Intraoperative Nursing
Krista Brecht Krisna Ogerio Donna Stanbridge Danielle Vigeant Suzanne Watt With contributions by: Jane Ashley Kathleen Osborn

Outcome-Based Learning Objectives
After studying this chapter, the learner will be able to: 1. Discuss the sequence of events for the patient from the beginning of surgery to arrival in the postanesthesia care unit. 2. Differentiate the roles of the surgical team. 3. Describe the interplay between each team member in the success of the surgical intervention. 4. Prioritize nursing interventions to maximize patient safety in the operating room. 5. Evaluate effective nursing measures for patient advocacy in the operating room. 6. Prioritize the nursing care of patients experiencing selected intraoperative complications. 7. Differentiate the role of the certified nurse and the anesthesiologist for the anesthetized patient.

THE GOAL of perioperative or intraoperative nursing practice
is to assist patients and their families to achieve a level of wellness equal to or greater than that which they had prior to the procedure (Association of periOperative Registered Nurses [AORN], Perioperative Nursing Data Set (PNDS-2007). The most important role of the perioperative nurse is to be a patient advocate. The essence of the advocacy in the perioperative role is defined as protection, communication (giving a voice), doing, comfort, and caring. Advocacy is described as an act of informing and supporting the individuals so that they may make the best decisions possible for themselves. It is also speaking up for someone who is unable to speak for himself. Advocacy is a critical issue for surgical patients who are unconscious or sedated and unable to make decisions related to their care. Protecting patients from harm is the essence of the advocacy role of nurses, and it is a critical component for patients whose family members are not readily accessible and whose only possible advocate is the nurse. This is often the case for the patient having surgery. Many perioperative issues involve advocacy. These may include helping patients who are uninformed or have not given adequate consent for surgical procedures, confronting an incompetent colleague, pressing for more analgesia for

a patient in pain, or supporting the patient’s view toward prolonging life with extraordinary treatment or technology.
Surgical patients can be compromised by stress, disease process, and sedation or general anesthesia, and they trust that a perioperative nurse will advocate in their best interest to ensure their privacy, dignity, rights, and safety.

The nurse must accept accountability for nursing actions that safeguard the rights of the surgical patients. Perioperative nurses act as patient advocates by protecting, and they must be able to quickly and accurately identify advocacy issues and be ready to intervene on behalf of their patients. In recent years, the acceptance of a conceptual model for patient care, published by AORN, has helped to distinguish the relationship of various components of nursing practice and the effect on patient outcomes (Beyea, 2000) (Figure 26–1 ).

Guidance for Professional Practice
The practice of perioperative nursing is guided by its own professional organization, the Association of periOperative Registered Nurses, as well as the Centers for Disease Control and


Intraoperative Nursing 619


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Surgical Team
Successful surgery relies on the interplay of many individuals working as a team, complementing each other’s skills and responsibilities. This multidisciplinary team includes the surgeon and assistants, anesthesiologist and assistants, the nursing team, and support staff. Each of these professionals is responsible for specific functions and plays a role in supporting the other groups. This overlap of responsibilities ensures the safety of patients while they are in a most vulnerable situation of not being able to give any personal input. The roles of each member are described next.

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AORN (2008). The PNDS Model. Retrieved on July 2, 2008 from Resources/PNDSAndStandardizedPerioperativeRecord/PNDSModel/.

Prevention (CDC) and the Joint Commission. AORN defines its mission as follows: “to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures by providing practice support and professional development opportunities to perioperative nurses.” AORN is composed of approximately 41,000 perioperative registered nurses in the United States and abroad who manage, teach, and practice perioperative nursing; who are enrolled in nursing education; and who are engaged in perioperative research (AORN, 2007a). This professional organization has developed a conceptual framework and vocabulary called the Perioperative Nursing Data Set (PNDS). The data set addresses the domains of safety, physiological responses, behavioral responses of the patient and family, and the environment of the perioperative setting within the health system. The CDC’s mission is to promote health and quality of life by preventing and controlling disease, injury, and disability. It also influences perioperative practice. In 1999, the CDC issued guidelines for the prevention of surgical infection. Additionally, it reflected the mission statement of the Joint Commission to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations (Joint Commission, 2007). The Joint Commission is an independent, not-for-profit organization that is the United States’ predominant accrediting body charged with maintaining and improving health care delivery. The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with its standards and other accreditation requirements. Joint Commission accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To earn and maintain the Joint Commission’s Gold Seal of Approval, an organization must undergo an on-site survey by

