NASC CRNFA cheat sheet

ASA physical status: I healthy; II mild systemic disease; III severe systemic disease not incapacitating; IV incapacitating threat to life; V moribund; VI brain-dead organ donor; add E for emergency.

Revised Cardiac Risk Index (Lee) major predictors: ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, creatinine >2.0 mg/dL, and high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular).

Surgical Care Improvement Project rules: prophylactic antibiotic within 60 minutes before incision (120 minutes for vancomycin or fluoroquinolones); discontinue within 24 hours after surgery (48 hours for cardiac).

Metformin is typically held 48 hours before elective surgery when contrast or significant renal risk is present; check creatinine before restarting.

A1c >8% or glucose >180-200 mg/dL correlates with higher surgical site infection risk; optimize before elective cases.

Bleeding risk: stop clopidogrel 5-7 days, ticagrelor 5 days, prasugrel 7 days, warfarin 5 days with INR check; aspirin is often continued for secondary prevention.

NPO guidelines (ASA): clear liquids 2 hours, breast milk 4 hours, infant formula/nonhuman milk 6 hours, light meal 6 hours, fatty meal 8 hours before elective anesthesia.

Informed consent requires capacity, disclosure of risks/benefits/alternatives, comprehension, and voluntariness; document the discussion and the patient's questions.

Surgical hand scrub: timed scrub 3-5 minutes with antimicrobial soap, or alcohol-based rub per manufacturer; keep hands above elbows and dry completely before gowning.

Gowning and gloving: open glove method for first gown, closed method preferred for sterility; never touch the outside of the gown or gloves with bare hands.

Counts: sponge, needle, and instrument counts performed at setup, before closure of a cavity, and at skin closure; any discrepancy triggers an intraoperative radiograph.

Suture selection: absorbable (polyglactin, poliglecaprone, catgut) for mucosa and deep tissue; nonabsorbable (nylon, polypropylene, silk) for skin and fascia where tension is expected.

Electrocautery: use lowest effective power, avoid alcohol-based prep pooling, and never activate near oxygen-enriched environments; dispersive pad on dry, well-perfused muscle.

Hemostasis: pressure, ligature, clips, electrocautery, and topical hemostatic agents (oxidized cellulose, thrombin, gelatin) in that escalation order.

Specimen handling: label with patient identifiers, site, and orientation; place in formalin for permanent pathology and fresh/saline for frozen section or culture.

Drains: Jackson-Pratt for closed suction, Penrose for passive drainage; document type, location, and output at handoff.

Spaulding classification: critical items (sterile body contact) require sterilization; semicritical (mucous membrane contact) require high-level disinfection; noncritical (intact skin) require low-level disinfection.

Steam sterilization: 121°C at 15 psi for 15-20 minutes or 132°C at 27 psi for 4 minutes; monitor with biological indicator (Geobacillus stearothermophilus).

Ethylene oxide: 37-63°C, 4-6 hours exposure; biological indicator is Bacillus atrophaeus; aeration required to remove residuals.

Sterile field: only sterile items may contact it; a 1-inch margin around the drape is considered contaminated; items below waist level are nonsterile.

Surgical site infection prevention: chlorhexidine-alcohol skin prep preferred over povidone-iodine for most clean-contaminated cases; maintain normothermia (36.5-37.5°C) and normoglycemia.

Standard precautions apply to all patients; transmission-based precautions (contact, droplet, airborne) added for known or suspected pathogens.

Needlestick: wash with soap and water, report immediately, and initiate post-exposure prophylaxis evaluation within hours; HIV PEP is most effective when started within 2 hours.

Hand hygiene moments: before patient contact, before aseptic task, after body fluid exposure, after patient contact, and after contact with patient surroundings.

MAC values: sevoflurane 2.0%, isoflurane 1.15%, desflurane 6.0%, nitrous oxide 105%; MAC decreases with age, hypothermia, pregnancy, and opioids.

Induction agents: propofol 1.5-2.5 mg/kg IV; etomidate 0.2-0.3 mg/kg (hemodynamic stability); ketamine 1-2 mg/kg (bronchodilation, dissociation); succinylcholine 1-1.5 mg/kg.

Neuromuscular reversal: neostigmine 0.04-0.07 mg/kg with glycopyrrolate 0.2 mg to prevent bradycardia; sugammadex 2-4 mg/kg for rocuronium reversal.

Local anesthetics: lidocaine max 4.5 mg/kg without epinephrine, 7 mg/kg with epinephrine; bupivacaine max 2.5 mg/kg (3 mg/kg with epinephrine); toxicity presents with perioral numbness, tinnitus, seizures, then cardiac arrest.

Malignant hyperthermia: triggered by volatile agents and succinylcholine; treat with dantrolene 2.5 mg/kg IV, hyperventilation, cooling, and bicarbonate for acidosis.

Opioid equianalgesia: morphine 10 mg IV ≈ hydromorphone 1.5 mg IV ≈ fentanyl 100 mcg IV; adjust for renal function and age.

Antibiotic prophylaxis timing: cefazolin 2 g (3 g if >120 kg) within 60 minutes of incision; redose every 4 hours intraoperatively or with >1500 mL blood loss.

