- Malignant hyperthermia (MH)
- A rare, inherited pharmacogenetic hypermetabolic crisis of skeletal muscle triggered by certain anesthetics.
- ASA I
- A normal healthy patient (non-smoking, no or minimal alcohol use).
- ASA II
- Mild systemic disease without substantive functional limitation (current smoker, social drinker, pregnancy, obesity BMI 30–40, well-controlled diabetes or hypertension).
- ASA III
- Severe systemic disease with substantive functional limitation (poorly controlled diabetes or hypertension, COPD, morbid obesity BMI of 40 or higher, ESRD on scheduled dialysis, MI/CVA/stents more than 3 months ago).
- ASA IV
- Severe systemic disease that is a constant threat to life (recent <3-month MI/CVA/stents, sepsis, DIC, ESRD not on scheduled dialysis).
- ASA V
- A moribund patient not expected to survive without the operation (ruptured AAA, massive trauma, intracranial bleed with mass effect).
- ASA VI
- A declared brain-dead patient whose organs are being removed for donation.
- ASA "E" suffix
- Added for an emergency procedure where delay would increase the threat to life or body part (e.g., ASA III E).
- Who assigns the ASA class
- The anesthesia provider; the perioperative nurse must recognize each class but does not assign it.
- NPO — clear liquids
- Minimum 2 hours' fasting (water, pulp-free juice, clear tea, black coffee, carbonated beverages).
- NPO — breast milk
- Minimum 4 hours' fasting.
- NPO — infant formula
- Minimum 6 hours' fasting.
- NPO — nonhuman milk
- Counts as a solid; minimum 6 hours' fasting.
- NPO — light meal
- Minimum 6 hours' fasting (toast plus a clear liquid).
- NPO — fried/fatty/full meal
- Minimum 8 hours or more of fasting.
- NPO memory anchor (2-4-6-8)
- 2 h clear liquids, 4 h breast milk, 6 h formula/nonhuman milk/light meal, 8 h fatty or full meal.
- Carbohydrate clear liquids (2023 update)
- Allowed up to 2 hours before surgery (up to ~400 mL) to support enhanced recovery (ERAS).
- Chewing gum before surgery
- Does NOT require canceling or delaying an elective procedure after the gum is removed (2023 ASA update).
- Normothermia range
- 36.0–38.0°C (96.8–100.4°F).
- Hypothermia definition
- Core temperature below 36°C.
- Consequences of hypothermia
- Increased surgical site infection, coagulopathy/bleeding, delayed drug metabolism and emergence, shivering (increased oxygen consumption), cardiac morbidity, and prolonged PACU stay.
- Active warming methods
- Forced-air warming (primary), warmed IV/irrigation fluids, conductive resistive blankets, and warmed humidified gases.
- Latex allergy highest-risk group
- Patients with spina bifida / myelomeningocele.
- Latex cross-reactive foods
- Banana, avocado, kiwi, chestnut, and papaya ("latex-fruit syndrome").
- Latex-allergic patient scheduling
- Schedule as the first case of the day to minimize aeroallergen exposure (latex-safe environment).
- First-line drug for intraoperative anaphylaxis
- Epinephrine.
- Surgical site marking
- The surgeon marks the correct site with the patient awake and participating when possible (Universal Protocol).
- Hair removal method
- Clip with clippers (not razors), only if necessary, immediately before surgery, to reduce surgical site infection risk.
- Braden Scale
- Validated pressure-injury risk tool; subscales are sensory perception, moisture, activity, mobility, nutrition, and friction/shear — a LOWER score means higher risk.
- Surgery duration pressure-injury threshold
- Procedures longer than 3 hours markedly increase pressure-injury risk.
- Caprini score
- A venous thromboembolism (VTE) risk-assessment tool (age, surgery type, BMI, malignancy, prior VTE, hypercoagulability, immobility).
- SCD application timing
- Mechanical prophylaxis (sequential compression devices) should be applied before induction of anesthesia for benefit.
- Fall risk tools
- Morse Fall Scale and Hendrich II.
- Bleeding-risk herbals ("4 G's")
- Garlic, ginger, ginkgo, and ginseng (plus vitamin E and fish oil).
- Metformin perioperatively
- Hold per protocol (contrast and lactic-acidosis concern).
- Beta-blockers perioperatively
- Generally continue; do NOT abruptly stop.
- Aldrete score parameters
- Activity, Respiration, Circulation, Consciousness, and Oxygen saturation — each scored 0–2.
- Aldrete maximum score
- 10.
- Aldrete discharge threshold
- A score of 9 or higher indicates readiness for Phase I discharge.
- Aldrete activity = 2
- Moves all four extremities voluntarily or on command.
- Aldrete circulation = 2
- Blood pressure within 20 mmHg above or below of the preanesthetic baseline.
- Aldrete oxygen saturation = 2
- SpO₂ greater than 92% on room air.
- PADSS
- Post Anesthesia Discharge Scoring System for Phase II / ambulatory discharge home (vital signs, ambulation, nausea/vomiting, pain, surgical bleeding).
- PACU priority sequence
- ABC — Airway and Breathing first, then Circulation and hemodynamics, then neuro/consciousness.
- Apfel score (PONV)
- Female sex, nonsmoker, history of PONV or motion sickness, and postoperative opioids — each worth 1 point.
- PACU urine output goal
- At least 0.5 mL/kg/hr.
- Components of a nursing diagnosis
- Problem (label) + etiology (related to) + defining characteristics (as evidenced by); for risk diagnoses, risk factors replace defining characteristics.
