nurse (center). At a higher level of practice, she goes to the clinic four weeks postoperatively for a follow-up evaluation of patient and family (right).
the community, Mrs Dexter is concerned about the length of her recovery and whether a mastectomy would interfere with her activities. She teaches swimming to children at the YWCA and wants to know how long and to what extent mastectomy surgery will limit her activities. After gathering as much information as possible, Elaine goes to Mrs Dexter’s room and introduces herself, By touching Mrs Dexter’s arm, she is able to assess her pulse and skin turgor. As she continues the physical assessment, Elaine is constantly assessing Mrs Dexter’s emotional status. She observes Mrs Dexter is not only anxious about the surgery, but she is also apprehensive about losing a body part and how her family might react. While she is checking the mobility of the patient’s arthritic left elbow, Elaine responds to some of the patient’s questions. Mrs Dexter’s questions about how long the biopsy will take reflects her concern about how long her condition
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will remain unknown and how long her family will be kept waiting. Elaine briefly explains the biopsy process. “If a mastectomy is done, you will probably be back in your room in two or two and one-half hours,” she says, adding that the staff will inform her husband of this. “If I have a mastectomy, will the wound be open and ugly?” she asks. “When I wake up, will I be able to tell what has happened or will someone have to tell me? Will someone be there when I find out what the outcome is, or will I be alone?’ Elaine assures Mrs Dexter that the recovery room nurse will be with her when she awakens. The recovery room nurse will be able to tell her what has been done, and later, the physician will visit her to explain what was done and why. Mrs Dexter then wonders if someone will tell her husband or if she will have to tell him. Elaine replies that a member of the surgical team will go to the waiting area to tell her husband as soon as the results of the biopsy are
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known. She makes a note to inform the recovery room nurse about Mrs Dexter’s anxiety and that her husband will have been informed. Using the nursing care plan developed for patients having breast biopsies with possible mastectomies, Elaine begins to individualize Mrs Dexter’s care. Later, when Mrs Dexter arrives in the holding area, Elaine continues her assessment. She notes that Mrs Dexter is drowsy and does not respond readily to questions. For verifying identification, Elaine compares the armband with the hospital admission form. The surgical site is confirmed by comparing the surgical consent form with the operating room schedule. Elaine then confirms the site with the surgeon. She also reviews the chart and checks laboratory reports and all necessary forms. In the OR, Elaine follows the individualized care plan. As she did at the beginning level, Elaine prepares the operating room and then positions and
pads the patient appropriately. She adds extra protection to the arthritic elbow. Because she is conscious of the patient’s need for emotional support, she cautions the staff about excessive noise and lowers the lights. Although Mrs Dexter is drowsy, Elaine shows her the electrocardiograph leads and quietly explains their purpose. She also explains the electrosurgical grounding pad as she places it. Prior to induction, Elaine tells the anesthesiologist about the patient’s left elbow. In addition to describing Mrs Dexter’s apprehension, Elaine relates to him the nursing care she has already provided. She touches Mrs Dexter during induction to give her emotional support and remains at her side to assist with intubation and to act in the event of any unexpected reaction. She believes it is essential to protect Mrs Dexter during the excitement phase. During the procedure, she does more than calculate blood loss. Remembering the range of blood values preopera-
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How was the perioperative role developed? In 1976,the Project 25 Task Force was charged with defining the role of professional operating room nursing, based on the premise that nursing should exercise self-regulationby defining its own practice. Defining the role meant making it clear and distinct,outlining it, and establishing its limits. The Task Force began by finding out what operating room nurses were doing.What kinds of activities were being performed by this person called an “operatingroom nurse?”The Task Force asked practicing AORN members to explain what they did on a day-to-daybasis. They also reviewed published materials such as the “Definition and objective for clinical practice of professional operating room nursing,” published in the November 1969 Journal (43-48), the report by AORN and the Western Interstate Commission for Higher Education, and the AORN Standards of Practice.The group identified the components of nursing practice and developed a definition tively, she anticipates the need for blood replacement and confers with the anesthesiologist. It is decided the patient needs blood, and Elaine sends appropriate personnel to obtain it. When the biopsy report is received and the decision made t o perform a mastectomy, a member of the team goes out to tell Mr Dexter . Monitoring aseptic technique, Elaine is conscious of her own actions as well as those of the other nurses. She realizes she is responsible for monitoring the environment for the safety of the patient. After the procedure, Elaine removes the grounding pad and observes the patient’s skin, as she did at the beginning level. Not only does she plan to accompany Mrs Dexter to the recovery room; she notifies them before leaving that the patient is coming.
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of perioperative nursing practice. The Task Force submitted to the 1978 AORN House of Delegates a report on the perioperative role, which included this basic definition: The perioperative role of the operating room nurse consists of nursing activities performed by the professional operating room nurse during the preoperative, intraoperative,and postoperativephases of the patient’ssurgical experience.Operating room nurses assume the perioperative role at a beginning level dependent on their expertise and competency to practice. As they gain knowledge and skills, they progress on a continuum to an advanced level of practice. The statement and full report were approved by the House of Delegates. (See AORN Journal, May 1978,1156-1175.)In 1978 and 1979,a new task force, Project 26,developed a master plan for implementing the perioperativerole, and these activitiesare now being carried out. (See AORN Journal, February 1979 Pre-Congress, 455-460.)