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The surgeon heads the surgical team and is responsible for making decisions related to the surgical procedure. Depending on the procedure, an assistant might be required. This assistant could be another surgeon, physician, resident in a university teaching hospital, or the registered nurse first assistant. The surgeon is responsible for performing the procedure and for coordinating the team. An expanded role for perioperative nurses is that of registered nurse first assistant (RNFA). The RNFA collaborates with the surgeon and performs the role of first assistant during the operation. This role includes handling tissue, providing exposure, using instruments, suturing the wound, and providing hemostasis. The role of an RNFA is highly specialized and demanding. In 2008, AORN approved a policy statement that defines the RNFA role, scope of practice, and qualifications.

Perioperative patient-focused model.

Anesthesia Care Provider
The anesthesiologist is a health care provider who specializes in the administration of anesthetic agents and provides care to alleviate pain and promote relaxation. This professional is responsible for maintaining the airway; monitoring and ensuring gas exchanges, respiration, and circulation; estimating and replacing blood and fluid losses; administering medications to maintain hemodynamic stability; managing care in the event of a physiological crisis; and constantly communicating with the surgical and nursing team. The anesthesiologist heads the anesthesia team and might be assisted by a respiratory therapist, anesthesia resident or fellow in a university teaching hospital, or a certified registered nurse anesthetist (CRNA). As Chapter 1 discussed, the CRNA is an advance practice nurse, educated with a master’s degree from an accredited nurse anesthesia educational program. CRNAs administer anesthesia and anesthesia-related care in four general categories: (1) preanesthetic preparation and evaluation; (2) anesthesia induction, maintenance, and emergence; (3) postanesthesia care; and (4) perianesthetic and clinical support functions. The CRNA works under the supervision of the anesthesiologist. In a large study examining morbidity associated with anesthesia, researchers found several factors that significantly reduce the risk of anesthesia. Among these are the direct availability of an anesthesiologist during surgery, the presence of a consistent anesthesia care provider throughout the case, and the presence of an anesthetic nurse (Arbous et al., 2005).