- Pediatric heat loss
- A high surface-area-to-mass ratio causes rapid heat loss and high hypothermia risk.
- Pregnant patient positioning
- Left uterine displacement / left lateral tilt after about 20 weeks to prevent aortocaval compression.
- Pregnant patient aspiration risk
- Treat as a "full stomach" (delayed gastric emptying, decreased lower-esophageal-sphincter tone).
- Bariatric/obese OSA screen
- The STOP-BANG questionnaire.
- Preoperative pregnancy screening
- Screen all women of childbearing potential per facility policy; elective surgery is generally deferred in pregnancy when possible.
- PNDS
- Perioperative Nursing Data Set — AORN's standardized perioperative nursing vocabulary.
- PNDS recognition milestone
- The first nursing specialty language recognized by the American Nurses Association (ANA).
- PNDS structure
- Standardized nursing diagnoses + interventions + nurse-sensitive patient outcomes.
- PNDS purpose
- Standardize and make perioperative care measurable, supporting electronic documentation, data aggregation, research, benchmarking, and quality improvement.
- PNDS Domain 1
- Safety (free from injury, positioning, retained items, infection prevention).
- PNDS Domain 2
- Physiologic responses (fluid/electrolyte/thermal balance, tissue perfusion, cardiac and respiratory status).
- PNDS Domain 3
- Behavioral responses — knowledge/psychosocial and rights/ethics (understanding, coping, informed consent, autonomy).
- PNDS Health System domain
- Administrative and structural data supporting safe, efficient care delivery.
- Nursing process steps
- Assessment → Nursing Diagnosis → Outcome Identification → Planning → Implementation → Evaluation.
- Characteristics of a good outcome
- Patient-centered, realistic, measurable, and time-bound (SMART); it describes the patient's state, not the nurse's task.
- Prioritization framework
- Maslow / ABCs — airway, breathing, circulation first, then safety, then psychosocial.
- Actual vs. risk problems
- Actual problems generally come before risk problems, but a high-probability, high-severity risk (e.g., MH-susceptible patient, fire risk) can take top priority.
- Four elements of valid informed consent
- Disclosure, comprehension, voluntariness, and competence/capacity.
- Who obtains informed consent
- The surgeon or provider performing the procedure (discloses risks, benefits, and alternatives).
- Nurse's role in consent
- Witness the signature, verify the consent is complete and accurate, confirm the patient appears to understand, advocate, and notify the provider if questions arise.
- Implied consent
- Used in a true emergency when the patient cannot consent and delay would threaten life or limb.
- Perioperative DNR rule
- A DNR is NOT automatically suspended for surgery; it must be discussed and a documented decision made ("required reconsideration").
- Jehovah's Witness consideration
- Respect a documented refusal of blood products; plan acceptable alternatives such as cell salvage.
- WHO Surgical Safety Checklist
- Sign In (before anesthesia), Time Out (before incision), and Sign Out (before the patient leaves the room).
- Verify consent timing
- Before sedation or premedication when possible (a capacity concern) and again as part of the time-out.
- Ulnar nerve injury
- The most common perioperative peripheral nerve injury — from elbow flexion plus forearm pronation or pressure at the medial epicondyle, causing "claw hand" and 4th/5th-digit sensory loss.
- Brachial plexus injury
- From arm abduction beyond 90°, shoulder braces, head rotation, or steep Trendelenburg — causing a "waiter's tip" deformity and arm weakness.
- Radial nerve injury
- From compression at the humerus (arm against the table edge, a BP cuff) — causing wrist drop.
- Common peroneal (fibular) nerve injury
- From lateral knee compression in the lithotomy or lateral position — causing foot drop.
- Sciatic nerve injury
- From excessive hip flexion or external rotation in lithotomy — causing a posterior leg and foot deficit.
- Saphenous nerve injury
- From medial knee compression against a stirrup in lithotomy — causing medial leg and foot sensory loss.
- Femoral nerve injury
- From excessive hip flexion/abduction or retractor pressure — causing quadriceps weakness and loss of knee extension.
- Arm abduction limit
- Keep arms abducted to 90° or less on arm boards.
- Arm board palm position
- Palms supinated (up) to offload the ulnar nerve.
- Shoulder braces in steep Trendelenburg
- NOT recommended — compression over the acromion can injure the brachial plexus; use non-sliding surfaces instead.
- Supine position
- The most common position; used for abdominal, cardiac, general/vascular, breast, hernia, and ENT surgery.
- Supine high-risk pressure sites
- The occiput and the heels (offload or float the heels).
- Trendelenburg position
- Head down; for lower-abdomen, pelvic, and robotic prostate/gyn surgery; increases ICP, IOP, and CVP, with a risk of endotracheal tube migration and facial/laryngeal edema.
- Steep Trendelenburg risk
- Postoperative vision loss (POVL), brachial plexus injury from sliding, and aspiration.
- Reverse Trendelenburg position
- Head up; for head/neck, thyroid, upper-abdomen, and shoulder surgery; decreases venous return (hypotension) and increases leg VTE risk.
- Lithotomy position
- For GYN, GU, perineal, rectal, and urologic surgery; raise and lower BOTH legs simultaneously and slowly with two people.
- Well-leg compartment syndrome
- A risk with prolonged lithotomy (more than 2–4 hours); periodically lower the legs.
- Prone position signature risk
- POVL / ischemic optic neuropathy — the eyes must be free of all pressure.