As she did at the beginning level, Elaine tells the recovery room nurse the patient’s name and type of surgery. But a t this level, she elaborates by describing the extent of the procedure, the operative course, and Mrs Dexter’s preoperative condition, including her level of anxiety. She conveys t o the recovery room nurse the patient’s apprehension about waking up alone and noticing her condition. She also tells the nurse that Mrs Dexter’s husband has been informed about the surgery, in case the patient asks about this after she awakens. After telling the recovery nurse about the wound suction, they both check it for proper drainage. They also check the dressing to assure it is intact and to evaluate bleeding. The side rails are raised to maintain safety during the recovery period. The postoperative evalu-
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ation at this level, as at the first level, includes an evaluation of the arthritic arm. Later, when Mrs Dexter awakens, she asks the recovery room nurse what has happened and learns she has had a mastectomy. At this more advanced level, Elaine also does a postoperative evaluation on the surgical unit to determine if Mrs Dexter was satisfied with care in the operating room. She evaluates the effectiveness of care, such as the status of the patient’s skin and neuromuscular skeletal system. With the unit nurse, Elaine evaluates Mrs Dexter’s arthritic arm and amount of range of motion. Checking with the nurse on continuity of care, Elaine learns the recovery room nurse was at the patient’s side when she awakened and appeared comforted when she learned her husband had been informed immediately after the biopsy report. Together, the two nurses begin discharge planning. Because Mrs Dexter’s swimming classes are important to her self-image, the nurses believe encouraging early activity may enhance her recovery. They decide that as soon as she is ready, Mrs Dexter should receive information about prostheses and postmastectomy exercises. Now that you have read about the second level on the perioperative role continuum, where do you place yourself? The geographic boundaries were expanded to the surgical unit for a more extensive preoperative assessment, enabling the nurse to gather pertinent information that further individualizes the care Mrs Dexter receives in the operating room. But think about it in terms of the advantages t o you. By doing a preoperative assessment, you are able to have the equipment and supplies needed. You know that special care will have to be given Mrs Dexter’s left arthritic arm. It saves time to assess
the situation and plan for how you will do an activity, rather than starting in the middle without knowing the person you are caring for and any of his problems, which may be unique to him. We also expanded the boundaries to incorporate a postoperative followup or evaluation on the unit. Its primary purpose is to evaluate the effectiveness of care given in the operating room. If one goal is to maintain the patient’s skin integrity by proper placement of the electrosurgical grounding pad, then we should follow up to see if that goal was attained. It is not always possible to evaluate the integrity of the skin immediately postoperatively. Sometimes it requires a 24-hour postoperative assessment. With the advent of audits and the pressures for evaluating effectiveness of nursing care, the operating room nurse has little choice but to evaluate. Let’s progress to the next level on the continuum. Elaine now has expanded
Elaine continues her assessment when Mrs Dexter is admitted to the hospital. Here she answers questions from the brochure she gave Mrs Dexter when she came to the clinic for her initial assessment.
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In her postoperative evaluation on the unit, Elaine confers with the nurse about recovery and discharge planning. They begin planning activities to help restore Mrs Dexter’s range of movement and self-image.
the geographic boundaries of her practice to the clinic where Mr and Mrs Dexter have arrived for a preadmission workup. Elaine begins the preoperative assessment. Taking Mrs Dexter’s health history and family background, Elaine learns several facts with psychosocial implications for the care plan. Mrs Dexter has never had major surgery before. Her mother died ten years ago of metastatic cancer originating in the breast, and two of her four aunts have had radical mastectomies. In the clinic interview, Elaine has more time to learn about the couple’s family life. Of the three children, Mrs Dexter expresses special concern about her 12-year-old daughter who has recently reached puberty and is conscious of her own body image. “How much should I tell her?” Mrs Dexter asks. ‘7 believe in being open with the children, but I don’t want to scare her needlessly.” “You should share what you feel comfortable sharing,” Elaine replies. “Perhaps you will want to explain that there’s a possibility of malignancy and
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that you may have to have surgery. You will need to determine how much information is comfortable for her. You may be surprised that she is curious and interested and has a number of questions.” Offering Mrs Dexter a brochure about surgery, Elaine observes that Mrs Dexter is well informed about the disease. But although she has elected to have a total mastectomy with axillary dissection, she confesses she still does not understand clearly how that is different from a radical procedure. After determining what Mrs Dexter learned from her discussion with the physician, Elaine reinforces his discussion by describing that the axillary lymph nodes will be removed but the pectoralis muscles will be preserved. Mr Dexter listens quietly during the interview. Asked if he has questions, he replies, no, that they have discussed the matter at home. Mrs Dexter raises an issue that has been bothering her. “Frankly, I’m worried about how I might look after surgery,” she says. “Men are only human. He hasn’t mentioned this, but I know it worries me.”
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laine confers with the unit nurse about discharge planning.
“Would you like to discuss your feelings about this?” Elaine asks him. “Iwant to do the right thing,” he says. “I know she will need all my love and support after the surgery. It would help me to know more about how the wound will look, so we will both know what to expect. I think I can trust my own reaction more if I have a little more information. Also, I will be able to help the children understand it better.” Elaine replies with a brief description of how the wound will look. “There will be a scar and stitches, as there are with other operations,” she says, “but the wound itself will be clean and dry. If a mastectomy is performed, the breast will not be there. It’s absence may seem stranger to you than the wound.” Elaine observes three patient problems: fear of being anesthetized, concern about loss of a body part, and anxiety about her husband’s and family’s initial response and adjustment to the surgery. For the first problem, she will plan to provide emotional support in the holding area and during induction. She plans t o discuss the second problem with the unit nurse so they can work together to reinforce information about recovery, prostheses, breast reconstruction, clothing, and counseling by Reach to Recovery volunteers. Elaine also plans for activities that may ease the husband’s anxiety during t h e perioperative phase. She tells Mrs Dex-
ter that if a decision is made to perform the mastectomy, she will personally go to the surgical waiting area and inform Mr Dexter about the decision. At the end of the interview, Elaine comments informally that her niece has participated in Mrs Dexter’s swimming program at the YWCA, and she knows it is a fine one. She adds she knows of other postmastectomy patients who are active swimmers. The initial clinic assessment also includes physical problems. Observing limited movement caused by the arthritic elbow, Elaine plans for special measures to protect it intraoperatively. When Elaine learns of Mrs Dexter’s admission to the hospital, she continues data collection to add to the nursing care plan she started in the clinic. She asks if Mrs Dexter has any questions about her hospitalization. Mrs Dexter asks for more information about the recovery period and where her family will be waiting. Elaine reassesses the patient’s arthritic arm to understand more fully the limitation of range of motion and adds more information to the nursing care plan. When Mrs Dexter arrives in the holding area before surgery, she recognizes Elaine and smiles. As in the other phases, it is important that the patient is identified, the consent checked, and the surgical site verified. Aware of Mrs Dexter’s anxiety from the clinic visit, Elaine has arranged to spend a few
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Elaine fully documents intraoperative nursing care and postoperative evaluation.
extra minutes with her in the holding area. Because this is Mrs Dexter’s first major surgery and because of her anxiety, Elaine will make a special point to inform the anesthesiologist of the patient’s emotional status. She will also stay beside her during induction, touching her arm, assisting with intubation, and applying cricoid pressure if necessary. In her intraoperative nursing activities at this higher level of practice, Elaine uses her advanced skills, which are based on experience and decisionmaking ability. She performs some of the same activities she did at the previous levels but with more scope and depth. She not only knows how to perform these activities; she also knows why she is performing them and what the results will be for the patient. Checking the chart in the holding area, she notices Mrs Dexter’s hemoglobin and hematocrit are below normal 812
levels. She discusses the abnormal blood values with the anesthesiologist, and they collaborate about possible blood replacement in the event of a mastectomy. At this level, Elaine continues to do physiological monitoring, but the depth increases as she distinguishes normal and abnormal cardiopulmonary data. She adjusts the ECG monitor to see a more accurate reading, obtains a strip, and makes interpretations. Based on her interpretations, she anticipates and arranges for availability of appropriate medications. Her more complete explanation of the electrosurgical grounding pad and its placement conveys her understanding of the principles of electrical conduction. When the decision is made to perform a mastectomy, Elaine goes to the surgical waiting area to inform Mr Dexter of the decision. She uses this opportunity to offer comfort and support, explaining
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urses must realize they are not confined to the operating room.