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2007a). The assessment provides a baseline against which information about the individual’s stability can be measured and monitored at any stage of her perioperative experience. The scrub nurse works directly with the surgeon within the sterile field passing instruments. calm transition area for the patient to wait immediately before surgery. Perioperative Nursing Education Given that most nursing programs offer limited or no operating room experience in their curricula. & van den Broek. Should hair removal be indicated. 2003. The practice of same-day admission has become popular for both financial reasons and because evidence suggests that surgical-site infection rates are reduced when the preoperative stay is reduced (Nichols. or per the institution’s policy or surgeon’s preference (Evidence-based practice information sheets. anesthesia. It provides a shield from the sights and sounds of the busy surgical suite and allows personnel to interview the patient and verify the documenta- Health Promotion Patient teaching for the intraoperative patient is usually done in a preadmission testing clinic or the day before the surgery in a . 2001). The responsibilities of the perioperative nurse in this setting are to verify the appropriate data have been obtained. assistant head nurse. and other items needed during the surgical procedure. The nursing care plans that are developed based on the assessment data are utilized to ensure continuity of care during each phase of the individual’s perioperative experience. in addition to the regular surgical attire. 2005). The preoperative holding area is a semirestricted area usually just inside of the surgical area. and application of an antiseptic agent when required. head nurse or nurse manager. positioning the surgical patient. Surgical Areas Patients needing surgery go to the operating room for a surgical procedure after having been admitted to the hospital on the same day as surgery. Surgical-site skin preparation includes a baseline assessment. sponges. hair removal. 2006). scrubbing and circulating. Nurses The perioperative nurse’s primary role in the operating room (OR) is that of the circulating nurse. aseptic technique. in which case the person is then called a scrub technician. Patients also access the operating room emergently through the emergency department. teamwork. nurses initiating a career in the OR get their perioperative education either at the hiring institution or by enrolling in a postgraduate or fellowship perioperative program. The perioperative nurse performs the preoperative assessment of patients in the holding area. health promotion in the perioperative arena has become more evident as perioperative nurses have gained great satisfaction from knowing that they are part of a team committed to an individual patient with an individualized outcome. The circulating nurse observes the surgical team from a broad perspective and assists the team to create and maintain a safe. There is some evidence that use of hair clippers is superior to use of a razor. cleaning of the surgical site and surrounding area. As with any specialty. In fact. the perioperative nursing assessment is the first step in providing individualized care for perioperative patients. The focus is aimed at promoting and maintaining wellness as well as identifying and preventing illness (Hurley & McAleavy. improve the field of view. This area provides a quiet. but more research is needed (Niel-Weise et al. and reinforce teaching as needed. hair removal is instead performed to improve access to surgical site. 2005). Prior to being admitted to the surgical setting. The circulating nurse’s duties are performed outside the sterile field and encompass responsibilities of nursing care management within the OR. nurse educator. This information is the basis for planning the patient’s individualized perioperative care. The sterile field is the area closely surrounding the OR table. 2007a).620 UNIT 5 Nursing Management of the Surgical Patient patient general surgical unit. facilitating a united effort while being the patient advocate whose actions are dedicated to ensuring that the patient’s rights and wishes are respected and carried out. 2007b). this framework enables perioperative nurses to shift from a task-oriented role to that of providing a holistic view of the patient.. comfortable environment for surgery. Surgical team members who work within the sterile field perform a surgical scrub of their hands and arms with special disinfecting solution and. Once in the preoperative area. perioperative assessment. The use of the nursing process emphasizes a patient-centered approach. The circulating nurse communicates patient care needs to each member of the surgical team. Research studies have revealed that hair removal does not reduce the incidence of surgical-site infections (SSIs). Niel-Weise. unless an extensive work-up or in-hospital treatments or tests are required prior to surgery. Programs may include the surgical environment. Other roles for RNs are team leader. These assessments provide valuable information to the entire perioperative team. Most states have taken legislative measures in order to ensure the presence of a registered nurse in the circulator role in the OR for every surgical procedure. Traditionally hair removal was extensive and often performed the day prior to surgery. surgical instruments. This role can also be performed by other personnel than an RN. don a sterile gown and gloves. safety considerations. Presurgical or Preoperative Holding Area The surgical area typically has a presurgical or preoperative holding area next to the operating rooms. The nursing process serves as a guide to make perioperative nursing assessments comprehensive and holistic in nature. and clinical nurse specialist. assess the patient for readiness both physically and emotionally. today. the nurse is now able to demonstrate the caring aspect of perioperative nursing by participating in a preoperative assessment of the patient. and wound healing and hemostasis (AORN. the patient dons a gown and cap. 624). patient teaching. nurses are often instructed through a cognitive apprenticeship model in the OR in which they take on increasingly complex responsibilities over time. In addition to didactic modules. care needs to be taken to maintain skin integrity and minimize injury. As illustrated through the PNDS (p. It is estimated that a minimum of 3 to 6 months of instruction is required to adequately educate nurses with no previous OR experience depending on the OR’s activities (AORN. even if the nurse’s main role is still to ensure patient safety throughout a patient’s surgical experience. the patient is normally anxious and stressed and assumes a passive role as the recipient of technical care. Therefore. The removal is ideally done outside of the surgical suite as close to the surgery time as possible (AORN. sterilization and disinfection. Willie.

