CNOR cheat sheet

ASA physical status: I healthy; II mild systemic disease; III severe systemic disease, not incapacitating; IV incapacitating, constant threat to life; V moribund, not expected to survive without surgery; VI brain-dead organ donor.

Difficult-airway predictors: Mallampati III–IV, thyromental distance under 3 fingerbreadths (about 7 cm), mouth opening under 3 cm, short thick neck, limited cervical extension, receding mandible.

ASA fasting intervals: 2 h clear liquids, 4 h breast milk, 6 h nonhuman milk or light meal, 8 h fatty or fried meal.

Informed consent is obtained by the practitioner performing the procedure; the nurse verifies completeness, voluntariness, and correct patient, then witnesses the signature.

Malignant hyperthermia susceptibility: avoid volatile anesthetics and succinylcholine; verify dantrolene 2.5 mg/kg and a trigger-free machine or circuit are available.

Latex allergy: schedule as first case of the day, stock a latex-free cart, remove latex gloves and latex-containing packaging from the room before the patient enters.

Continue beta-blockers and statins perioperatively; hold warfarin about 5 days with an INR check, and stop direct oral anticoagulants per agent-specific protocol.

Minimum documented elements: allergies, NPO status, correct site and side, signed consent, history and physical within 30 days with interval update, implants and devices.

Universal Protocol has three parts: preprocedure verification, marking of the operative site, and a time-out immediately before starting the procedure.

WHO Surgical Safety Checklist phases: sign in before induction, time out before incision, sign out before the patient leaves the operating room.

Prophylactic antibiotics: infuse within 60 min before incision; vancomycin and fluoroquinolones within 120 min; redose at two half-lives or blood loss over 1500 mL.

Venous thromboembolism risk is scored (Caprini); low risk gets early ambulation, moderate gets mechanical prophylaxis, high gets pharmacologic prophylaxis plus mechanical.

Normothermia plan: forced-air warmer, warmed intravenous and irrigation fluids, and a target core temperature of at least 36 degrees C.

Perioperative glycemic target is generally 110–180 mg/dL; check glucose before induction and hourly during long cases.

Blood plan is risk-based: type and screen for moderate risk, type and crossmatch for cases with expected major blood loss; verify blood bank availability.

Positioning plan selects the position, padding, and table accessories before the patient enters, using Braden score and procedure requirements.

Preference card review confirms planned supplies, implants, and instruments, and any special equipment is requested in advance.

Counts of sponges, sharps, and instruments are performed by two people at the initial count before incision, at cavity closure, at skin closure, and at end of case; results are reported to the circulator.

Maintain core temperature at or above 36 degrees C using forced-air warming and warmed fluids; hypothermia increases surgical site infection, bleeding, and cardiac events.

Electrosurgical dispersive pad: dry, hairless, well-perfused muscle near the surgical site, avoiding bony prominences, scars, hair, implants, and areas below the heart.

Tourniquet time is typically 60–90 min with an absolute limit near 2 h; if longer is needed, deflate for 10 min before reinflation.

Local anesthetic maximums for a healthy adult: lidocaine 4.5 mg/kg plain and 7 mg/kg with epinephrine; bupivacaine 2.5 mg/kg plain and 3 mg/kg with epinephrine.

Adequate adult urine output is about 0.5 mL/kg/h; report output below that with hypotension or tachycardia to the anesthesia provider.

Surgical fire prevention: let alcohol-based preps dry fully, keep oxygen concentration as low as tolerated, and place the electrosurgical pencil in a holster when not in use.

Positioning protects pressure points, eyes, and nerve paths: brachial plexus in Trendelenburg and lateral, peroneal nerve in lithotomy, and dependent ear and shoulder in lateral.

SBAR structures escalation: Situation, Background, Assessment, Recommendation.

I-PASS structures handoffs: Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver.

Documentation is contemporaneous, objective, accurate, and complete; no blank lines, and errors are corrected with a single line, initials, date, and time.

A time-out is documented with patient identity, procedure, site and side, consent, allergies, positioning, implants and special equipment, and antibiotic administration.

Verbal and telephone orders are written, read back completely to the prescriber, confirmed, and countersigned per policy.

Incident reports are risk-management documents and are never filed in the medical record.

HIPAA requires the minimum necessary information be shared only with those directly involved in the patient's care.

Final counts are documented with the names of the two people who performed them and the outcome of any discrepancy resolution.

Handoff content: patient identity, procedure and anesthesia type, allergies, medications, lines and drains, blood loss, urine output, counts, specimens, skin condition, and plan.

Aldrete score assesses activity, respiration, circulation, consciousness, and oxygen saturation; a score of 8 or higher out of 10 supports discharge from the PACU.

