Intraoperative Phase

- Giving nursing care to client undergoing surgery

- It is a start from the time the client was admitted to the OR during operation until it ends and transferred to the
PACU

Environment of the operating room:

 Preparation of the surgical suite and team safety
 Layout
 Health and hygiene of the surgical team
 Surgical attire
 Surgical scrub

Members of the surgical team:

 Patient
 Anesthesiologist or anesthetist surgeon
 Surgeon
 Nurses (scrub and circulating)
 Surgical technologist

Insert picture – operative team

Nurses should serve as a patient advocate

Roles:

1. Surgeon
- responsible for determining the preoperative dis, the diagnosis, choice and execution of the surgical
procedure, the explanation of the risk and benefits, obtaining inform consent and the postoperative
management and the patient’s

2. Scrub nurse
- RN or scrub tech
- Preparation of supplies and equipment on the sterile field; maintenance of patient safety and integrity:
observation of the scrubbed team for breaks in the sterile fields; provision of appropriate sterile
instrumentation, sutures, and supplies; sharps count

3. Circulating nurse
- Responsible for creating a safe environment, managing the activities outside the sterile field, providing
nursing care to the patient
- Document intraoperative nursing care and ensures surgical specimens are identified and placed in the
right media
- In charge of the instrument and sharps count and communicating relevant information to individual
outside of the OR, such as family members
 4. Anesthesiologist and anesthetist
- Anesthetizing the patient appropriate levels of pain relief, monitoring the patient’s physiologic status
and providing the best operative conditions for surgeons

5. Other personnel
- Pathologist, radiologist, perfusionist, EVS personnel

Prevention of infection
 The surgical environment – stark appearance and cool temperature. Located central to all supporting services
o Unrestricted zone – where street clothes are allowed
o Semi restricted zone – where attire consists of scrub clothes and caps
o Restricted zone – where scrubs clothes, shoe covers, caps, as masks are worn
 Surgical asepsis
o Ensure sterility
o Alert of breaks – surgical conscience
o Surgical conscience
 The awareness, which develops from a knowledge base, of the importance of strict adherence
to principles of aseptic and sterile techniques
 Guidelines:
 All materials in contact with the wound and within the sterile field must be sterile
 Gowns are sterile in the front from chest to the level of the sterile field and sleeves form
2 inches above the elbow to the cuff
 Only the top of a draped table is considered sterile. During draping, the drape is held
well above the area and is placed from front to back
 Whenever a sterile barrier is breached, the area is considered contaminated
 Every sterile field is constantly maintained and monitored. Items of doubtful sterility are
considered unsterile
 Sterile field are prepared as close as possible to time of use
 Before an operation:
 It is necessary to sterilize and keep all instruments, materials, ad supplies that come in
contact with the surgical site
 Every item handed by the surgeon and the surgeon’s assistants must be sterile
 The patient’s skin and the hands of the members of the surgical team must be
thoroughly scrubbed, prepared, and kept as aseptic as possible
 Dayak – is an indicator of sterility; will change color; clear but will change into a darker
color when already sterile
 Surgeons will do the final painting
 During the operation
 The surgeon, surgeon’s assistants, a d the scrub burse must wear sterile gowns and
gloves and must not touch anything that is not sterile
 Maintaining a sterile technique is a cooperative responsibility of the entire team
 Each member must develop a surgical conscience, a willingness to supervise and be
supervised by others regarding the adherence to standards
 All personnel assigned to the operating room must practice god personal hygiene. This
includes daily bathing and clothing change
  Those personnel having colds, sore throats, open sores, and/or other infections should
not be permitted in the operating room
 Operating room attire (which includes scrub suits, gowns, head coverings, and face masks)
should not be worn outside the operating room suite. If such occurs, change all attire before re-
entering the clean area. (the operating room and adjacent supporting areas are classified as
“clean areas”)
 All members of the surgical team having direct contact with the surgical site must perform the
surgical hand scrub before the operation
 All materials and instruments used in contact with the site must be sterile
 The gowns worn by surgeon and scrub and other scrub members are considered sterile
from shoulder to waist (in the front only), including the gown sleeves
 If sterile surgical are torn, punctured, or have touched an unsterile surface or item, they
are considered contaminated
 The safest, most practical method of sterilization for most articles is steam under pressure
 Label; all prepared, packaged, and sterilized items with an expiration date
 Use articles packaged and sterilization in cotton muslin wrappers within 28 calendar days
 Use articles sterilized in cotton muslin wrappers and sealed in plastics within 180 calendar days
 Unsterile articles must not come in contact with sterile articles
 Make sure the patient’s skin is as clean as possible before a surgical procedure
 Take every precaution to prevent contamination of sterile areas or supplies by airborne
organisms