. hands-free dispensers. and diagnostic tests are on the patient’s chart. The perioperative nurse ensures that the results of all laboratory. or exploration of body tissue or organs. Surgical hand preparation. that they have been reviewed and are consistent with each other. improved skin health. A speech recognition robot allows the surgeon to control the operating bed. This room is a restricted area where the team of health care professionals wears . repair. for communicating with other areas of the hospital or consultants. medical devices accompanying the patient or indwelling medical devices. This includes oxygen. Additionally. and the robotic surgical assistant enables the surgeon to control precise technical movements of a robotic arm from a console station. The perioperative nurse also notes the medical diagnosis. and reduced use of time and resources (Larson et al. shoe covers. Due to the rapid growth of surgical technologies and innovation during the past decade. All relevant information is communicated to the surgical team. and with the patient involved. commonly referred to as “scrubs. Equipment should be readily available in the preoperative holding area for patient care and monitoring. Robotic systems are currently in use for certain cardiac procedures with plans for expansion on the horizon. • Use a standardized hand scrub procedure that follows manufacturer’s written guidelines and is approved by the health care facility. The operating Operating Room Surgery may involve the removal. Below is a list of recommended surgical hand preparation practices (AORN. 2001). The NPO status of the patient is also confirmed by the nurse to assess any potential risk of aspiration. lighting. trousers. the nurse must verify that all the relevant documents and studies (films. This verification should occur before the patient leaves the preoperative area and enters the procedure/surgical room. psychosocial conditions. The operating room or suite is where the surgery will be performed. • Remove all jewelry from hands and forearms before performing hand hygiene. radiographic. and other devices with simple voice commands. or instructions especially with regard to cultural or spiritual beliefs. In addition digital information is becoming the standard format for accessing patient information and images. waterless hand preparation boasts a reduction in microbial counts of hands. scans. attire that was donned in the surgery dressing room. surgical facilities are examining ways to improve the use of physical resources and health care professionals’ time. McVey. allergies are documented as per facility policy. sometimes leading to undesirable changes of hand skin flora and colonization. In the holding area. Surgical robots make it likely that future surgeries could be performed at one facility with the surgeon operating the console from a distant facility. patient’s physical appearance. fast-acting. Compared to the traditional surgical scrub. previously known as a “surgical scrub. 2000).” is performed prior to participating in a surgical procedure in order to reduce the potential risk of SSI by reducing the number of microorganisms on intact skin of the hands and forearms. This has been done in part to address the abundance of equipment needed in today’s operating rooms as well as ergonomic issues. an emergency medical cart and defibrillator should be nearby (Bailey. procedure. the patient is asked to empty the bladder to prevent incontinence or overdistention because an overly full bladder can hinder access to the surgical site and predispose the patient to inadvertent surgical bladder injury. and Chart 26–1 (p. drainage. Recent trends in surgery include the move toward less invasive techniques with shorter hospital stays and faster recovery periods. replacement. and/or capped teeth. and be stored in disposable. 2006). and mask. Accurate documentation of height and weight is important for proper dosage calculation of the anesthetic agents.) are available prior to the start of the procedure. advise the surgical team whether the patient is a member of Jehovah’s Witnesses and does not accept blood products or whether the patient is hard of hearing and does not have his hearing aid (Hurley & McAleavy. 2007b). Showing respect for patients’ spiritual beliefs. FDA-approved antiseptic agent.” includes a shirt. 2005. etc. The nurse accompanies the patient to the operating room where the patient will be placed on the operating table and prepared for surgery. For example. On it. and for conferring with other health care providers. nonirritating. video displays. Preoperative Operating Room Checklist The preoperative checklist is a tool for continuing the patient assessment. 622) highlights the differences between a surgical scrub and hand rub preparation method: • Do not wear artificial nails. One of the newest trends promising to transform surgery is the intelligent OR. • Use only lotions that are approved by infection control staff. water. 2005). dentures. When the operating room suite is ready to receive the patient.. cap. pulse oximetry. Any abnormal results are documented and reported to the surgical team as well as any special needs. Sullivan. and physical limitations facilitates rapport and trust that enable nurses to understand the important role these factors play in how people cope with fear and anxiety related to their perceived perioperative experience. Traditional scrub techniques with prolonged use of detergent. electrocardiogram machine. suction. and a blood pressure cuff. concerns. • Keep skin free from open lesions and breaks. and any prostheses. many operating rooms have been renovated or reconstructed. visual skin assessment. Those directly involved in the surgical procedure will have scrubbed and will be wearing sterile gowns. jewelry. and psychosocial conditions. Hand preparation considerations include use of a broadspectrum. Urinary catheterization is performed in the OR as necessary (Iorio et al. This attire. and site and as applicable implant is also needed. Team consensus about the intended patient. lotions must be compatible with the hand antiseptic and gloves. and brushes have contributed to the deterioration of skin. & Pevreal. The intelligent OR incorporates advanced robotic surgical systems. previous surgical experience. The nurse also ensures that prescribed preoperative medications have been taken by the patient and any medications that have been ordered to be given just prior to surgery such as antibiotics are documented on the chart accompanying the patient. physical impairments or limitations. One of the nurse’s roles in robotic surgery is to assist the surgeon at the patient’s side during the operation. A robotic endoscopic camera facilitates optimal views of the surgical field.CHAPTER 26 Intraoperative Nursing 621 tion.