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that his reaction to the surgery will be important to his wife’s recovery. She adds there will be a delay before he can see her due to the longer procedure. Elaine continuously monitors a variety of factors influencing physiological status. Noticing the Mayo stand is resting on the patient’s extremities, she takes appropriate action. As she calculates blood loss, her preoperative assessment and increased knowledge enable her to recognize the physiological effects of excessive blood loss. Mrs Dexter could possibly have a failure of the thermoregulatory mechanism, which necessitates Elaine having the blood warmer ready. She sends appropriate personnel to obtain blood. Well in advance of closure, Elaine notifies the recovery room that Mrs Dexter is having a mastectomy. The recovery nurse can then be prepared for the patient’s arrival. Elaine is accountable for a correct sponge count. When a sponge is not found, she initiates a recount, and the sponge is located. If the sponge had not been found, an x-ray would have been taken, and Elaine would have filed an incident report fully describing the situation, which could be used in case of legal action. This reflects her knowledge of medico-legal issues and protects the surgical team and hospital. A t the end of the procedure, she not only assesses the skin in the area of the electrosurgical grounding pad but also fully docu-
ments its position and the skin condition on the intraoperative nursing record. Elaine accompanies Mrs Dexter to the recovery room so she can assist the recovery room nurse in the event of an immediate postoperative complication requiring nursing intervention. Along with the other information she conveys to the recovery room nurse, Elaine discusses the patient’s level of anxiety. She reports that Mr Dexter has been informed about the surgery but that Mrs Dexter has not. She adds that Mrs Dexter does not want to wake up alone and asks the recovery room nurse to try to be at her side when she awakens. After evaluating the arthritic arm, Elaine also inspects the arm on the operative side to evaluate the amount of edema and any signs of cyanosis. She assists the recovery room nurse in raising the side rails and then completes documentation of intraoperative care and immediate postoperative evaluation. The next day, during her postoperative evaluation on the surgical unit, she asks Mrs Dexter if she has any questions about her surgery. She replies that, although she is tired and uncomfortable, she believes her husband is responding well. She adds that in a few days she hopes to be more active in her care and will probably have questions. As Elaine is checking Mrs Dexter’s skin and documenting any adverse effects
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from tape or preparation solution, the patient says she is pleased about the use of her arm on the operative side. After her evaluation, Elaine confers with the unit nurse about recovery and discharge planning. Elaine tells her about Mrs Dexter’s concern about the appearance of the wound and her apprehensions about reactions of her husband and daughter. The two nurses agree the patient should be taught about prosthetic devices and outside resources as soon as possible to reinforce her self-image and desire to return to an active life. When the Dexters return to the clinic for a four-week postoperative followup, Elaine arranges to meet with them. She wants to determine how they have adjusted to the surgery psychologically and the patient’s readiness to resume her activities. Mrs Dexter says it has been difficult to adjust to the loss and apprehension about possible recurrence of the disease. But she says talks with other breast cancer patients have helped. One of the volunteers is also a swimmer and advised Mrs Dexter where to shop for a new bathing suit. She found one that is flattering and has been to the YWCA twice for brief swims. Postoperative exercises are also helping her regain her strength. Judging from her comments, expressions, and relaxed posture, Elaine believes Mrs Dexter is recovering as expected. She reports she is comfortable talking to her husband and children about the surgery. She tells Elaine she has been thinking about breast reconstruction and is ready to begin seriously discussing the possibility with her surgeon and Elaine. During this third description, you again identified nursing functions you are already performing. You may question some, but remember, these are examples given t o demonstrate the perioperative role. All hospitals and
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operating rooms have their own policies and procedures. That does not negate the need for a definition of practice that will include all operating room nurses, regardless of their scope of practice. Nurses who work with patients having surgery need to realize they are not confined to the operating room. Many AORN members work in clinics and make preoperative assessments. They follow the patient through his entire course of illness, commencing with the first visit to the surgeon’s office when the decision is made to have surgery. These nurses are practicing within the scope of the perioperative role. The term perioperative was chosen because it encompasses all three time periods. It is a clear, concise way of incorporating OR nursing activities into one word. My plea is that nurses who care for patients during surgery continue t o increase their performance level as they gain additional knowledge and experience. AORN has delineated a definition of practice for nursing in the operating room. All evidence suggests that you do practice the perioperative role. Notes 1. Patricia Allen, “The perioperative role in practice,” AORN Journaf 29 (February 1979) 264. 2. “Standards of nursing practice,” in AORN Standards of Practice (Denver: Association of Operating Room Nurses, lnc, 1978) section 1, 1-10, 3. “Operating room nursing: Perioperative role,” AORN Journal 27 (May 1978) 11 65. 4. /bid, 1164-1165.