HANDLING STERILE ARTICLES:

 When you are changing a dressing, removing sutures, or preparing the patient for a surgical procedure, it will be
necessary to work . the field should be established on a stable, can, flat, dry surface
 An article is either sterile or unsterile; there is no in-between. If there is doubt about the sterility of an item,
consider it unsterile
 Any time the sterility of a filed has been compromised, replace the contaminated field and setup
 Do not open sterile articles until they are ready to use
 Do not leave sterile articles unattended once they are opened and placed on a sterile field
 Do not return sterile articles to a container once they have been removed form the container
 Never reach over a sterile field
 When pouring a sterile solution into sterile containers with the solution bottle. Once opened and first poured,
use bottles of liquid entirely. If any liquid is left in the bottle , discard it
 Never use an outdated article. Unwrap it, inspect t it, and if reusable, rewrap it in a new wrapper for sterilization

NURSING CARE DURING SURGERY

 Assisting with positioning:

- the dorsal recumbent (supine) position is commonly used for hernia repair, mastectomy, or bowel
resection
- Trendelenburg’s position permits displacement of the intestines into the upper abdomen and its often
used during surgery of the lower abdomen or pelvis
- the lithotomy position exposes the perineal and rectal areas, and is ideal for vaginal repairs, dilatation
and curettage =, and most rectal surgeries
- the lateral position is used for clients undergoing kidney, chest, or hip surgery
 - the laminectomy (prone) position is used during surgical procedures involving the spine
- insert pic – patient lying

RISK FOR PERIOP POSITIONING

 Interventions include:
- Proper body positioning
- Addressing risk for pressure ulcer formation
- Prevention of obstruction of circulation, respiration, and nerve conduction

INTRAOPERATIVE PHASE: ANESTHESIA

- Greek word – anesthesis, meaning “negative sensation”
- Artificially induced stated of partial of total loss of sensation, occurring with or without consciousness
- Induced state of partial or total loss of sensation, occurring with or without loss of consciousness
- Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some instances,
achieve a controlled level of unconsciousness

**ASA Classfication

ASA 1 Healthy Person

ASA 2 Mild Systemic disease

Anesthetic Triad

1. Analgesia-NOL Monitoring
2. Amnesia-BIS
3. Muscle relaxation

Phases of Anes

1. Induction
2. Maintenance
3. Emergence

Anesthesia agents

 Inhalation anesthesia agents

- Gases or volatile liquids that produce general anesthesia
- 2 types:
 Gaseous agents
- Nitrous oxide
- Colorless, odorless, nonexplosive gas referred as ”carrier of gases”
 Volatile agents
- Liquids that are easily vaporized and produce anesthesia when inhaled
- Ether, chloroform, halothane, enflurane, methoxyflurane, isoflurane, desflurane
- All these agents require a special vaporizer for administration

Inhalational Anesthetic Agents

1. Gas
a. Nitrous oxide
Advanteage : light analgesia
 Disadvantage: accumulation in airway spaces
2. Volatile liquieds
a. Isoflurane
Adva
b.