Wash hands. Note: Step 2 is performed for the first scrub of the day or as required. Control can be maintained from the surgical field by touch-screen or voice control interfaces. and the OR bed. Hand preparation time for step 3 generally requires 2 minutes. checklists. Proceed to operating room. Proceed to operating room.. To accommodate an optimal workflow and facilitate observation of aseptic technique. using antimicrobial-impregnated sponge. Rinse. The use of protocols. integration systems are available that permit the control of medical devices. or from a nursing station (Figure 26–2 ). lighting. maintains versatility. certain physical considerations need to be taken into account. Scrub time for step 3 may vary according to product instructions from 3 to 5 minutes. Inadvertent patient injury may occur due to an instrument malfunction. synchronizes services. promotes communication. 2. 3. Wash hands with soap and water. Rinse and thoroughly dry hands and arms. Use a disposable nail cleaner to clean nail beds under running water. access to images. Instruments vary according to specialty and type of procedure. Intentional OR design considers the logistics of flow. positions of exits and entrances. Other perioperative nursing responsibilities include ensuring proper instrument functionality intraoperatively through cleaning and inspection. .622 UNIT 5 Nursing Management of the Surgical Patient CHART 26–1 Traditional and Waterless Surgical Hand Preparation Waterless Surgical Hand Preparation 1. and the routing of all this digital information to any particular monitor for display or to one or more recording devices for archiving. or to pathologists or radiologists via teleconferencing links. and management. Use a disposable nail cleaner to clean nail beds under running water. The majority of surgical instruments are composed of high-grade stainless steel. Apply alcohol-based surgical hand scrub product according to manufacturer’s instructions. Use the counted stroke technique or the recommended amount of time according to the manufacturer’s instructions. Discard nail cleaner after use. 5. loss of small parts inside the patient. 4. resulting in an undesirable effect such as tearing tissue. 2. In addition. Figure 26–3 displays the contrast between traditional open surgery and endoscopic instrumentation. and detailed documentation of OR equipment is associated with a significant decrease in perioperative patient injury (Arbous et al. The ultimate goal of surgical technology adoption is to enhance patient care and improve patient outcomes. 2005). facility. information and communication systems. and adopts technological advances while including all stakeholders in order to promote successful adoption. Surgical table setup is specific to the procedure. OR design may be categorized into three major areas: physical. Note: Step 2 is performed for the first scrub of the day or as required. DS=day surgery) FIGURE 26–3 Surgical instruments : (A) traditional versus (B) endoscopic. 3. 4. Rinse. optimizes the use of resources. and surgeon preference. (Note: SDA=Same day surgery. Traditional Surgical Hand Preparation 1. Wash hands with soap and water. room requires convenient real-time access to these digital data and a way to manage the digital information acquired within the operating room. including the dimensions of the OR suite. although advances in surgery such as robotics and minimally invasive surgery (MIS) have resulted in in- SDA Unit DS Holding Area Operating room suite (a) Post Anesthesia Care Unit (b) FIGURE 26–2 Layout of a typical surgical unit. Discard nail cleaner after use. and location of support services. then forearms. or improper reprocessing leaving a residue of bioburden that can result in postoperative complications. Scrub tables are often standardized in order to facilitate efficiency and changeover of staff.