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Survey finds role is being practiced Are registered nurses who work in the operating room doing patient assessments and evaluations before, during, and after surgery? Recently AORN past-presidents, Board members, and national committee chairmen conducted a telephone survey to answer this question. Preoperative. Of the 443 respondents,273 or 61% answered yes, they were doing preoperative assessments. of the 99 who answered no, 9 indicated they had plans to implement an assessment program. There were 46 who said assessments were being done occasionally or selectively-on heart patients, “major” cases, or other specific categories. Five responded that some other category of nurse, such as clinical specialists or recovery room nurses, did the initial assessment. A special observation may be drawn from these results. There were 17 nurses who answered no, they were not doing preoperative assessments, but then clarified their answer by saying, “in the holding area only,” or “only upon admission to the operating room.” These answers should be tallied as yeses. These responses lead to the question, How many of the ‘no’ respondents actually do assessments but answered negatively because they confine their thinking to a location rather than focusing on the activity, which is the assessment no matter where it is performed. Postoperative.Asked whether they perform postoperative evaluations, 188 answered affirmatively, and 183 said no. There were 37 who indicated evaluations were done either selectively or occasionally, again on “major” cases or in specialty areas such as cardiovascular surgery, as cases merited. Seven said other nurses do the evaluation; 19 said audit was the only type of followup; and 9 failed to answer the question. The survey is open to a variety of interpretations, and the results identify a number of new questions. Do practicing nurses in the OR understandthe definition and
Results of telephone survey Do your registered nurses do any kind of patient assessment preoperatively? Yes 273 No 99 Selectively 46 Not OR nurse 5 17 Holding area or OR only Did not answer 3 __ 443 Do your registered nurses do any kind of postoperative assessment? Yes 188 No 183 Selectively 37 Not OR nurse 7 Audit only 19 Did not answer 9 __ 443 scope of practice of the perioperativerole? Are the nursing process componentsassessment and evaluation-universally adopted and incorporated into their practice? Are these activities so inherent in practice that OR nurses fail to recognize they are performing them unless a formal structure is given to the activity? For example, data collection through observation, interviewing, and chart review is so natural to OR nurses that they forget this is a formal part of the nursing process and the perioperative role. The statistics in this report indicate that nurses in the OR are functioning in the perioperative role on a wide scale and that these specific components of the nursing process are being implemented. The study also indicatesthe need for continued efforts in implementing assessment and evaluation, to further make the perioperative role a reality.
Judith Pfister, RN Assistant executive director/ professional
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Perioperative role in three dimensions Julia A Kneedler, RN Do nurses realize the extent to which they are practicing in the perioperative role? Interviews with nurses about the role, published in the Journal during the past year led us to believe they do not. In the February issue, Sharon McFarland was asked if she sees surgical patients before they come to the OR. She replied that she rarely sees patients in the unit due to staffing and time. She went on to say she arranges to do a short preoperative assessment in the holding area with almost every patient, talking with him about his illness, checking for allergies, looking for skin problems, and making sure he is warm and comfortable. She gave examples of how she does assessment, planning, implementation, and evaluation-the four components of the nursing process. But she seemed to believe that t o be practicing i n the AORN Journal, November 1979, V o l 3 0 , N O 5
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Fig 1. The model illustrates that the perioperative role is like the bellows on an old-fashioned camera. At the center are the four components of the nursing process. The “Standards of Nursing Practice: OR” and the perioperative role are merely extensions of the nursing process.
perioperative role, she had to go to the patient unit preoperative1y.l We would like to emphasize that the application of the four components may differ from nurse to nurse and from operating room to operating room. Application may vary during the three phases of surgery and may take place in different geographic areas of the hospital. But that doesn’t mean the perioperative role isn’t being practiced. Contrary to the view of many, the perioperative role statement was not in-
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tended to be new and different. It was intended to be a clear, concise statement of actual practice. AORN has accepted the nursing process as a definition of nursing and used it as the basis for specifically delineating practice i n the operating room. The model of t h e perioperative role depicts the components of the nursing process as its core or base (Fig 1). We believe these four components of the nursing process are the basis for the “Standards of Nursing Practice: OR.”2
AORN Journal, November 1979, V o l 3 0 , No 5
The perioperative role: A continuum /
preoperative assessment homeiclinic preoperative assessment /surgical unit preoperative assessment preoperative surgical suite phase Fig 2
/
i ntraoperative basic competency phase
excellence
postoperative phase recovery room
1 postoperative evaluation surgical unit
\ postoperative evaluation homeiclinicl
As you can see, the Standards reflect the nursing process, but some of the four components have additional parts. For example, assessment has two parts: collecting data and then identifying a nursing diagnosidpatient problem. Planning involves establishing patient goals and an individualized plan of care. The perioperative role uses the same theoretical framework. It involves the same four components as the nursing process. According to the perioperative role statement by the Project 25 Task Force, “The perioperative role of the operating room nurse consists of nursing activities performed by the professional operating room nurse during the preoperative, intraoperative, and postoperative phases of the patient’s surgical e~perience.”~ As the shows,the perioperative role is merely an extension of the nursing Process. Like the bellows of an oldfashioned camera, it expands. Applying the nursing process to the operating room, you still use all the compo-
nents-assessment, planning, implementation, and evaluation. You also have three time periods during which you provide patient care-preoperative, intraoperative, and postoperative. Then you add the environ-
Julia A Kneedler, RN, EdD, is assistant director of education at AORN Headquarters, Denver, She received a BSN from Walls Walls College,College place, Wash, a n MS i n medical-surgical nursing from Loma Linda University, Loma Linda, Calif, and an EdD in adult continuing education from the University of Northern Colorado, Greeley.
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ment where nursing activities occurthe operating room, holding area, surgical unit, and clinic or home. Last, but no less important, are the specific nursing activities, such as positioning patients; doing sponge, needle, and instrument counts; providing emotional support; maintaining an aseptic, controlled environment; identifying the patient, and evaluating the effectiveness of care given in the operating room. (These are examples from the perioperative role ~tatement.~) These many facets have been put together and described succinctly as the perioperative role. You continue t o apply the same principles. But because the scope of your practice has expanded, and you have performed a preoperative assessment, you can individualize care. As a demonstration of the perioperative role in action, the Project 26 Task Force presented a slide program at the 1979 AORN Congress in St Louis. This article is based on that presentation. Focus862
ing on Elaine Patterson, an operating room nurse at St Joseph’s Hospital, Denver, it depicts the perioperative role at three points on a continuum (Fig 2). A staff nurse when this article was written, she is now a cardiovascular team leader. The patient is Mrs Dexter, admitted with a diagnosis of a mass in the right breast. She is scheduled for a right breast biopsy with frozen section and possible mastectomy. This situation illustrates the perioperative role at the first level. When Mrs Dexter arrives in the holding area, Elaine is there to greet her. She has reviewed the chart, making sure the laboratory information and operative consent are present and in order. The patient has her head turned away. Elaine touches her shoulder, and when Mrs Dexter turns toward her, she can see tears in her eyes. “I’m sorry,’’ she says. “I tried not to cry. It’s difficult enough to go under
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Elaine becomes more involved with the patient and family as the geographic boundaries of herpractice expand. At the first level (left), Elaine assesses Mrs Dexter in the holding area. She compares the identification band with the hospital admission form. She expands her practice by going to the unit to perform her assessment (center), where she answers Mrs Dexter’s questions about recovery. Expanding her practice to the clinic (right), Elaine conducts her initial assessment by gathering more data about the patient‘s background and health history. Photographs by Elinor S Schrader. The Journal thanks the staff at St Joseph’s Hospital for their assistance in preparing this article.