Transport requires continuous pulse oximetry, supplemental oxygen, side rails up, bag-valve mask available, and an escort trained in airway management.

Handoffs are delivered in person at the bedside so the receiving nurse can see the patient and ask questions before the transferring nurse leaves.

Protective airway reflexes, stable vital signs, and adequate pain control are verified before the patient leaves the anesthetizing location.

Specimens are transferred with verified labels, requisitions, and the receiving staff member's acknowledgement documented.

Document transfer time, receiving unit and provider, mode of transport, monitoring used, and the patient's condition at handoff.

Spaulding classification: critical items enter sterile tissue and require sterilization; semicritical items contact mucous membranes and need high-level disinfection; noncritical items contact intact skin and need low-level disinfection.

Steam sterilization parameters: gravity displacement at 121 degrees C for about 30 min, or prevacuum at 132 degrees C for about 4 min.

Biological indicators: Geobacillus stearothermophilus monitors steam; Bacillus atrophaeus monitors ethylene oxide and dry heat.

Chemical indicators: external indicators show the package was processed; internal indicators show sterilant penetrated the package.

Sterile storage: items at least 8–10 inches above the floor, 2 inches from outside walls, and 18 inches below the ceiling.

Sterility is event-related: an item remains sterile indefinitely if the package is intact and dry and storage conditions were maintained; expiration dating is not required.

Immediate-use (formerly flash) sterilization is a last resort and is not used for implants unless no alternative exists and a full cycle with biological monitoring is run.

Instrument decontamination sequence: point-of-use treatment, enzymatic or detergent cleaning, mechanical washer-disinfector, inspection, packaging, sterilization, and monitoring.

Malignant hyperthermia: earliest signs are masseter spasm, unexplained rising end-tidal CO2, and tachycardia; stop triggers, hyperventilate with 100% oxygen, give dantrolene 2.5 mg/kg IV, and cool.

Anaphylaxis: stop the trigger, give epinephrine 0.01 mg/kg IM (maximum 0.5 mg) in the anterolateral thigh, repeat every 5–15 min as needed, and give rapid crystalloid.

Adult ACLS: compressions 100–120 per minute at 5–6 cm depth with full recoil, 30:2 without an advanced airway, and immediate defibrillation for ventricular fibrillation or pulseless ventricular tachycardia.

Local anesthetic systemic toxicity: stop injection, secure the airway, give 20% lipid emulsion 1.5 mL/kg bolus then infusion, and avoid vasopressin, calcium channel blockers, and beta-blockers.

Suspected venous air embolism: place the patient in left lateral decubitus with head down, give 100% oxygen, and aspirate air from a central catheter if one is in place.

Massive hemorrhage: activate the massive transfusion protocol, use balanced resuscitation near 1:1:1, and give tranexamic acid per protocol.

Operating room fire: use RACE (rescue, alarm, confine, extinguish or evacuate) and PASS (pull, aim, squeeze, sweep) for the extinguisher; stop flow of oxygen to the field first.

One full-time equivalent equals 2080 paid hours per year (40 hours per week); required FTEs equal total workload hours divided by 2080.

Staffing is based on patient acuity, procedure complexity, skill mix, and standards, not solely on room count or historical ratios.

Capital budget covers durable equipment with a life over one year and is typically depreciated; operating budget covers consumables, salaries, and services.

Block utilization equals used block time divided by allocated block time; persistently low utilization triggers release of block back to the general pool.

Preference cards are surgeon-specific supply and instrument lists that must be reviewed and updated regularly to prevent waste, delays, and cancellations.

Inventory control uses par levels, just-in-time ordering, consignment agreements, and periodic cycle counts to avoid stockouts and expiration waste.

Quality indicators tracked include surgical site infection rate, on-time first-case starts, turnover time, retained items, and case cancellation rate.

Competency is validated at hire, annually, and when new technology or procedures are introduced; cross-training improves flexibility and retention.

Negligence requires four elements proven together: duty to the patient, breach of the standard of care, causation, and damages.

The standard of care for perioperative nursing is defined by nurse practice acts, professional standards and recommended practices, facility policy, and expert testimony.

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury; it requires immediate containment, notification, and root cause analysis.

Just culture separates human error (console), at-risk behavior (coach), and reckless behavior (punish) to promote reporting and learning.

Advocacy obligates the nurse to speak up when the patient cannot, including stopping a procedure for wrong site, unverified consent, or a break in sterile technique.

Mandatory reporting obligations include impaired colleagues, suspected abuse or neglect, and specified communicable diseases, per state law.

Confidentiality under HIPAA applies to all patient identifiers, including verbal discussions, screens, white boards, and social media.

Certification maintenance requires ongoing continuing education and revalidation of the credential within the defined cycle.