The intraoperative cost of MIS surgery is often more. and nurses.. The PNDS describes the practice of perioperative nursing practice in four domains: safety. patients’ short lengths of stay.g. The model is used to depict the relationship of nursing process components to the achievement of optimal patient outcomes (AORN.. Other Anesthesia Advances in anesthesia. This will prevent and limit anxieties created by the already stressful surgical experience. behavioral responses. The nurse conducts the preanesthetic assessment by looking at the patient from a holistic viewpoint. 2002). which results from the insufflation of the abdomen with gas that is required for laparoscopic procedures. vaginal). and the many routines. If regional anesthesia is being used. 622) resulting in less surgical trauma and immunosuppression than open surgery (Boo et al. name and date of birth. and selection of short-acting anesthetic agents. To provide space to view and perform surgery. Advantages of a laparoscopic surgery over open surgery include less scarring. oral. 624). Members of the team ask the patient questions. Comprehensively written nursing care plans have been specifically adapted to the perioperative environment as clinical pathways. Open surgery involves an incision under the rib cage on the right side of approximately 15 to 38 cm (6 to 15 in. Also. preoperative procedures. and the ability of surgeons to adapt and acquire these new surgical skills. hypnotics. the abdomen is inflated with gas (usually carbon dioxide). the Perioperative Nursing Data Set vocabulary can be used as part of the data collection tool (Chart 26–2. shorter hospitalization. In addition. The fourth domain. rectal. fewer problems with incisions. Initial reservations included the limitations of equipment. interventions. Surgical instruments are costly and require proper maintenance and care in order to preserve their longevity. remove arms from gown. such as improvements in airway devices. The perioperative nursing assessment is the first step in providing individualized care to the perioperative patient. have improved patient outcomes (Arbous et al. and ensures that the consent is signed and that all documentation. a screen is placed in front of the patient’s face. and is easily absorbed and excreted by the body through the circulatory and respiratory system. or tranquilizers are administered in order to decrease feelings of anxiety and provide sedation. apply electrocardiogram (ECG) leads. Trocars or ports (tubes with valves) are then inserted through these small incisions in order to provide imaging through a telescope attached to a camera for viewing on a monitor while other ports are accessed for instruments used to perform the surgery. p. The discomfort usually subsides within 24 to 48 hours postoperatively. It must produce sleep (hypnosis). Because of the fast-paced environment of the OR. patients should be kept informed on an ongoing basis. 2005. patients are cared for by the anesthetist. introduction of new instruments. concerns included performing surgery on larger patients and the spreading of cancer cells intraoperatively. surgeons. The laparoscopic cholecystectomy will be used to illustrate the differences between MIS and open surgery. whereas open surgery procedures can require 3 to 5 days of hospitalization. quicker recovery. lack of . 2006).CHAPTER 26 Intraoperative Nursing 623 novative discoveries of surgical materials and instruments. chart.. NOTES attempts to further minimize the effects of surgery through a totally noninvasive technique. use of quickly reversible inhalation agents. and health care systems. some procedures and protocols can be documented on a flow sheet. 2007). and orders have been completed. usually four. Anesthesia needs to accomplish several things. and preoperative checklist. Often patients undergoing laparoscopic surgery will be discharged the same day as surgery. Laparoscopic removal of the gallbladder involves several small incisions. The latter concerns have been overcome through advances in equipment and instrumentation and adaptive surgical techniques that have enabled the use of laparoscopic gastric bypass surgery for bariatric patients. therefore. and so forth. Sedatives. Tarrac.. inexpensive. The perioperative nurse greets the patient on arrival by first asking the patient his name and checks this with the patient’s identification bracelet. To harmonize care in all perioperative settings. less pain. and hospital card using at least two identifiers. 2007). and less use of opioids. Study reports confirm MIS to be oncologically safe (Bonjer et al. Patient Preparation Once they enter the surgical suite. 2007). This means recognizing the individual person as a dynamic entity made up of components that are continuously interacting with one another. the patient will remain awake. the smaller incisions available with MIS require the use of finer instruments as shown in Figure 26–3b (p. does not support combustion when using surgical energy sources. Many patients complain of discomfort similar to muscle ache in the shoulder area following laparoscopic surgery. but is offset by the reduced hospital stay and quicker recovery (Noblett & Horgan. which reduces the negative secondary effects associated with opioid use. Every effort should be made to limit activity with the patient until she has received a general anesthetic or been given a relaxant if warranted. the medical record. the health care system. comprises structural data elements and focuses on clinical processes and outcomes. urethral. The Future of Surgery: Natural Orifice Translumenal Endoscopic Surgery Natural Orifice Translumenal Endoscopic Surgery (NOTES) is the exploration of methods to perform surgery through any of the body’s natural orifices (e. that are one-quarter to one-half inch in size. The nurse reviews the patient’s chart. faster return to normal activities (work). For example. and outcomes that surgical patients and their families experience. Carbon dioxide is used because it is readily accessible. for example. Surgical Approaches Minimally invasive surgery became widespread when the laparoscopic cholecystectomy became a standard of surgical care in the early 1990s.) in order to allow surgeons access with their hands to perform surgery. a patient should have the bladder catheterized following the general anesthetic whenever possible. The first three domains reflect phenomena of concern to perioperative nurses and are composed of nursing diagnoses. physiological responses. This is a referred pain and is due to the distention of the diaphragm.