anesthesia the first time. But I’ll also be the last to know what is happening to me.” ‘‘It’sall right if you cry,” Elaine says. “It’s understandable that you’re upset. I understand your apprehension about being the last to know. Unfortunately, that is unavoidable. But you can trust that we will do our best for you.” With this brief conversation, Mrs Dexter seems to relax, so Elaine goes on to verify the surgical site. Mrs Dexter nods when Elaine asks if it is the right breast that will be operated on. She also explains that her leR elbow is arthritic and cannot be straightened. Elaine assesses the amount of extension in the joint by observing how far Mrs Dexter can move it comfortably. A preoperative assessment has been done. You may question its depth and the environment where i t occurred. Nevertheless, Elaine has performed an assessment at the beginning level on the perioperative continuum. She is
practicing nursing i n the operating room within the perioperative role definition. The planning phase begins when Elaine assesses Mrs Dexter and starts to individualize her care. For example, Elaine realizes she will need to plan for special padding and extra protection of the arthritic elbow. In the OR, the case is opened and supplies and equipment made ready. In the intraoperative period, the implementation component of the perioperative role begins. Elaine transfers Mrs Dexter to the operating bed. As she works, she explains briefly what is happening to help reduce Mrs Dexter’s anxiety. A warm blanket is placed over her and the safety straps applied to maintain her safety during the procedure. Elaine alerts the patient as she places the electrocardiograph (ECG) leads and the electrosurgical grounding pad. Noticing the armband is on the arm on the operative side of the body, Elaine
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The intraoperative phase. Elaine’s practice increases in scope and depth. At the first level (left), she individualizes care with extra elbow padding. As her practice advances (center), she is aware of the patient‘s needs during the excitement phase, and she anticipates the anesthesiologist’s need for assistance. Elaine has increasing patient contact as her practice progresses. At right, she comforts Mr Dexter in the waiting area after informing him of his wife’s mastectomy.
removes it to the nonoperative arm. Elaine applies protective padding to the arthritic arm before placing it in a functional position for the procedure. Prior to induction, she tells the anesthesiologist about Mrs Dexter’s level of apprehension and her arthritic left arm. Then she stands near Mrs Dexter during induction, providing emotional support and assisting the anesthesiologist. A biopsy is done, and a specimen is sent to the pathology laboratory. When it comes back, the result is positive for malignancy, and the surgeon makes the decision to perform a mastectomy. As the procedure progresses, Elaine monitors the patient’s physiological status by calculating blood loss as she counts sponges. When blood replacement is necessary, Elaine sends other personnel to obtain it. She also controls and maintains an aseptic environment by telling the scrub nurses that a lap sponge hanging off the table is contaminated. At the end of the procedure, Elaine removes the electrosurgical
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grounding pad and assesses the integrity of the patient’s skin in that area. During the intraoperative period, Elaine performed many nursing activities included in the examples in the perioperative role statement. (See AORN Journal, May 1978,1164-1165.) 0 telling the patient what is happening 0 determining psychological status 0 giving prior warning of noxious stimuli 0 standing near or touching the patient during procedures or induction 0 communicating emotional status to other appropriate members of the health care team providing physical safety for the patient maintaining a n aseptic, controlled environment effectively managing human resources Elaine did not have to relearn these functions. She drew on her already ac-
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quired knowledge and skills. For the perioperative role, the only difference is the application of knowledge and skills-in other words, performance. Immediately after the procedure, Elaine accompanies Mrs Dexter to the recovery room. She tells the nurse Mrs Dexter’s name and the type of surgery performed and shows her the wound suction. At this point, Elaine does an immediate evaluation of Mrs Dexter’s arthritic arm to determine if the positioning procedure used in the operating room was effective in protecting her arm from injury. The side rails are raised to maintain safety during the recovery period. Do you perform nursing activities reflecting the scope of the perioperative role (preoperative, intraoperative, and postoperative)? I believe most operating room nurses perform these types of functions daily. You assess the patient before, during, and after surgery. You plan, implement, and evaluate. Do you think you practice the perioperative
role at the level just described? Think about your practice as the next level is described. Make your own decision. At this level, we expand the geographic boundaries. Elaine begins her preoperative assessment on the surgical unit. Reviewing the chart, she learns about the patient’s health history and family background. Mrs Dexter, who is 45, has sons age 17 and 14 and a daughter age 12.Her husband is a bank vicepresident, and she is not employed outside the home. Under family history, Elaine notes that Mrs Dexter’s mother died ten years ago from metastatic cancer originating in the breast. Talking with the unit nurse, she learns that the patient is anxious but wants to be informed about the procedure. She has discussed the disease process with her physician. After being informed of the types of treatment for breast cancer, Mrs Dexter has decided she would prefer the surgeon t o perform a total mastectomy with axillary dissection if a malignancy is found. Active in
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Elaine’s perioperative nursing practice expands during the postoperative phase. At the first level, Elaine’s postoperative evaluation takes place in the recoveryroomwhere she and the recovery room nurse check the wound suction (left). As she progresses, Elaine goes to the unit one day postoperatively to conduct her evaluation with the unit nurse (center). At a higher level of practice, she goes to the clinic four weeks postoperatively for a follow-up evaluation of patient and family (right).