General Anesthesia

 Reversible loss of consciousness is induced by inhibiting neuronal impulses in several areas of the central
nervous system
 State can be achieved

Effects of general anesthesia

 Intravenous agents
- Agents than produce anesthesia in large doses through sedative- hypnotic-analgesic actions
- 3 categories:
 Barbiturates and others
- Act directly in the CNS producing and effect ranging form mild sedation to sleep
- Thiopental Sodium, Ketalar, Propofol (diprivan) – MJ used; milky white
 Opioid analgesics
- Pain free
- Demerol, morphine sulfate, valium
 Muscle relaxants
- Anesthesia adjuncts
- Provide muscle relaxation during surgery and/or facilitate the passage of an
endotracheal tube
- Pavulon, norcuron, tracrium, etc.

 Local anesthesia (regional or topical)

- Agents that block nerve conduction in a specific area
- Interrupts transmission of sensory nerve impulses so it: NUMBS WHAT TOUCHES
- Sensory nerve impulse transmission forma specific body area or region is briefly disrupted
- Motor function may be affected
- Client remains conscious and able to follow instructions
- Gag and cough reflexes remain intact
- Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety
- Require multiple injections with “CAINE” drug (novacaine, lidocaine)
- DURATION = 1 min to 20-30 min
 Can be prolonged with added epinephrine
- Assess for allergy

- TYPES OR REGIONAL ANESTHESIA

 Topical (surface)
- Applied directly to the skin and mucous membranes
- Easily absorbed and acts rapidly
 Local (infiltration)
- Used for minor and superficial procedures in which the agent is injected into a specific
area
 - Local with MAC (Monitored Anesthesia Care) – used with the presence of an
anesthesiologist
 Nerve block
- A technique in which the anesthetic agent is injected into and around a nerve or a verve
of a group that supplies sensation to a small area of the body
 Intravenous block (Bier Block)
- Involves the intravenous injection of a local agent and use of an occlusion tourniquet to
prevent absorption into general circulation
- Used for procedures involving the arm, wrist, hand and the lower extremities
 Spinal
- Occurs when the anesthetic agent is injected into the CSF within the subarachnoid space
- Injected into the L345; end of spinal cord L1 or L2
- Indications
o Surgical procedures below the diaphragm
o Patients with cardia or respiratory disease
- Advantages
o Mental status monitoring
o Shorter recovery
- Disadvantages
o Necessary extra expertise
o Possible patient pain
- Contraindications
o Coagulopathy
o Uncorrected hypovolemia
- Involved meds
o Lidocaine
o Bupivacaine
o Tetracaine
- Patient assessment
o Continuous heart rate, rhythm, and pulse oximetry level (normal value: 95-
100%)
o Level of anesthesia
o Motor functions and sensation return monitoring

Complications

 Epidural (pedidural)
- Involves the injection of an anesthetic agent into the epidural space, the area outside
the dura mater, but inside spinal column
- Administered via bolus injection or through a small, thin catheter
- Can be used for anorectal, vaginal, and perineal as well as higher intraabdominal
procedures
- Injected into epidural space rather than subarachnoid fluid (usually safer)
- Used in OR and OB
- Epidural catheter can be left in place for postop pain management (PCA)

- COMPLICATIONS OF LOCAL/REGIONAL ANESTHESIA

 Anaphylaxis
 Administration technique
  Systemic absorption
 Overdosage
 Assess for
 Central nervous system stimulation
 Central nervous system and cardiac depression
 Restlessness, excitement
 Incoherent speech
 Headache, blurred vision
 Metallic taste, nausea and vomiting
 Tremors, seizures
 Increased pulse, respirations, and blood pressure
- TREATMENT OF COMPLICATIONS
 Establish an open airway
 Give oxygen
 Notify the surgeon
 Fast-acting barbiturate is usual treatment
 If toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death
may result

 General anesthesia
- Reversible loss of consciousness is induced by inhibiting neural impulses in several areas of the central
nervous system
- State can be achieved by a single agent or a combination of agents
- Central nervous system is depressed, resulting in analgesia, amnesia, and unconsciousness, with loss of
muscle tone and reflexes