- Prone abdomen support
- Chest rolls/bolsters free the abdomen to allow diaphragm movement and reduce venous congestion and blood loss.
- Lateral position axillary roll
- Placed just caudad to the dependent axilla (NOT in the axilla) to offload the dependent brachial plexus and axillary vessels.
- Fowler/sitting/beach-chair risk
- Venous air embolism (VAE) when the surgical site is above the level of the heart.
- Jackknife (Kraske) position
- A modified prone position for anorectal procedures; the hips are flexed over a table break with the head and feet lower than the hips.
- Universal Protocol components
- (1) Pre-procedure verification, (2) marking the operative site, and (3) the time-out.
- Two patient identifiers
- Required to verify the correct patient (e.g., name plus date of birth) — never the room number alone.
- Site marking rule
- Mark when more than one site is possible (laterality, multiple structures, spinal levels), by the licensed practitioner who will be present, with the patient involved, using an unambiguous mark visible after prep and draping.
- Time-out timing
- Immediately before incision or the start of the procedure; the entire team actively participates and stops non-critical activity.
- Time-out verifies
- Correct patient identity, correct procedure, and correct site/side — plus position, implants/equipment, images, antibiotic prophylaxis, and a fire-risk assessment.
- Items counted
- Soft goods/sponges, sharps (needles, blades), instruments, and miscellaneous small items (vessel loops, clips, bovie-tip cleaners).
- Count #1 (initial)
- The baseline count performed before the procedure begins.
- Count before cavity-within-cavity closure
- Performed before closing one cavity inside another (e.g., the uterus before the peritoneum).
- Count at wound closure
- Performed before wound closure begins.
- Count at skin closure
- The final count at the end of the procedure.
- Count at staff relief
- A handoff count at any permanent relief of the scrub person or the RN circulator.
- Who performs the count
- Two people — one of whom is the RN circulator — together with the scrub person.
- How counts are performed
- Concurrently, audibly, and visually, separating and counting each item in a logical, consistent sequence.
- Count discrepancy first action
- Inform the surgeon immediately and suspend closure if feasible.
- Count discrepancy steps
- Inform the surgeon → recount → search (wound, field, drapes, floor, kick buckets, trash, linen, under the table) → obtain an intraoperative radiograph → document everything.
- Most commonly retained surgical item
- A soft-good sponge.
- Retained surgical item (RSI) classification
- A "never event" (CMS non-reimbursable) and a Joint Commission sentinel event.
- RSI adjunct technologies
- Radiofrequency (RF) detection, bar-coded sponge systems, and intraoperative radiography — they supplement, not replace, the manual count.
- Fire triangle — oxidizer
- Oxygen and nitrous oxide — owned by the anesthesia professional.
- Fire triangle — ignition source
- The ESU/electrocautery, lasers, light cords, and drills — owned by the surgeon.
- Fire triangle — fuel
- Alcohol-based prep, drapes, sponges, gowns, hair, and the ETT — managed by the RN circulator and team.
- Most common OR fire location
- Airway and head-and-neck fires in an oxygen-enriched environment under the drapes (often during MAC with supplemental oxygen).
- Open oxygen delivery goal
- Use the lowest effective FiO₂; aim below 30% oxygen when possible for open delivery.
- Alcohol prep dry time
- Allow alcohol-based prep to dry fully (typically 3 minutes or more, longer in hair) before draping or incision.
- Fire on the patient — response
- STOP the procedure → remove the burning material and extinguish → stop the flow of oxidizing gases → care for the patient → remove drapes and inspect.
- Airway fire — response
- Stop the gases and disconnect the circuit, remove the ETT, pour saline, then re-establish ventilation.
- RACE
- Rescue, Alarm, Contain, Extinguish/Evacuate (room fire response).
- PASS
- Pull the pin, Aim at the base, Squeeze, Sweep (fire-extinguisher use).
- OR fire-extinguisher type
- CO₂ (clean, no residue) is common; a Class C or ABC extinguisher is appropriate for electrical fires.
- ESU monopolar current path
- Active electrode → patient → dispersive (return) electrode → generator.
- Dispersive electrode placement
- On clean, dry, well-vascularized muscle mass close to the surgical site; avoid bony prominences, scar, hair, implants, and tattoos; ensure full uniform contact.
- REM / CQM
- Return-electrode monitoring / Contact Quality Monitoring — deactivates the ESU if pad contact is inadequate, preventing burns.
- Bipolar ESU
- Current flows only between the forceps tines; no dispersive pad is needed; safer near delicate or neural tissue and implanted devices.
- Surgical smoke hazards
- Toxic gases, bioaerosols, viable cells, blood fragments, and viruses (e.g., HPV).
- Smoke evacuator distance
- Hold the capture inlet 2 inches (about 5 cm) or less from the source; use a ULPA filter.
- Masks vs. surgical plume
- Standard surgical masks do NOT protect against ultrafine plume particulates — smoke evacuation is the primary control.
- Tourniquet pressure — upper extremity
- Approximately 200 mmHg in a normotensive average-build patient; best set from Limb Occlusion Pressure (LOP) plus a margin.
- Tourniquet pressure — lower extremity
- Approximately 250 mmHg; best set from Limb Occlusion Pressure (LOP) plus a margin.
- Tourniquet time — upper extremity
- About 60 minutes maximum guidance.
- Tourniquet time — lower extremity
- About 90 minutes maximum guidance.