Diagnosis: Risk for Acute/Chronic Pain Intervention: Collaborates in initiating patient-controlled analgesia. Intervention: Manages specimen handling and disposition. Intervention: Develops individualized plan of care. Outcomes: Patient’s surgery performed using aseptic technique and in a manner to prevent cross contamination. and human rights. Outcome: Patient is free from signs and symptoms of physical injury. Intervention: Identifies and reports philosophical. Intervention: Assesses susceptibility for infections. Intervention: Evaluates response to medication. Intervention: Identifies cultural and value components related to pain. Intervention: Implements protective measures to prevent injury due to laser sources. Intervention: Evaluates for signs and symptoms of injury to skin and tissue. Intervention: Minimizes the length of invasive procedure by planning care. Intervention: Records devices implanted during the operative or invasive procedure. Diagnosis: Risk for Injury: Positioning Intervention: Applies safety devices. Intervention: Performs required counts. Intervention: Identifies baseline tissue perfusion. Intervention: Explains expected sequence of events. X4 I13 I27 I30 I57 I85 I101 I106 I56 I50 X38 I24 I51 I61 I69 I71 I108 I16 I54 X28 I3 I21 I22 I94 I31 X29 I11 I39 I72 I73 I77 I93 I84 I112 X40 I38 I39 I77 . Intervention: Implements protective measures to prevent injury due to electrical sources. Intervention: Performs skin preparation. Intervention: Provides care to each individual in a manner that preserves and protects the patient’s autonomy. Intervention: Provides pain management instructions. Intervention: Identifies physiological status. Intervention: Evaluates response to instructions. ability to cope. Intervention: Evaluates for signs and symptoms of injury to skin and tissue. Diagnosis: Risk for Infection Intervention: Administers care to invasive device sites. and spiritual beliefs and values. Intervention: Provides continuity of care. Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical sources. Intervention: Verifies operative procedure. Intervention: Dresses wound at completion of procedure. dignity. understanding of procedure and sequence of events. Intervention: Identifies baseline cardiac function. Intervention: Identifies physical alterations that may affect procedure-specific positioning. Intervention: Classifies surgical wound. Diagnosis: Risk for Anxiety related to knowledge deficit and stress of surgery Intervention: Assesses coping mechanisms based on psychological status. Outcomes: Verbalizes/indicates decreased anxiety. Intervention: Provides instruction based on age and identified need. cultural. Intervention: Implements alternative methods of pain control. Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical devices. Intervention: Identifies physiological barriers to communication.624 UNIT 5 Nursing Management of the Surgical Patient CHART 26–2 Code X29 I26 I126 I60 I65 I66 I59 I64 Perioperative Nursing Data Set Yes No Comments Diagnosis/Intervention/Outcome Diagnosis: Risk of Injury related to transfer and transport Intervention: Confirms identity before the operative or invasive procedure. Diagnosis: Risk for Injury Intervention: Applies safety devices. Outcome: Patient is free from signs and symptoms of physical injury. Intervention: Implements pain guidelines. Questions answered. Intervention: Assesses pain control. Intervention: Evaluates response to pain management interventions. Outcome: Demonstrates adequate pain management. Outcomes: Verbalizes comfort related to transfer/transport.