- Effects:
 The body systems affected by general anesthetics are neurologic, respiratory, and
cardiovascular systems
 General anesthesia is best suited surgery of the head, neck, upper torso, and back: for
prolonged surgical procedures: or for clients are unable to lie quietly who are unable to
prolonged period of time
 General anesthetics agents affect all tissues in the body to some degree

- Stages:
 Stage 1 – onset (amnesia/analgesia)
- From administration to loss of consciousness
- Assessment
o client maybe drowsy or dizzy
o may experience auditory or visual hallucinations
- Nursing interventions
o close O.R. doors
o keep room quiet
o standby to assist anesthesiologist
 Stage 2 – excitement/delirium
- Loss of consciousness to loss of eyelid reflexes
- Most dangerous stage
- Assessment
o increase autonomic activity
 o irregular breathing
o client may struggle
- Nursing interventions
o Remain quietly at client’s side
o Assist anesthesiologist, if needed
o Remain alert for any emergency situations
o Considered an extremely dangerous stage that could result in laryngospasms
o Vomiting
o Aspiration
o Arrythmias
o Myoclonic movement - twitches or jerks usually are caused by sudden muscle
contractions, called positive myoclonus, or by muscle relaxation, called
negative myoclonus

 Stage 3 – surgical anesthesia

- From the regular pattern of respirations to the total paralysis of the intercostal muscles
and cessation of voluntary ventilation
- Assessment
o Client is unconscious
o Muscles are relaxed
o No blink or gag reflex
- Nursing interventions
o Begin preparation (if indicated) only when anesthetist indicates stage 3 has
been reached and client is under control
o Recheck patient positioning
o Reaffirm safety precautions

 Stage 4 – danger (death)

- From the time cessation pf ventilation to failure of the circulation, caused by high levels
of anesthesia in the CNS.
- Accidentally reached
- NOT DESIRABLE
- Assessment:
o Client is not breathing
o May or may not have a heartbeat
- Nursing interventions
o If arrest occurs, respond immediately to assist in establishing airways
o Provide immediate arrest tray, drugs, syringes, long needles
o Assist surgeon with closed or open cardiac massage

- COMPLICATIONS FROM GENERAL ANESTHESIA

 Malignant hyperthermia – possible treatment with dantrolene
- A potentially fatal hypermetabolic, genetically transmitted syndrome
- Physiologically, the patient apparently has a defect in the reticuloendothelial system of
the muscle cell allowing the anesthetic to trigger a sudden rise of calcium within the
muscle cell and sets off a series of biochemical reactions that lead to an increased
metabolic rate, transforming the energy of the contracted muscle into heat
(hyperthermia)
 - TREATMENT
o Discontinue inhalant anesthetic, and the surgery
o Give dantrolene sodium (Dantrium) IV, 100% oxygen, dextrose 50%, diuretic,
antiarrhythmics, sodium bicarbonate
o Do hypothermic measures – cooling blanket, iced IV saline or iced saline lavage
of stomach, bladder, rectum
 Overdose
 Unrecognized hypoventilation
 Complications of specific anesthetic agents
 Complications of intubation

 Balanced anesthesia
- Combination of intravenous drugs and inhalation agents used to obtain specific effects
- Combination used to provide hypnosis, amnesia, analgesia, muscles relaxation, and reduced reflexes
with minimal disturbances of physiologic function

 Conscious sedation
- IV delivery of sedative, hypnotic and opioid drugs reduces the level of consciousness but allows the
client to maintain a patent airway and to respond to verbal commands
- Most common drugs
 Diazepam  Fentanyl
 Midazolam  Alfentanil
 Meperidine
- Nursing Assessment
 Airway
 Level of consciousness
 Oxygen saturation
 Electrocardiographic status
 Vital signs – monitored q 15 min

Intraoperative Complication
- Signs and symptoms
 Tachycardia – most consistent early symptoms; usually sudden and unexplained
 Tachypnea
 Unstable BP
 Arrythmias
 Dark blood at the surgical field
 Cyanosis and mottling of skin
 Profuse sweating
 Fasciculations and/or rigidity
 Metabolic/respiratory acidosis
 Sudden rise in temperature (43°C)