- Tourniquet reperfusion
- Deflate for about 10–15 minutes for reperfusion before reinflating; document inflation, deflation, and total time.
- Laser Safety Officer (LSO)
- A designated person who posts warning signs, controls room access, and covers windows.
- Laser eye protection
- Wavelength-specific eye protection for everyone in the nominal hazard zone, including the patient.
- ALARA
- As Low As Reasonably Achievable — the radiation-safety principles of Time, Distance, and Shielding.
- Inverse-square law (radiation)
- Doubling the distance from the source quarters the dose.
- Preferred skin prep agent
- Alcohol-based chlorhexidine gluconate (CHG) for most intact skin.
- Skin prep technique
- From the incision site outward to the periphery; the most contaminated area is prepped last.
- Draping rule
- Apply drapes from the prepped (sterile) site outward; never reposition a drape once it is placed.
- Strike-through
- Moisture wicking from non-sterile to sterile, which contaminates the field.
- Medication labeling on the field
- Label ALL medications and solutions on and off the sterile field — including saline and water — even if only one is in use.
- Medication verification on the field
- Name and concentration verified aloud and visually (read-back) between the RN circulator and the scrub person; high-alert meds verified by two people.
- Specimen verification at the field
- The surgeon states the specimen name, site/laterality, and any special instructions; the scrub person and circulator confirm aloud (read-back).
- Specimen labeling
- Label the container (not just the lid) with two patient identifiers, the source/site/laterality, and the tests requested.
- Formalin specimen handling
- Routine permanent specimens go in 10% formalin; do NOT put cultures or frozen-section/special specimens in formalin.
- EBL — sponge weight
- 1 gram is approximately equal to 1 mL of blood.
- EBL — suction calculation
- Suction-canister volume minus the irrigation used.
- Blood product verification
- Two-person verification (two identifiers, unit number, ABO/Rh, expiration).
- Pneumoperitoneum pressure
- Intra-abdominal CO₂ pressure is typically about 12–15 mmHg.
- Robotic docked-patient rule
- The patient is inaccessible once docked — rehearse emergent undocking for codes and conversions.
- Capacitive coupling
- An MIS electrosurgery hazard where current transfers through intact insulation to adjacent conductive instruments or tissue — keep the active tip in view and use the lowest effective settings.
- Insulation failure (MIS)
- A break in the laparoscopic instrument insulation that can cause out-of-view thermal injury — inspect insulation before use.
- RN circulator requirement
- One perioperative RN circulator dedicated to each patient for the entire duration of every operative procedure.
- Circulating role delegation
- CANNOT be delegated to unlicensed personnel — it requires independent nursing knowledge, skill, and judgment.
- RN circulator core duties
- Patient advocacy, preoperative verification, the time-out, sterile-field surveillance, counts, documentation, and specimen/medication/equipment management.
- Scrub role personnel
- May be filled by a perioperative RN, an LPN/LVN, or a Surgical Technologist (CST/ST).
- RN scrub rule
- When an RN is in the scrub role, a separate RN must be in the circulating role.
- LPN/ST scrub supervision
- An LPN or surgical tech in the scrub role works under the supervision of the RN circulator (delegated and supervised).
- RNFA
- RN First Assistant — a perioperative RN with additional formal education who assists the surgeon (tissue handling, retraction, hemostasis, suturing, closure).
- RNFA concurrent-role rule
- The RNFA does NOT concurrently function as the scrub person or the circulator — it is a distinct, dedicated role.
- Scope-of-practice authority
- Defined by the state Nurse Practice Act (NPA) and Board of Nursing — not by facility convenience or surgeon preference.
- Delegation accountability
- Delegation transfers the task, not the accountability — the RN remains accountable for the outcome.
- What cannot be delegated
- The nursing process — assessment, nursing diagnosis, planning, evaluation, patient teaching — and the circulating role.
- Five Rights of Delegation
- Right task, right circumstance, right person, right direction/communication, and right supervision/evaluation.
- Case cart
- A closed, covered cart pre-assembled per the surgeon's preference card with the sterile instruments, supplies, and equipment for a specific case, delivered from Sterile Processing.
- Preference card
- Drives case-cart contents; keep it accurate and updated to reduce waste and missing items.
- Instrument life cycle
- Decontamination → inspection/assembly → packaging → sterilization → storage → case cart → OR → return to decontamination.
- Cost-effective resource use
- Open only what is needed — opened and unused sterile supplies are a major waste driver.
- Single-use device reprocessing
- Permitted only through FDA-cleared third-party reprocessors.
- Device adverse-event reporting
- Reportable under the Safe Medical Devices Act / FDA MedWatch / MDR — preserve the device and packaging for investigation.
- OR temperature range
- About 68–75°F (20–24°C).
- OR relative humidity range
- Generally about 20–60%.
- OR air pressure
- Positive pressure (air flows out of the OR).
- OR air changes per hour
- At least 20 total ACH (the current new-construction standard); legacy ORs may operate at 15 ACH.
- OR traffic zones
- Unrestricted → semi-restricted → restricted; masks are required in restricted areas with open sterile supplies.
- NFPA 99
- Governs OR electrical-equipment safety — biomedical inspection, preventive maintenance, and electrical-safety testing.
- Documentation principle
- "If it was not documented, it was not done."
- Documentation qualities
- Accurate, complete, legible, objective, timely, and contemporaneous.
- Late-entry rule
- Label it as a late entry with the actual date and time; never backdate, erase, or obliterate.
- Paper-chart error correction
- Draw a single line through the error with your initials and the date; the original must remain readable.
