CNOR key terms

The patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives. The nurse verifies it is signed, witnessed, and obtained by the authorized provider.

A six-level classification (I–VI) used by anesthesia providers to describe a patient's overall health before surgery. Higher classes generally indicate greater anesthetic and surgical risk.

A bedside assessment of the oropharyngeal structures visible with the mouth open and tongue protruded. It estimates the difficulty of visualizing the larynx during intubation.

The period during which a patient abstains from food and fluids before anesthesia to reduce the risk of aspiration. Orders are based on procedure type and patient factors.

Diagnostic tests, history, and screening completed before the day of surgery to identify conditions that could affect anesthesia or recovery. Results guide preoperative planning and readiness for surgery.

An individualized, written plan developed from preoperative assessment data that sets nursing diagnoses, goals, interventions, and expected outcomes across the surgical experience.

Teaching provided before surgery about what to expect, breathing exercises, pain control, and preparation steps. It reduces anxiety and supports informed participation in care.

A standardized, audible accounting of sponges, sharps, and instruments by the circulating nurse and scrub person at defined points during the procedure. Discrepancies are resolved before the patient leaves.

A sponge, instrument, or other surgical material unintentionally left inside a patient after a procedure. It is a preventable serious event associated with infection, obstruction, and reoperation.

An infection developing at or near an incision within a defined postoperative period. Prevention includes aseptic technique, appropriate antibiotic timing, glucose control, and normothermia.

Maintenance of a patient's core temperature near 36–37°C during surgery. Warming prevents hypothermia-related complications such as infection, bleeding, and delayed recovery.

Placing and supporting the patient to allow surgical access while protecting skin, nerves, joints, and circulation. Requires padding, alignment, and verification of pressure points.

Localized damage to skin and underlying tissue resulting from sustained pressure, shear, or friction. Intraoperative risk increases with long procedures, immobility, moisture, and poor positioning.

Use of high-frequency electrical current to cut or coagulate tissue. The nurse ensures proper grounding pad placement, avoids flammable substances, and manages smoke.

A brief, standardized pause immediately before incision in which the team verbally confirms patient identity, procedure, site, consent, and readiness. All team members must participate and resolve discrepancies.

A structured tool used at three phases-sign in, time-out, and sign out-to verify critical safety steps. It improves teamwork and reduces preventable surgical harm.

A communication framework-Situation, Background, Assessment, Recommendation-used to convey concise, organized information about a patient. It is common during hand-offs and urgent escalations.

The transfer of patient information, responsibility, and accountability between care providers. Effective hand-offs use standardized formats and allow opportunity for questions.

A scoring system assessing activity, respiration, circulation, consciousness, and oxygen saturation to determine readiness for discharge from postanesthesia care.

A defined area around the operative site where only sterile items and personnel may contact. Once established, it must be continuously monitored and maintained.

Practices that prevent microorganisms from contaminating sterile areas, including gowning, gloving, and maintaining sterile boundaries. Breaks in technique must be corrected immediately.

A structured hand and forearm antisepsis procedure performed before donning sterile attire. It reduces transient and resident skin flora to lower surgical site contamination risk.

Infection control practices applied to all patients regardless of diagnosis, including hand hygiene, gloves, and safe handling of sharps and body fluids.

Barrier garments such as gloves, gowns, masks, and eye protection worn to prevent exposure to blood, body fluids, and hazardous materials.

The first reprocessing step that removes organic and inorganic soil from reusable instruments. Cleaning must occur before disinfection or sterilization to allow effective microbial kill.

A validated process that destroys all microbial life, including bacterial spores, on reusable items. It requires cleaning, proper packaging, and monitoring.

A process that eliminates most microorganisms but not necessarily all bacterial spores. It is used for semi-critical items such as endoscopes that contact mucous membranes.

A system categorizing medical devices as critical, semi-critical, or noncritical based on the body tissue contacted and the level of reprocessing required.

A preparation containing viable spores used to monitor whether a sterilization cycle achieved the conditions needed to kill highly resistant microorganisms.

A gravity-displacement steam cycle used for urgent items when time does not allow standard reprocessing. It includes cycle monitoring and documented justification.

A rare, life-threatening hypermetabolic reaction to volatile anesthetics or succinylcholine. Signs include rising temperature, rigidity, tachycardia, and acidosis; treatment is dantrolene.

A severe, rapidly developing systemic allergic reaction with airway swelling, bronchospasm, hypotension, and rash. Immediate epinephrine and airway support are essential.

A toxic reaction to local anesthetics causing neurologic and cardiac symptoms, from tinnitus and seizures to arrhythmias. Treatment includes airway support and lipid emulsion therapy.

A fire occurring during surgery when an ignition source, oxidizer, and fuel are present. Prevention includes safe electrosurgery use, avoiding pooled oxygen, and managing alcohol-based prep.

A surgeon-specific document listing instruments, supplies, sutures, and setup details for a procedure. It is updated as practices change to support accurate case preparation.

A cart assembled with the supplies and instruments needed for a specific scheduled procedure. Accurate picking reduces intraoperative delays and wasted materials.

The assignment of a specific task to another team member who has the competence to perform it. The delegating nurse retains accountability for appropriate supervision and outcomes.

An organizational approach that encourages reporting of errors and near misses while distinguishing human error from reckless behavior. It supports learning and fair accountability.

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. It requires immediate investigation and root-cause analysis.

A nurse's internal standard of honesty and vigilance in maintaining asepsis and reporting breaks in technique, even when no one is observing.