Operating Room Skills Checklist

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Directions for Completing Skills Checklist


The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar.

Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience.
B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.

PROFESSIONAL PRACTICE

ABCD
Maintain privacy and dignity for each patient pre-, intra-, and postoperatively
Perform all nursing functions within the RN’s scope of practice
ABCD
Report necessary findings/situations to appropriate person/organization i.e.: possible drug diversion/impairment to board of nursing
Report necessary findings/situations regarding medication errors to risk management
Report necessary findings/situations regarding sentinel events to risk management

INTERDISCIPLINARY COMMUNICATION

ABCD
Communicate with patient using age and cultural appropriate methods
Collaborate with interdisciplinary teams in the pre-operative, perioperative, and post-operative environments
Perform and maintain accurate patient records and documentation related to nursing interventions, plan of care, nursing diagnoses, response to operative procedure, etc.
Maintain patient confidentiality according to HIPAA guidelines i.e.: status updates to family members
Utilize and follow read-back process for verbal orders
Implement effective solutions for communication with patient when barriers exist i.e.: physiological, cultural, language
Anticipate needs of patient, surgeon and other members of the surgical team i.e.: equipment, supplies, instruments, etc.
Delegate appropriate tasks to other personnel as necessary
Manage outside personnel when present in the OR environment i.e.: supply/equipment vendors, students

SAFETY/ENVIRONMENT OF CARE

ABCD

EMERGENCY MANAGEMENT/ANESTHESIA

ABCD
ABCD
Cardiac arrest
Malignant hyperthermia
Anaphylaxsis
Difficult intubation

INFECTION CONTROL

ABCD
Perform universal protocol
Use Personal Protective Equipment (PPE) when indicated in the surgical environment
Determine and select appropriate sterilization method for cleaning and disinfecting contaminated equipment and instruments
Select appropriate packaging for equipment and instruments used in the OR
Maintain appropriate environmental conditions for sterilization process i.e. temperature and humidity
Document all activities associated with the cleaning, disinfecting, sterilizing, packaging, transporting and storage of surgical instruments and supplies
Manage materials and instruments used in the surgical environment acquired from outside sources, vendors

PREOPERATIVE RESPONSIBILITIES

ABCD
Verify patient identity using two patient identifiers
Confirm presence of DNR orders and/or advance directive
Ability to confirm procedure
Ability to confirm operative site markings as part of verifying correct operative site
Verify consent form is complete
Perform complete physical assessment
Perform pain assessment prior to procedure, immediately after, and upon transfer to PACU
Review all pertinent patient data pre-operatively i.e.: lab values, allergies, secondary diagnoses/conditions, NPO status
Ability to analyze patient data in the pre-operative phase and report any significant findings to appropriate team members
Perform pre-operative teaching for surgical patient and their family
Identify patient’s potential physiological responses to operative experience i.e.: tissue perfusion, body temperature/thermal regulation, infection
Develop, monitor, and revise plan of care for the operative patient, including age-specific, cultural, and spiritual considerations
Review medication history i.e.: pre-op meds, previous surgical history, drug/alcohol use
Formulate nursing diagnoses based upon comprehensive assessment, review, and knowledge of individual patient
Document pre-operative and peri-operative assessments
ABCD
Safety straps
Sequential Compression Device
Antiembolic stockings
Elbow protectors
Thermoregulatory devices
Monitoring devices

INTRAOPERATIVE RESPONSIBILITIES

ABCD
Perform, maintain, and adjust patient positioning in the operating room
Perform surgical site preparation (independently or with other operative team members)
Monitor effects of anesthetic agents and other drugs while patient is in the operating room
Label medications, containers, solutions, specimens, including assessment of package integrity, expiration dates
Maintain sterile field by utilizing aseptic technique
Perform surgical counts before, during and post procedure
Perform and document intraoperative blood salvage
Optimize behavioral and physiological responses of the patient to the operative procedure(s)
Manage environmental factors of the OR i.e.: noise, traffic, temperature
Prepare, confirm, and present implants to sterile field
Transport specimens as indicated by organizational policy and procedure
Assist and/or supervise surgical environmental cleaning for spills, room turnover, terminal cleaning
ABCD
Basal skull fracture
Closed head injury
CVA
DT's
Encephalitis
Externalized VP shunts
Meningitis
Neuromuscular disease
Seizures
Spinal cord injury
TIA
Aneurysm Precautions

COMMON SURGERY SUBSPECIALTIES:

ABCD
General surgery
Endoscopic procedures
Ear, nose & throat
Gynecology
Neurology
Opthalmology
Oral
Pediatrics
Plastics
Robotics
Thoracic/Open Heart
Transplant
Trauma
Urology
Vascular
Orthopedics

POSTOPERATIVE RESPONSIBILITIES

ABCD
Perform hand off process when indicated to ensure continuity of care
Evaluate patient’s physiological status/hemodynamics to facilitate transfer to PACU, ICU, home
Provide peri and post-operative education and documents activities

Age Specific:

ABCD
Infant (Birth to 1 year)
Toddler (1-3 years)
Pre-school (3-6 years)
School Age (6-12 years)
Adolescent ( 12-18 years)
Young Adult ( 18-30 years)
Mature Adult (30-60 years)
Elderly (>60 years)
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