The surgical team consists of the surgeon, one or more surgical assistants, the anesthesia provider, and the OR nursing staff. Perioperative, or OR, nurses include the holding area nurse, circulating nurse, scrub nurse or a non-nurse “scrub person,” and specialty nurse. The number of assistants, circulating nurses, and scrub nurses depends on the complexity and projected length of the surgical procedure. For some minor procedures, only a circulating nurse and scrub person may be needed in addition to the surgeon. More complex procedures may require additional nursing staff to either circulate or scrub.
Perioperative Nursing Staff
Perioperative, or OR, staff have several roles during surgery, depending on their education, experience, skill, and job responsibilities. Regardless of their role, the OR nurse uses clinical decision-making skills, develops a plan of nursing care, and coordinates care delivery to patients and their family members.
Holding area nurses work in those operating suites that have a presurgical holding area next to the main ORs. The patient waits in this area until the OR is ready. The holding area nurse coordinates and manages the care while the patient is in this area. Responsibilities include greeting the patient on arrival, reviewing the medical record and preoperative checklist, verifying that the operative consent forms are signed, and documenting the risk assessment (Fig. 17-1). This nurse also assesses the patient’s physical and emotional status, gives emotional support, answers questions, and provides additional education as needed.
The holding area is busy, with many staff members performing different procedures before surgery (e.g., starting IV lines, inserting epidural catheters). The holding area nurse promotes an atmosphere of comfort, privacy, and confidentiality. Depending on the facility’s policy, family members may wait with the patient.
Circulating nurses or “circulators” are registered nurses who coordinate, oversee, and are involved in the patient’s nursing care in the OR. The circulating nurse’s actions are vital to the smooth flow of events before, during, and after surgery. He or she is responsible for coordinating all activities within that particular OR. The circulator sets up the OR and ensures that supplies, including blood products and diagnostic support, are available as needed. All anticipated equipment is gathered and inspected by the circulator to make certain that it is safe and functional before the surgery. Depending on the procedure and position required, the circulator makes up the operating bed (OR table) with gel pads (to prevent pressure ulcers), safety straps and armboards (for patient positioning), and either heating pads under the sheets or disposable warming blankets placed over the patient as indicated (to prevent hypothermia) (Weirich, 2008).
If there is no holding area nurse, the circulator assumes the responsibilities of that nursing role as well. Even when there is a holding area nurse, The Joint Commission’s National Patient Safety Goals (NPSGs) require that the circulator also greets the patient and reviews findings with the holding area nurse.
Once the patient is ready to be moved into the OR, the circulating nurse, along with the OR team, assists the patient in transferring to the operating bed. The nurse positions the patient, protecting bony areas with extra padding while providing comfort and reassurance. While observing the patient, the circulating nurse also assists the anesthesia provider with the induction of anesthesia by positioning the patient and applying cricoid pressure, when requested. The circulator then may assist with additional positioning, insert a Foley catheter if needed, apply the grounding pad, test equipment, and “prep” (scrub) the surgical site before the patient is draped with sterile drapes.
Throughout the surgery, the circulating nurse:
Depending on facility policy, the circulating nurse may record drugs, blood, and blood components given. (This also may be a function of the anesthesia provider.)
Before the procedure is over, the circulating nurse completes documentation in the OR and nursing records, including the presence of drains or catheters, the length of the surgery, and a count of all sponges, “sharps” (needles, blades), and instruments. He or she notifies the postanesthesia care unit (PACU) of the patient’s estimated time of arrival and any special needs.
Scrub nurses or scrub persons set up the sterile table (Fig. 17-2), drape the patient, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Knowledge of the surgical procedure allows the scrub person to anticipate which instruments and types of sutures the surgeon will need. Anticipating these needs reduces the duration of anesthesia for the patient. In addition, the surgeon’s anxiety and tension are reduced when the scrub nurse or person is familiar with the procedure and can anticipate and respond accordingly. Throughout the surgical procedure, the scrub person (with the circulating nurse) maintains an accurate count of sponges, sharps, and instruments and amounts of irrigation fluid and drugs used.
A specially trained person who is not a nurse may perform the scrub role. Such people are called operating room technicians (ORTs) or surgical technologists. Often certified surgical technologists (CSTs) are used in the OR.
Specialty nurses may be in charge of a particular type of surgical specialty (e.g., orthopedic, cardiac, ophthalmologic) and are responsible for nursing care specific to patients needing that type of surgery. The specialty nurse assesses, maintains, and recommends equipment, instruments, and supplies used in that specialty.
If the facility uses laser technology, a nurse specially trained in the use, care, and maintenance of the laser is needed. He or she may be called a laser specialty nurse or a laser nurse coordinator. (Laser is an acronym for light amplification by the stimulated emission of radiation.) A laser gives off a high-powered beam of light that cuts tissue more cleanly than do scalpel blades. This process creates intense heat, rapidly clots blood vessels or tissue, and turns target tissue (e.g., a tumor) into vapor. All personnel must observe safety measures (e.g., wear eye shields, read door signs) during laser procedures to prevent injury to the patient and staff (AORN, 2010h).
Psychosocial Integrity
The client brought to the holding area before surgery tells the nurse he has never had surgery before and is afraid of anything “medical.” Which nursing action is most likely to reduce this client’s anxiety?