TYPES OF SUTURES
- Absorbable or non-absorbable
- Monofilament or multifilament (braided)
 - Dyed or undyed
- Sized 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate
progressively smaller)
- New antibacterial sutures
- Non-absorbable - Absorbable
 Not biodegradable and permanent  Degraded via inflammatory response
 Nylon  Licryl monocryl
 Prolene  PDS
 Stainless steel  Chromic
 Silk (natural, can break down over  Cat gut (natural)
years)

- Natural suture - Synthetic

 Biological  Synthetic polymers
 Cause of inflammatory reaction  Do not cause inflammatory response
 Cat gut (connective from cow or  Nylon
sheep)  vicryl
 Silk (from silkworm fibers)  monocryl
 Chromic catgut  PDS
 prolene

SURGICAL NEEDLES
- wide variety with different company’s naming systems
- 2 basic configurations for cured needles
 Cutting – cutting edge can cut through tough tissues, such as skin
 tapered – no cutting edge. for softer tissues inside the body

WOUND EVALUATION
- Time of incident
- Size of wound
- depth of wound
- tendon/nerve involvement
- bleeding at site

WHO SURGICAL SAFETY CHECKLIST

Sign in
 prior to induction of anesthesia
 patient confirmed
 identity
 site
 procedure
 consent

prior to induction to anesthesia (sign in)

↓
prior to incision (time out)
 ↓
prior to patient leaving the operating theater (sign out)

NURSING GOALS FOR THE PATIENT IN THE INTRAOP PERIOD

 Reducing anxiety
 Preventing positioning injuries
 Maintaining patient safety
 Maintaining the patient’s dignity
 Avoiding complications

NURSING PROCESS
 Intervention
o Safety
o Advocacy
o Verification
o Counting – SIN (sponges, instruments, needles)

 Evaluation
o Expected
o Unexpected
o Documented
o Informing client and family
o Surgical wating room
o Ongoing updates by OR team

INTRAOPERATIVE SAFETY

 Maintenance of sterile technique

 Continuous patient monitoring
 Instrument count
 Sponge count
 Breaks for personnel

Rapid Sequence Induction (RSI)

Is a method of aachieving rapid control of the airway while minimizing the risk of regurgitation and aspiration of gastric
contents.

Commonly used where GA must be induced before the patient has had the time to fast long enough to empty the
stomach

Steps:

a. Pre-oxygenating the patient

b. Cricoid pressure
c. Intravenous induction of anesthesia
d. Inserting ETT
Cricoid pressure/Sellick’s maneuver

 Application of backward pressure on the cricoid cartilage with a force of 20-40 newtons to occlude the
esophagus, preventing aspiration of gastric contents during induction of anesthesia.

New trends in intubation

Laryngeal Mask Airway (LMA)

1st generation (simple airways)

Adjuncts to Anesthesia

 Flotrac-hemodynamic monitoring system, minimally invasive technique to estimate CO and CI

 Bair hugger-
o Is a convective temperature management system to maintain core body temperature
o Consists of a reusable warming unit and a single-use disposable warming blankets for use before, during,
and after surgery
 BIS monitor (bispectral index
o Used to monitor depth of anesthesia
 Foor pump
o Mechanical prophylaxis in preventing venous thromboembolism
o Reduing swelling, increase circulation and decreases DVT
 Fluid warmer
o Actively warm fluids while being administered (in-line warming)

TIVA/TCI

Total Intravenous Anesthesia/Target Controoled Infusion

 A technqieu of GA which uses a combination of agents given exclusively by the IV route without the use fo
inhilation agents
 Marsh and Schnider models

Local or Regional Anesthesia

 Sensory nerve impulse transmission from a specific body area or region is briefly disrupted
 Motor fuction my be affected
 Client remains conscious and able to follow instructions
 Gag and cough reflexes remain intact
 Sedatives, opioid analgesics, or hypnotics are often used as supplements to reduce anxiety