the community, Mrs Dexter is concerned about the length of her recovery and whether a mastectomy would interfere with her activities. She teaches swimming to children at the YWCA and wants to know how long and to what extent mastectomy surgery will limit her activities. After gathering as much information as possible, Elaine goes to Mrs Dexter’s room and introduces herself, By touching Mrs Dexter’s arm, she is able to assess her pulse and skin turgor. As she continues the physical assessment, Elaine is constantly assessing Mrs Dexter’s emotional status. She observes Mrs Dexter is not only anxious about the surgery, but she is also apprehensive about losing a body part and how her family might react. While she is checking the mobility of the patient’s arthritic left elbow, Elaine responds to some of the patient’s questions. Mrs Dexter’s questions about how long the biopsy will take reflects her concern about how long her condition
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will remain unknown and how long her family will be kept waiting. Elaine briefly explains the biopsy process. “If a mastectomy is done, you will probably be back in your room in two or two and one-half hours,” she says, adding that the staff will inform her husband of this. “If I have a mastectomy, will the wound be open and ugly?” she asks. “When I wake up, will I be able to tell what has happened or will someone have to tell me? Will someone be there when I find out what the outcome is, or will I be alone?’ Elaine assures Mrs Dexter that the recovery room nurse will be with her when she awakens. The recovery room nurse will be able to tell her what has been done, and later, the physician will visit her to explain what was done and why. Mrs Dexter then wonders if someone will tell her husband or if she will have to tell him. Elaine replies that a member of the surgical team will go to the waiting area to tell her husband as soon as the results of the biopsy are
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known. She makes a note to inform the recovery room nurse about Mrs Dexter’s anxiety and that her husband will have been informed. Using the nursing care plan developed for patients having breast biopsies with possible mastectomies, Elaine begins to individualize Mrs Dexter’s care. Later, when Mrs Dexter arrives in the holding area, Elaine continues her assessment. She notes that Mrs Dexter is drowsy and does not respond readily to questions. For verifying identification, Elaine compares the armband with the hospital admission form. The surgical site is confirmed by comparing the surgical consent form with the operating room schedule. Elaine then confirms the site with the surgeon. She also reviews the chart and checks laboratory reports and all necessary forms. In the OR, Elaine follows the individualized care plan. As she did at the beginning level, Elaine prepares the operating room and then positions and
pads the patient appropriately. She adds extra protection to the arthritic elbow. Because she is conscious of the patient’s need for emotional support, she cautions the staff about excessive noise and lowers the lights. Although Mrs Dexter is drowsy, Elaine shows her the electrocardiograph leads and quietly explains their purpose. She also explains the electrosurgical grounding pad as she places it. Prior to induction, Elaine tells the anesthesiologist about the patient’s left elbow. In addition to describing Mrs Dexter’s apprehension, Elaine relates to him the nursing care she has already provided. She touches Mrs Dexter during induction to give her emotional support and remains at her side to assist with intubation and to act in the event of any unexpected reaction. She believes it is essential to protect Mrs Dexter during the excitement phase. During the procedure, she does more than calculate blood loss. Remembering the range of blood values preopera-
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How was the perioperative role developed? In 1976,the Project 25 Task Force was charged with defining the role of professional operating room nursing, based on the premise that nursing should exercise self-regulationby defining its own practice. Defining the role meant making it clear and distinct,outlining it, and establishing its limits. The Task Force began by finding out what operating room nurses were doing.What kinds of activities were being performed by this person called an “operatingroom nurse?”The Task Force asked practicing AORN members to explain what they did on a day-to-daybasis. They also reviewed published materials such as the “Definition and objective for clinical practice of professional operating room nursing,” published in the November 1969 Journal (43-48), the report by AORN and the Western Interstate Commission for Higher Education, and the AORN Standards of Practice.The group identified the components of nursing practice and developed a definition tively, she anticipates the need for blood replacement and confers with the anesthesiologist. It is decided the patient needs blood, and Elaine sends appropriate personnel to obtain it. When the biopsy report is received and the decision made t o perform a mastectomy, a member of the team goes out to tell Mr Dexter . Monitoring aseptic technique, Elaine is conscious of her own actions as well as those of the other nurses. She realizes she is responsible for monitoring the environment for the safety of the patient. After the procedure, Elaine removes the grounding pad and observes the patient’s skin, as she did at the beginning level. Not only does she plan to accompany Mrs Dexter to the recovery room; she notifies them before leaving that the patient is coming.
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of perioperative nursing practice. The Task Force submitted to the 1978 AORN House of Delegates a report on the perioperative role, which included this basic definition: The perioperative role of the operating room nurse consists of nursing activities performed by the professional operating room nurse during the preoperative, intraoperative,and postoperativephases of the patient’ssurgical experience.Operating room nurses assume the perioperative role at a beginning level dependent on their expertise and competency to practice. As they gain knowledge and skills, they progress on a continuum to an advanced level of practice. The statement and full report were approved by the House of Delegates. (See AORN Journal, May 1978,1156-1175.)In 1978 and 1979,a new task force, Project 26,developed a master plan for implementing the perioperativerole, and these activitiesare now being carried out. (See AORN Journal, February 1979 Pre-Congress, 455-460.)
As she did at the beginning level, Elaine tells the recovery room nurse the patient’s name and type of surgery. But a t this level, she elaborates by describing the extent of the procedure, the operative course, and Mrs Dexter’s preoperative condition, including her level of anxiety. She conveys t o the recovery room nurse the patient’s apprehension about waking up alone and noticing her condition. She also tells the nurse that Mrs Dexter’s husband has been informed about the surgery, in case the patient asks about this after she awakens. After telling the recovery nurse about the wound suction, they both check it for proper drainage. They also check the dressing to assure it is intact and to evaluate bleeding. The side rails are raised to maintain safety during the recovery period. The postoperative evalu-
AORN Journal, November 1979, V o l 3 0 , N o 5
ation at this level, as at the first level, includes an evaluation of the arthritic arm. Later, when Mrs Dexter awakens, she asks the recovery room nurse what has happened and learns she has had a mastectomy. At this more advanced level, Elaine also does a postoperative evaluation on the surgical unit to determine if Mrs Dexter was satisfied with care in the operating room. She evaluates the effectiveness of care, such as the status of the patient’s skin and neuromuscular skeletal system. With the unit nurse, Elaine evaluates Mrs Dexter’s arthritic arm and amount of range of motion. Checking with the nurse on continuity of care, Elaine learns the recovery room nurse was at the patient’s side when she awakened and appeared comforted when she learned her husband had been informed immediately after the biopsy report. Together, the two nurses begin discharge planning. Because Mrs Dexter’s swimming classes are important to her self-image, the nurses believe encouraging early activity may enhance her recovery. They decide that as soon as she is ready, Mrs Dexter should receive information about prostheses and postmastectomy exercises. Now that you have read about the second level on the perioperative role continuum, where do you place yourself? The geographic boundaries were expanded to the surgical unit for a more extensive preoperative assessment, enabling the nurse to gather pertinent information that further individualizes the care Mrs Dexter receives in the operating room. But think about it in terms of the advantages t o you. By doing a preoperative assessment, you are able to have the equipment and supplies needed. You know that special care will have to be given Mrs Dexter’s left arthritic arm. It saves time to assess
the situation and plan for how you will do an activity, rather than starting in the middle without knowing the person you are caring for and any of his problems, which may be unique to him. We also expanded the boundaries to incorporate a postoperative followup or evaluation on the unit. Its primary purpose is to evaluate the effectiveness of care given in the operating room. If one goal is to maintain the patient’s skin integrity by proper placement of the electrosurgical grounding pad, then we should follow up to see if that goal was attained. It is not always possible to evaluate the integrity of the skin immediately postoperatively. Sometimes it requires a 24-hour postoperative assessment. With the advent of audits and the pressures for evaluating effectiveness of nursing care, the operating room nurse has little choice but to evaluate. Let’s progress to the next level on the continuum. Elaine now has expanded
Elaine continues her assessment when Mrs Dexter is admitted to the hospital. Here she answers questions from the brochure she gave Mrs Dexter when she came to the clinic for her initial assessment.