- Implant documentation
- Record the type, manufacturer, lot/serial number, size, expiration, and location of placement (bidirectional traceability per FDA/AATB/TJC).
- Count documentation
- Items counted, number of counts, names/roles of the counters, count results (correct or incorrect), and the actions taken for an incorrect count.
- Positioning documentation
- Position used, devices and padding, safety-strap location, arm-board angle (90° or less), and the skin/pressure-point assessment before and after.
- ESU documentation
- Generator settings, dispersive-pad placement site, and the skin condition under the pad before and after.
- Tourniquet documentation
- Cuff location, cuff pressure, inflation and deflation times (total tourniquet time), and the skin assessment before and after.
- Hand-off communication risk
- TJC identifies ineffective hand-off communication as a leading root cause of sentinel events.
- SBAR — Situation
- Patient name, the procedure performed, the surgeon, and current status.
- SBAR — Background
- Pertinent history, allergies, relevant labs, baseline status, and anesthesia type.
- SBAR — Assessment
- Intraoperative events (EBL, fluids/blood, urine output), airway/anesthesia status, drains and lines, the count outcome, and antibiotics given with the time.
- SBAR — Recommendation
- Postoperative orders, the pain plan, monitoring needs, the surgeon's instructions, who to call, and anticipated problems.
- Safe hand-off practices
- Face-to-face and interactive with read-back/verification, minimized interruptions, a standardized tool, and documentation of the hand-off.
- OR-to-PACU report
- Given jointly by the circulating RN and the anesthesia provider.
- Who obtains informed consent (legal duty)
- The physician/surgeon (and the anesthesia provider for anesthesia) — a non-delegable duty.
- Witnessing a signature attests
- That the patient is the signer, signed voluntarily, and appears to have capacity — NOT that the patient understood every clinical detail.
- Consent before sedation
- Obtain consent before preoperative sedatives are given, because sedation can invalidate capacity.
- Sedated patient with questions
- STOP and notify the surgeon; do not have a sedated patient sign and do not fill in the gaps yourself.
- Interpreter rule
- Use a qualified medical interpreter — not family members — for a language barrier, and document it.
- Emancipated minor
- A minor who is married, in the military, court-declared, or sometimes financially independent — may consent for self.
- Incapacitated-adult consent
- Obtained from a legally authorized representative (healthcare POA/proxy, court-appointed guardian, or the state surrogate hierarchy).
- Ambulatory discharge escort
- A responsible adult must drive the patient home and stay for the first 24 hours after sedation or anesthesia.
- Post-anesthesia restrictions
- No driving, operating machinery, or signing legal documents for 24 hours after sedation or general anesthesia.
- Teach-back
- Evaluating patient understanding by having them explain it in their own words ("show me / tell me").
- HIPAA minimum necessary
- Access or disclose only the protected health information (PHI) needed for the task.
- OR schedule/board
- Is PHI — limit its display to need-to-know and avoid posting full identifiers publicly.
- Social media and PHI
- Never post patient information, images, or identifiable details — a recurring source of HIPAA breaches.
- Permitted disclosures (TPO)
- Treatment, payment, and healthcare operations do not require separate authorization.
- Occurrence/incident report
- An internal risk-management and QI tool — it is NOT part of the medical record and is not referenced in the chart.
- Asepsis
- The absence of pathogenic microorganisms.
- Sterile-field doubt rule
- When in doubt, consider it contaminated.
- Sterile-to-sterile rule
- Only sterile items may touch sterile surfaces.
- Sterile gown zone
- The front from chest level (mid-chest/nipple line) to the level of the sterile field, and the sleeves from about 2 inches above the elbow to the cuff.
- Gown back
- Never considered sterile, even on a wraparound gown.
- Stockinette cuff
- NOT sterile (it wicks moisture); it must be covered by the glove.
- Sterile table level
- Tables are sterile only at table level; anything below table height is non-sterile.
- Sterile package margin
- About a 1-inch (2.5 cm) edge of a wrapper or drape is considered non-sterile — the principle of an unsterile perimeter is the testable point.
- Sterile-person movement
- Sterile persons pass each other back-to-back or front-to-front and keep their hands at or above waist level and in front.
- Unsterile-person rule
- Unsterile persons face and approach the sterile field but never reach over it.
- Surgical hand scrub — method 1
- A traditional scrub with an antimicrobial agent (e.g., CHG 4% or an iodophor), commonly 2–5 minutes per the manufacturer IFU.
- Surgical hand scrub — method 2
- A waterless alcohol-based surgical hand rub, preceded by a pre-wash and nail cleaning, allowed to dry completely before gowning.
- Hand position during scrub
- Hands held above the elbows so runoff flows from cleanest (hands) to least clean (elbows).
- Artificial nails
- Prohibited in the perioperative setting because they harbor pathogens.
- Closed gloving
- Hands remain inside the gown cuffs and never touch the outside of the gloves — the lowest contamination risk and preferred for initial gloving.
- Open gloving
- Hands come through the cuffs first — a higher contamination risk; used without a full gown or to change a single glove.
- Assisted gloving
- A gloved team member holds the glove open for another (e.g., gloving the surgeon).
- Double-gloving
- Recommended by AORN to reduce glove perforation and bloodborne exposure; a colored under-glove (perforation-indicator system) reveals breaches.
- Unrestricted zone
- Street clothes permitted (front desk, locker rooms, waiting areas).