Anticoagulation reversal: protamine 1 mg per 100 units heparin; vitamin K plus PCC for warfarin; idarucizumab for dabigatran; andexanet alfa for factor Xa inhibitors.

Abdominal wall layers: skin, subcutaneous fat, Scarpa fascia, external oblique, internal oblique, transversus abdominis, transversalis fascia, preperitoneal fat, peritoneum.

Inguinal canal contents: spermatic cord (male) or round ligament (female); boundaries are the inguinal ligament inferiorly, conjoint tendon medially, internal oblique laterally.

Femoral triangle: inguinal ligament superiorly, sartorius laterally, adductor longus medially; contains femoral nerve, artery, vein (lateral to medial), and lymphatics.

Hesselbach triangle: inferior epigastric vessels laterally, rectus abdominis medially, inguinal ligament inferiorly; direct hernias protrude here.

Blood supply to the stomach: left gastric (celiac), right gastric (hepatic), short gastric and left gastroepiploic (splenic), right gastroepiploic (gastroduodenal).

Calot triangle: cystic duct, common hepatic duct, and inferior surface of liver; contains the cystic artery and is the dissection target in cholecystectomy.

Cardiac conduction: SA node fires 60-100 bpm; AV node delays 0.1 seconds; His-Purkinje system conducts at 1-4 m/s; normal PR 0.12-0.20 s.

Renal physiology: GFR ~125 mL/min; oliguria is <0.5 mL/kg/h; creatinine rises 0.3 mg/dL or 50% defines AKI (KDIGO).

Supine: arms tucked at <90° abduction to prevent brachial plexus stretch; pad heels and occiput; avoid pressure on the ulnar nerve at the medial epicondyle.

Trendelenburg: >30° increases intracranial and intraocular pressure and impairs ventilation; secure the patient against sliding with a footboard or gel pad.

Lithotomy: hip flexion <90° and abduction <45° to limit femoral nerve and peroneal injury; use candy-cane stirrups and confirm symmetric positioning.

Prone: pad eyes, breasts, genitals, and knees; maintain neutral cervical spine; arms tucked or abducted <90°; avoid pressure on the brachial plexus.

Lateral decubitus: place an axillary roll 2 cm caudal to the axilla to protect the brachial plexus; pad the dependent ear, shoulder, and hip.

Tourniquet: inflate to 100 mmHg above systolic for arm and 150-250 mmHg for leg; limit to 2 hours (arm) or 2-2.5 hours (leg) and document times.

Fire triangle: oxidizer (oxygen/nitrous), ignition (electrocautery/laser), fuel (drapes, hair, alcohol prep); allow alcohol-based prep to dry fully before draping.

Surgical smoke: evacuate with a smoke evacuator; surgical smoke contains benzene, formaldehyde, and viral particles, so N95 or equivalent is recommended.

Postanesthesia recovery: monitor airway, breathing, circulation, consciousness, pain, and temperature; discharge from PACU uses the Aldrete score ≥9.

Malignant hyperthermia can occur up to 24 hours postoperatively; suspect with unexplained hypercarbia, tachycardia, rigidity, and hyperthermia.

Postoperative fever mnemonics: within 24 hours (atelectasis), 24-72 hours (pneumonia, UTI), 3-5 days (surgical site infection), 5-7 days (abscess, anastomotic leak), after 7 days (drug fever, DVT).

Hypovolemic shock: tachycardia, narrow pulse pressure, cool extremities, urine output <0.5 mL/kg/h; resuscitate with crystalloid and blood products as indicated.

Anastomotic leak: tachycardia, fever, ileus, abdominal pain, and rising WBC; CT with contrast or re-exploration is diagnostic and therapeutic.

DVT prophylaxis: mechanical (SCDs) plus pharmacologic (enoxaparin 40 mg daily, heparin 5000 units q8-12h) based on Caprini risk score.

Wound dehiscence: sudden gush of serosanguineous fluid, abdominal pain, and fascial separation; requires immediate surgical repair.

Postoperative nausea and vomiting: Apfel score (female, nonsmoker, history of PONV, postoperative opioids); use ondansetron 4 mg, dexamethasone 4-8 mg, and droperidol.

CRNFA scope: first assistant duties include wound closure, hemostasis, and tissue handling under direct supervision of the operating surgeon; the CRNFA does not perform the primary procedure.

Scope of practice is defined by state nurse practice act, facility credentialing, and professional certification, not by employer preference alone.

Informed consent: verify the patient's understanding, confirm the surgeon obtained consent, and advocate for the patient's questions before transport.

Never events (e.g., wrong-site surgery, retained foreign body) require immediate disclosure to the patient and family, plus institutional reporting.

Conflict of interest: disclose financial relationships with device or pharmaceutical companies; decline gifts that could influence clinical judgment.

Documentation: record time-outs, counts, implants, specimens, and patient position; late entries are marked as such and never altered.

Delegation: RNs may delegate tasks to unlicensed assistive personnel only when the task is within the delegate's training and the RN retains accountability.

Patient advocacy: report unsafe practice through the chain of command; mandatory reporting applies to impaired colleagues and suspected abuse.