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In her postoperative evaluation on the unit, Elaine confers with the nurse about recovery and discharge planning. They begin planning activities to help restore Mrs Dexter’s range of movement and self-image.
the geographic boundaries of her practice to the clinic where Mr and Mrs Dexter have arrived for a preadmission workup. Elaine begins the preoperative assessment. Taking Mrs Dexter’s health history and family background, Elaine learns several facts with psychosocial implications for the care plan. Mrs Dexter has never had major surgery before. Her mother died ten years ago of metastatic cancer originating in the breast, and two of her four aunts have had radical mastectomies. In the clinic interview, Elaine has more time to learn about the couple’s family life. Of the three children, Mrs Dexter expresses special concern about her 12-year-old daughter who has recently reached puberty and is conscious of her own body image. “How much should I tell her?” Mrs Dexter asks. ‘7 believe in being open with the children, but I don’t want to scare her needlessly.” “You should share what you feel comfortable sharing,” Elaine replies. “Perhaps you will want to explain that there’s a possibility of malignancy and
am
that you may have to have surgery. You will need to determine how much information is comfortable for her. You may be surprised that she is curious and interested and has a number of questions.” Offering Mrs Dexter a brochure about surgery, Elaine observes that Mrs Dexter is well informed about the disease. But although she has elected to have a total mastectomy with axillary dissection, she confesses she still does not understand clearly how that is different from a radical procedure. After determining what Mrs Dexter learned from her discussion with the physician, Elaine reinforces his discussion by describing that the axillary lymph nodes will be removed but the pectoralis muscles will be preserved. Mr Dexter listens quietly during the interview. Asked if he has questions, he replies, no, that they have discussed the matter at home. Mrs Dexter raises an issue that has been bothering her. “Frankly, I’m worried about how I might look after surgery,” she says. “Men are only human. He hasn’t mentioned this, but I know it worries me.”
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laine confers with the unit nurse about discharge planning.
“Would you like to discuss your feelings about this?” Elaine asks him. “Iwant to do the right thing,” he says. “I know she will need all my love and support after the surgery. It would help me to know more about how the wound will look, so we will both know what to expect. I think I can trust my own reaction more if I have a little more information. Also, I will be able to help the children understand it better.” Elaine replies with a brief description of how the wound will look. “There will be a scar and stitches, as there are with other operations,” she says, “but the wound itself will be clean and dry. If a mastectomy is performed, the breast will not be there. It’s absence may seem stranger to you than the wound.” Elaine observes three patient problems: fear of being anesthetized, concern about loss of a body part, and anxiety about her husband’s and family’s initial response and adjustment to the surgery. For the first problem, she will plan to provide emotional support in the holding area and during induction. She plans t o discuss the second problem with the unit nurse so they can work together to reinforce information about recovery, prostheses, breast reconstruction, clothing, and counseling by Reach to Recovery volunteers. Elaine also plans for activities that may ease the husband’s anxiety during t h e perioperative phase. She tells Mrs Dex-
ter that if a decision is made to perform the mastectomy, she will personally go to the surgical waiting area and inform Mr Dexter about the decision. At the end of the interview, Elaine comments informally that her niece has participated in Mrs Dexter’s swimming program at the YWCA, and she knows it is a fine one. She adds she knows of other postmastectomy patients who are active swimmers. The initial clinic assessment also includes physical problems. Observing limited movement caused by the arthritic elbow, Elaine plans for special measures to protect it intraoperatively. When Elaine learns of Mrs Dexter’s admission to the hospital, she continues data collection to add to the nursing care plan she started in the clinic. She asks if Mrs Dexter has any questions about her hospitalization. Mrs Dexter asks for more information about the recovery period and where her family will be waiting. Elaine reassesses the patient’s arthritic arm to understand more fully the limitation of range of motion and adds more information to the nursing care plan. When Mrs Dexter arrives in the holding area before surgery, she recognizes Elaine and smiles. As in the other phases, it is important that the patient is identified, the consent checked, and the surgical site verified. Aware of Mrs Dexter’s anxiety from the clinic visit, Elaine has arranged to spend a few
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Elaine fully documents intraoperative nursing care and postoperative evaluation.
extra minutes with her in the holding area. Because this is Mrs Dexter’s first major surgery and because of her anxiety, Elaine will make a special point to inform the anesthesiologist of the patient’s emotional status. She will also stay beside her during induction, touching her arm, assisting with intubation, and applying cricoid pressure if necessary. In her intraoperative nursing activities at this higher level of practice, Elaine uses her advanced skills, which are based on experience and decisionmaking ability. She performs some of the same activities she did at the previous levels but with more scope and depth. She not only knows how to perform these activities; she also knows why she is performing them and what the results will be for the patient. Checking the chart in the holding area, she notices Mrs Dexter’s hemoglobin and hematocrit are below normal 812
levels. She discusses the abnormal blood values with the anesthesiologist, and they collaborate about possible blood replacement in the event of a mastectomy. At this level, Elaine continues to do physiological monitoring, but the depth increases as she distinguishes normal and abnormal cardiopulmonary data. She adjusts the ECG monitor to see a more accurate reading, obtains a strip, and makes interpretations. Based on her interpretations, she anticipates and arranges for availability of appropriate medications. Her more complete explanation of the electrosurgical grounding pad and its placement conveys her understanding of the principles of electrical conduction. When the decision is made to perform a mastectomy, Elaine goes to the surgical waiting area to inform Mr Dexter of the decision. She uses this opportunity to offer comfort and support, explaining
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urses must realize they are not confined to the operating room.