- Semi-restricted zone
- Surgical attire and head covering required (peripheral support/storage, corridors, processing).
- Restricted zone
- Surgical attire, head covering, AND masks when open sterile supplies or scrubbed persons are present (the OR/procedure rooms and clean core).
- OSHA Bloodborne Pathogens Standard
- 29 CFR 1910.1030 — requires PPE at no cost, an exposure-control plan, a free hepatitis B vaccine, sharps containers, and post-exposure follow-up.
- OR pressure vs. isolation room
- The OR is positive pressure; an airborne-infection isolation (AII) room is negative pressure.
- OR airflow direction
- HEPA-filtered and unidirectional from the ceiling supply downward, returning low on the walls.
- Spaulding — critical
- Items that enter sterile tissue or the vascular system → STERILIZATION (instruments, implants, needles, scalpels).
- Spaulding — semicritical
- Items that contact mucous membranes or non-intact skin → high-level disinfection minimum (flexible endoscopes, laryngoscope blades, vaginal probes).
- Spaulding — noncritical
- Items that contact intact skin only → low- or intermediate-level disinfection (BP cuffs, OR-table surfaces, stethoscopes).
- Reprocessing sequence
- Point-of-use treatment → cleaning/decontamination → inspection → disinfection or packaging → sterilization → storage.
- Point-of-use treatment
- Keep instruments moist at the end of the case so bioburden does not dry — "you cannot sterilize what is not clean."
- High-level disinfectants
- Glutaraldehyde (2.4% or greater), OPA (0.55%), hydrogen peroxide, and peracetic acid.
- Intermediate-level disinfection
- Tuberculocidal (kills M. tuberculosis); low-level disinfection does NOT kill TB or spores.
- Steam sterilization mechanism
- Coagulation and denaturation of cellular proteins — the gold standard (fast, nontoxic, least costly).
- Gravity-displacement steam cycle
- Commonly 30 minutes at 250°F (121°C) or 15 minutes at 270°F (132°C), plus dry time.
- Prevacuum (dynamic-air-removal) steam cycle
- Commonly 4 minutes at 270–275°F (132–135°C) plus dry time; better penetration of lumens and porous loads.
- Ethylene oxide (EO)
- Excellent penetration for heat-sensitive lumened devices; toxic, flammable, and carcinogenic, requiring mandatory aeration. Its biological indicator is Bacillus atrophaeus.
- Hydrogen peroxide gas plasma
- Low temperature, short cycles, and no toxic residue (breaks down to water and oxygen, no aeration); it CANNOT process cellulose, liquids, or long/narrow lumens. Its biological indicator is Geobacillus stearothermophilus.
- Ozone sterilization
- Low-temperature and environmentally friendly with lumen/material limits. Its biological indicator is Geobacillus stearothermophilus.
- Liquid peracetic acid
- Just-in-time liquid sterilization for immersible devices used immediately (not stored or wrapped).
- IUSS definition
- Immediate-Use Steam Sterilization (formerly "flash") of a cleaned, unwrapped item intended for immediate use.
- IUSS — when permitted
- Only when there is an urgent need and no other sterile item is available; never routinely or for convenience or inventory shortfalls.
- IUSS prevacuum cycle
- Commonly 4 minutes at 270°F (132°C) or 3 minutes at 275°F (134°C).
- IUSS and implants
- Implants should NOT be IUSS-sterilized except in a documented emergency, and then require a rapid-readout BI and quarantine.
- Mechanical/physical monitors
- Real-time sterilizer readouts of time, temperature, and pressure, reviewed every cycle.
- Chemical indicator — Type 1
- Process indicator (external, e.g., autoclave tape); distinguishes processed from unprocessed items.
- Chemical indicator — Type 2
- Specific-test indicator (e.g., the Bowie-Dick test of air removal).
- Chemical indicator — Type 5
- Integrating indicator that reacts to all critical variables and correlates to a BI — the most reliable internal CI.
- Chemical indicator — Type 6
- Emulating (cycle-verification) indicator for a specific stated cycle.
- Chemical indicators prove
- Exposure to the process only — they do NOT prove sterility.
- Biological indicator (BI)
- Contains live, highly resistant bacterial spores; the only direct proof of microbial kill (no growth = pass).
- BI organism — steam/plasma/ozone
- Geobacillus stearothermophilus.
- BI organism — EO/dry heat
- Bacillus atrophaeus (formerly B. subtilis).
- BI frequency — steam
- At least weekly, preferably daily, and with every load that contains an implant.
- BI frequency — EO/low-temp
- A BI in every load.
- Implant-load BI
- Every implant load requires a rapid-readout BI with a Type 5 CI; implants are quarantined until the BI result is negative.
- Bowie-Dick test
- A daily air-removal/steam-penetration test for prevacuum sterilizers, run in an empty chamber as the first cycle of the day (about 270°F/132°C for ~3.5 minutes); it tests air removal, NOT sterilization.
- Event-related sterility
- A package is sterile until an event compromises it (wet, torn, dropped, crushed, broken seal) — not tied to an arbitrary date.
- Standard Precautions
- Apply to ALL patients all the time; treat all blood and body fluids as potentially infectious.
- Contact Precautions
- For C. difficile and MDROs → gown and gloves; C. diff requires soap and water because alcohol gel does not kill spores.
- Droplet Precautions
- For influenza, N. meningitidis, and pertussis → a surgical mask within about 3–6 feet.
- Airborne Precautions
- For TB, measles, and varicella → an N95 respirator and a negative-pressure airborne-infection isolation room.