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that his reaction to the surgery will be important to his wife’s recovery. She adds there will be a delay before he can see her due to the longer procedure. Elaine continuously monitors a variety of factors influencing physiological status. Noticing the Mayo stand is resting on the patient’s extremities, she takes appropriate action. As she calculates blood loss, her preoperative assessment and increased knowledge enable her to recognize the physiological effects of excessive blood loss. Mrs Dexter could possibly have a failure of the thermoregulatory mechanism, which necessitates Elaine having the blood warmer ready. She sends appropriate personnel to obtain blood. Well in advance of closure, Elaine notifies the recovery room that Mrs Dexter is having a mastectomy. The recovery nurse can then be prepared for the patient’s arrival. Elaine is accountable for a correct sponge count. When a sponge is not found, she initiates a recount, and the sponge is located. If the sponge had not been found, an x-ray would have been taken, and Elaine would have filed an incident report fully describing the situation, which could be used in case of legal action. This reflects her knowledge of medico-legal issues and protects the surgical team and hospital. A t the end of the procedure, she not only assesses the skin in the area of the electrosurgical grounding pad but also fully docu-
ments its position and the skin condition on the intraoperative nursing record. Elaine accompanies Mrs Dexter to the recovery room so she can assist the recovery room nurse in the event of an immediate postoperative complication requiring nursing intervention. Along with the other information she conveys to the recovery room nurse, Elaine discusses the patient’s level of anxiety. She reports that Mr Dexter has been informed about the surgery but that Mrs Dexter has not. She adds that Mrs Dexter does not want to wake up alone and asks the recovery room nurse to try to be at her side when she awakens. After evaluating the arthritic arm, Elaine also inspects the arm on the operative side to evaluate the amount of edema and any signs of cyanosis. She assists the recovery room nurse in raising the side rails and then completes documentation of intraoperative care and immediate postoperative evaluation. The next day, during her postoperative evaluation on the surgical unit, she asks Mrs Dexter if she has any questions about her surgery. She replies that, although she is tired and uncomfortable, she believes her husband is responding well. She adds that in a few days she hopes to be more active in her care and will probably have questions. As Elaine is checking Mrs Dexter’s skin and documenting any adverse effects
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from tape or preparation solution, the patient says she is pleased about the use of her arm on the operative side. After her evaluation, Elaine confers with the unit nurse about recovery and discharge planning. Elaine tells her about Mrs Dexter’s concern about the appearance of the wound and her apprehensions about reactions of her husband and daughter. The two nurses agree the patient should be taught about prosthetic devices and outside resources as soon as possible to reinforce her self-image and desire to return to an active life. When the Dexters return to the clinic for a four-week postoperative followup, Elaine arranges to meet with them. She wants to determine how they have adjusted to the surgery psychologically and the patient’s readiness to resume her activities. Mrs Dexter says it has been difficult to adjust to the loss and apprehension about possible recurrence of the disease. But she says talks with other breast cancer patients have helped. One of the volunteers is also a swimmer and advised Mrs Dexter where to shop for a new bathing suit. She found one that is flattering and has been to the YWCA twice for brief swims. Postoperative exercises are also helping her regain her strength. Judging from her comments, expressions, and relaxed posture, Elaine believes Mrs Dexter is recovering as expected. She reports she is comfortable talking to her husband and children about the surgery. She tells Elaine she has been thinking about breast reconstruction and is ready to begin seriously discussing the possibility with her surgeon and Elaine. During this third description, you again identified nursing functions you are already performing. You may question some, but remember, these are examples given t o demonstrate the perioperative role. All hospitals and
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operating rooms have their own policies and procedures. That does not negate the need for a definition of practice that will include all operating room nurses, regardless of their scope of practice. Nurses who work with patients having surgery need to realize they are not confined to the operating room. Many AORN members work in clinics and make preoperative assessments. They follow the patient through his entire course of illness, commencing with the first visit to the surgeon’s office when the decision is made to have surgery. These nurses are practicing within the scope of the perioperative role. The term perioperative was chosen because it encompasses all three time periods. It is a clear, concise way of incorporating OR nursing activities into one word. My plea is that nurses who care for patients during surgery continue t o increase their performance level as they gain additional knowledge and experience. AORN has delineated a definition of practice for nursing in the operating room. All evidence suggests that you do practice the perioperative role. Notes 1. Patricia Allen, “The perioperative role in practice,” AORN Journaf 29 (February 1979) 264. 2. “Standards of nursing practice,” in AORN Standards of Practice (Denver: Association of Operating Room Nurses, lnc, 1978) section 1, 1-10, 3. “Operating room nursing: Perioperative role,” AORN Journal 27 (May 1978) 11 65. 4. /bid, 1164-1165.
AORN Journal, November 1979, Vol30, No 5
Survey finds role is being practiced Are registered nurses who work in the operating room doing patient assessments and evaluations before, during, and after surgery? Recently AORN past-presidents, Board members, and national committee chairmen conducted a telephone survey to answer this question. Preoperative. Of the 443 respondents,273 or 61% answered yes, they were doing preoperative assessments. of the 99 who answered no, 9 indicated they had plans to implement an assessment program. There were 46 who said assessments were being done occasionally or selectively-on heart patients, “major” cases, or other specific categories. Five responded that some other category of nurse, such as clinical specialists or recovery room nurses, did the initial assessment. A special observation may be drawn from these results. There were 17 nurses who answered no, they were not doing preoperative assessments, but then clarified their answer by saying, “in the holding area only,” or “only upon admission to the operating room.” These answers should be tallied as yeses. These responses lead to the question, How many of the ‘no’ respondents actually do assessments but answered negatively because they confine their thinking to a location rather than focusing on the activity, which is the assessment no matter where it is performed. Postoperative.Asked whether they perform postoperative evaluations, 188 answered affirmatively, and 183 said no. There were 37 who indicated evaluations were done either selectively or occasionally, again on “major” cases or in specialty areas such as cardiovascular surgery, as cases merited. Seven said other nurses do the evaluation; 19 said audit was the only type of followup; and 9 failed to answer the question. The survey is open to a variety of interpretations, and the results identify a number of new questions. Do practicing nurses in the OR understandthe definition and
Results of telephone survey Do your registered nurses do any kind of patient assessment preoperatively? Yes 273 No 99 Selectively 46 Not OR nurse 5 17 Holding area or OR only Did not answer 3 __ 443 Do your registered nurses do any kind of postoperative assessment? Yes 188 No 183 Selectively 37 Not OR nurse 7 Audit only 19 Did not answer 9 __ 443 scope of practice of the perioperativerole? Are the nursing process componentsassessment and evaluation-universally adopted and incorporated into their practice? Are these activities so inherent in practice that OR nurses fail to recognize they are performing them unless a formal structure is given to the activity? For example, data collection through observation, interviewing, and chart review is so natural to OR nurses that they forget this is a formal part of the nursing process and the perioperative role. The statistics in this report indicate that nurses in the OR are functioning in the perioperative role on a wide scale and that these specific components of the nursing process are being implemented. The study also indicatesthe need for continued efforts in implementing assessment and evaluation, to further make the perioperative role a reality.
Judith Pfister, RN Assistant executive director/ professional
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