- Antibiotic prophylaxis timing
- Within 60 minutes before incision (120 minutes for vancomycin or fluoroquinolones); redose for long cases or major blood loss.
- SSI bundle — glycemic control
- Control perioperative blood glucose (generally below 200 mg/dL, often 110–150; cardiac patients below 180).
- Neutral (hands-free) zone
- Sharps passed via a designated tray or magnetic mat so only one person handles a sharp at a time.
- Needle recapping
- Do NOT recap (or use a one-handed scoop); activate safety features and dispose at the point of use.
- Terminal cleaning
- A thorough end-of-day cleaning of the entire OR and adjacent areas, performed even for rooms not used.
- C. diff cleaning agent
- A sporicidal agent (e.g., EPA List K or bleach-based).
- Disinfectant contact time
- Surfaces must remain visibly wet for the full label dwell time.
- MH triggers
- Volatile (inhaled) anesthetics (sevoflurane, desflurane, isoflurane, halothane) and the depolarizing blocker succinylcholine.
- MH non-triggers
- Nitrous oxide, propofol, etomidate, ketamine, benzodiazepines, opioids, local anesthetics, and non-depolarizing blockers.
- MH gene and defect
- An RYR1-gene mutation produces a defective ryanodine receptor, causing uncontrolled calcium release from the sarcoplasmic reticulum.
- MH gold-standard test
- The caffeine-halothane contracture test (CHCT) on a muscle biopsy.
- MH earliest / most sensitive sign
- Rising end-tidal CO₂ (EtCO₂) that is unresponsive to increased minute ventilation.
- MH latest sign
- Hyperthermia (rapidly rising core temperature) — do NOT wait for fever to act.
- Dantrolene mechanism
- A direct skeletal-muscle relaxant that binds RYR1 and blocks calcium release from the sarcoplasmic reticulum (it treats the cause).
- Dantrolene initial dose
- 2.5 mg/kg IV given rapidly through a large-bore IV.
- Dantrolene repeat dosing
- Repeat 2.5 mg/kg as frequently as needed until the patient responds; there is no absolute ceiling if the patient is still reacting.
- Standard dantrolene (Dantrium/Revonto)
- 20 mg per vial; reconstitute each vial with 60 mL sterile water and shake until clear — labor-intensive.
- Ryanodex
- 250 mg per vial; reconstitute with only 5 mL sterile water (50 mg/mL) — far faster to prepare.
- MHAUS hotline
- 1-800-644-9737 (24-hour).
- MH first steps
- Stop the triggers, call for help and the MH cart, hyperventilate with 100% oxygen at 10 L/min or more, and give dantrolene immediately.
- MH and calcium channel blockers
- AVOID them (verapamil, diltiazem) with dantrolene — the combination can cause hyperkalemia and cardiovascular collapse.
- MH cooling
- Cool when the core temperature is above 39°C; stop cooling at below 38°C to avoid overshoot hypothermia.
- MH post-crisis
- Observe in the ICU for at least 24 hours (recrudescence risk) and continue dantrolene 1 mg/kg every 4–6 hours for at least 24 hours.
- MH cart dantrolene minimum
- At least 36 vials of 20 mg dantrolene, or the equivalent Ryanodex stock (three vials of 250 mg).
- Massive transfusion definition
- 10 or more units of PRBCs in 24 hours, replacement of one entire blood volume, or 4 or more units in 1 hour with ongoing bleeding.
- Balanced transfusion ratio
- A 1:1:1 ratio of PRBCs to FFP to platelets.
- Massive transfusion complications
- Hypothermia, hypocalcemia (citrate binds calcium), hyperkalemia, acidosis then alkalosis, and dilutional coagulopathy.
- Hemorrhagic shock — early signs
- Tachycardia and a narrowed pulse pressure appear BEFORE hypotension; hypotension is a late finding.
- Transfusion reaction — first action
- STOP the transfusion immediately, keep the IV line open with normal saline (new tubing), and notify the provider and blood bank.
- Blood-compatible IV fluid
- 0.9% normal saline only — never dextrose or lactated Ringer's with blood, because they cause hemolysis or clotting.
- Acute hemolytic reaction (AHTR)
- The most dangerous reaction — ABO incompatibility from a clerical/ID error; fever and chills, flank/back pain, hypotension, hemoglobinuria, and DIC.
- Febrile non-hemolytic reaction (FNHTR)
- The most common reaction — antibodies against donor leukocytes; fever plus chills; prevented by leukoreduced products.
- Mild allergic transfusion reaction
- Urticaria and itching only — the only reaction that may sometimes be resumed slowly after an antihistamine.
- Anaphylactic transfusion reaction
- Often from anti-IgA in an IgA-deficient recipient; bronchospasm and hypotension WITHOUT fever; give epinephrine and use washed/IgA-deficient products.
- TRALI
- Transfusion-Related Acute Lung Injury — the leading cause of transfusion-related death; non-cardiogenic pulmonary edema within 6 hours; diuretics do NOT help.
- TACO
- Transfusion-Associated Circulatory Overload — volume overload with hypertension and JVD; sit the patient upright, give oxygen, and give diuretics.
- Anaphylaxis — first drug
- Epinephrine (first and definitive) — IM 0.3–0.5 mg (1:1000) when awake, or titrated IV boluses of 10–100 mcg under anesthesia.
- Latex anaphylaxis prevention
- A latex-safe environment; schedule the patient as the first case of the day and use latex-free supplies.
- LAST
- Local Anesthetic Systemic Toxicity — from toxic plasma levels; bupivacaine is the most cardiotoxic.
- LAST sign sequence
- CNS first (perioral numbness, metallic taste, tinnitus, seizures), then cardiovascular (bradycardia, widened QRS, arrhythmias, collapse).
- LAST antidote
- Lipid emulsion 20% (Intralipid).
- LAST lipid bolus — 70 kg or more
- 100 mL IV over 2–3 minutes, then about 200–250 mL over 15–20 minutes.
- LAST lipid bolus — under 70 kg
- 1.5 mL/kg IV (lean body weight), then a 0.25 mL/kg/min infusion.
- LAST lipid maximum
- About 12 mL/kg total.
- LAST epinephrine modification
- Reduce to 1 mcg/kg or smaller boluses — high-dose epinephrine impairs lipid resuscitation.
- LAST drugs to avoid
- Vasopressin, calcium channel blockers, beta-blockers, and local anesthetics (lidocaine, procainamide).
- CPR compression standards
- Rate 100–120/min, depth 2–2.4 inches (5–6 cm), full recoil, and switch compressors every 2 minutes.
- Defibrillation — shockable rhythms
- VF and pulseless VT — defibrillate as early as possible (biphasic commonly 120–200 J).
- Non-shockable rhythms
- Asystole and PEA → CPR plus epinephrine 1 mg IV/IO every 3–5 minutes.
- Anesthesia awareness
- The patient becomes conscious during general anesthesia with explicit recall; the risk is higher with TIVA and cardiac/trauma/obstetric cases and is reduced with depth-of-anesthesia (BIS) monitoring.
- Aspiration prevention
- NPO verification and rapid-sequence induction (RSI) with cricoid pressure (the Sellick maneuver) for at-risk patients.
- Venous air embolism (VAE) mechanism
- Air enters an open vein when the surgical site is above the heart, forming an air lock in the right heart.
- VAE highest-risk position
- The sitting ("beach chair") position for posterior-fossa/neurosurgery, cervical spine, and shoulder surgery.
- VAE most sensitive intraoperative sign
- A sudden drop in end-tidal CO₂ (plus a "mill-wheel" murmur on precordial Doppler).
- Durant maneuver
- For VAE — position the patient in left lateral decubitus plus Trendelenburg (head down) to trap air in the right-ventricle apex.
- VAE and nitrous oxide
- Discontinue nitrous oxide (it expands air bubbles) and give 100% oxygen.
- AORN
- The Association of periOperative Registered Nurses — it defines evidence-based perioperative practice (Guidelines, Scope & Standards, position statements) and is not a regulator.
- AORN Guidelines for Perioperative Practice
- The systematically reviewed, evidence-based recommendations updated annually — the OR's de facto best-practice standard.
- ANA Code of Ethics — Provision 2
- The nurse's primary commitment is to the patient.
- ANA Code of Ethics — Provision 3
- The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
- Autonomy
- Respect for the patient's right to self-determination (informed consent, refusals, advance directives, religious objections).
- Beneficence
- The duty to do good and act in the patient's best interest.
- Nonmaleficence
- "First, do no harm" — avoiding injury (correct counts, correct site, safe positioning, sterile technique).
- Justice
- Fairness — the equitable allocation of resources and care regardless of status.
- Primary patient advocate
- The perioperative RN, because the patient is often anesthetized and unable to speak for themselves.
- Stop the line
- Anyone on the team can and should halt the procedure for a safety concern.
- CNOR certifying body
- The Competency & Credentialing Institute (CCI).
- Certification vs. licensure
- Licensure is the minimum legal safety floor; certification demonstrates specialty expertise.
- TJC (The Joint Commission)
- A voluntary accreditor that owns the National Patient Safety Goals, the Universal Protocol/time-out, and Sentinel Event policy; accreditation grants "deemed status."
- CMS
- Sets the Conditions of Participation for Medicare/Medicaid reimbursement, defines and penalizes "never events," and grants deemed status to accreditors.
- OSHA
- Protects employees and staff (not patients); enforces the Bloodborne Pathogens Standard, PPE, HazCom/SDS, and sharps and waste-anesthetic-gas safety.
- FDA
- Regulates medical devices, implants, drugs, and biologics; oversees recalls, MedWatch, single-use device reprocessing, and implant tracking/UDI.
- CDC
- Issues infection-prevention guidance (Standard and Transmission-Based Precautions, SSI prevention, the Spaulding classification, NHSN) — recommendations, not law.
- AAMI
- A standards-development organization that publishes sterilization and reprocessing standards (ANSI/AAMI ST79 steam, ST108 water).
- Just Culture distinctions
- Human error → console; at-risk behavior → coach; reckless behavior → discipline (non-punitive, but not no-blame).
- Sentinel event
- A patient-safety event reaching the patient that results in death, permanent harm, or severe temporary harm (e.g., retained item, wrong-site surgery, surgical fire); it triggers a Root Cause Analysis (RCA).
- Evidence-Based Practice (EBP)
- Integrates the best available research evidence with clinical expertise and patient values; models include PICO(T) and the Iowa Model.
- QI frameworks
- PDSA/PDCA, Lean, Six Sigma, root cause analysis (RCA), and FMEA (proactive risk reduction).
- Recertification (CNOR)
- Maintained by Professional Activity Points or contact hours within the 5-year cycle — recertification by exam is no longer an option (eliminated Jan 1, 2021).