627) lists common intravenous medications used for anesthesia or as adjuncts to anesthesia. These drugs cause rapid. The gas crosses the alveolar membrane. Intravenous Agents A variety of intravenous (IV) agents are used to induce and maintain anesthesia. and implications of commonly used anesthetic gases. the side effects. Intervention: Assesses readiness to learn based on psychological status. sedative. Common drugs include barbiturates such as thiopental sodium (Pentothal) and sodium methohexital (Brevital). Intervention: Includes family and support persons in the preoperative teaching.CHAPTER 26 Intraoperative Nursing 625 CHART 26–2 Code Perioperative Nursing Data Set—Continued Yes No Comments Diagnosis/Intervention/Outcome Diagnosis: Deficient Knowledge Intervention: Assesses readiness to learn based on physiological status. 1999). awareness and recall (amnesia). The opioid analgesics have good cardiovascular stability but cause respiratory depression. supportive environment. Examples of benzodiazepines include midazolam (Versed). The anesthesia care provider considers the patient and selects the agent or a combination of agents that will produce the best anesthesia with the fewest negative effects for the patient. The Pharmacology Summary box (p. The patient inhales the vapors into the lungs. Patients emerge from propofol quite quickly during the recovery period. Other IV medications used in anesthesia include benzodiazepines and opioid analgesics. but they have limited analgesic effects. A number of theories have been proposed to explain how inhaled anesthetic agents work. Frequently. Nonbarbiturate drugs that depress the CNS may also be used to induce anesthesia. The benzodiazepines are antianxiety agents that also have hypnotic. dissolves in the blood. and alfentanil. fentanyl citrate (Sublimaze). It is associated with a difficult emergence phase that is characterized by hallucinations and disassociative feelings (feeling separate from the environment). Risk of the patient’s vomiting or thrashing during induction is reduced. Intervention: Provides instruction about prescribed medications. The Pharmacology Summary box (p. Outcome: Patient demonstrates knowledge of the physiological responses to the operative or other invasive procedure. Induction of anesthesia may be accomplished with the administration of a sedative hypnotic or anxiolytic drug. The patient who is recovering from ketamine will do better in a quiet. Propofol (Diprivan) is a rapid-acting hypnotic that causes minimal excitation effects during induction. and is carried to body tissues via circulation where it attaches to receptor sites on the cells to produce its effects. a mixture of gases is used to maintain anesthesia. Fentanyl is more potent than morphine and is the most commonly used analgesic in anesthesia. These drugs quickly (within seconds) produce sedation and unconsciousness. A variety of anesthetic agents can produce these effects. Etomidate suppresses cortisol secretion causing hypotension. X30 I19 I20 I79 I103 I67 I63 I30 I104 I105 Association of periOperative Registered Nurses. Anesthetic agents pass through a vaporizer and are mixed with oxygen. Intervention: Provides information and explains Patient Self-Determination Act. Opioids are used in anesthesia for their analgesic effect. and diazepam (Valium). Common medications include morphine sulfate. primarily depression of the central nervous system (CNS). Propofol is metabolized rapidly so it does not accumulate in the blood when used to maintain anesthesia. 2008 from http://www. . These effects are not significant in short procedures but can be an issue in longer PNDSResources/. Retrieved June 29. Inhalation Agents Inhalation agents are frequently used for anesthesia because they are fast acting and easily controlled. A test dose is initially given to test for allergy. Both drugs can cause respiratory and cardiovascular depression. AORN. PNDS Resources. (2002). Intervention: Develops individualized plan of care. freedom from pain (analgesia). short-acting depression of the CNS (sedative hypnotic). Etomidate (Amidate) produces rapid hypnosis but with less effect on the respiratory and cardiovascular systems than the barbiturate drugs. Intervention: Provides instruction about wound healing and wound care. and muscle relaxation. Etomidate is used primarily in short procedures. sufentanil. lorazepam (Ativan). Intervention: Identifies psychological barriers to communication. Midazolam is sometimes used to induce anesthesia but these drugs are more commonly used as premedication to reduce the patient’s anxiety because they have an amnesic effect. Intervention: Identifies individual values and wishes concerning care. The effects of anesthesia diminish as the gas is washed out of the lungs with 100% oxygen and the remainder is metabolized by the liver. A smaller test dose is initially given to make sure the patient tolerates the mediation without reaction. Benzodiazepines are used in combination with other drugs to produce conscious sedation or as adjuncts to regional anesthesia to produce sedation and muscle relaxation. 626) lists the advantages. and muscle relaxant effects. Ketamine hydrochloride (Ketalar) is a fast-acting CNS depressant that causes profound anesthesia but little skeletal muscle relaxation.aorn. This makes it an attractive alternative for use with high-risk patients. but no single theory explains the various effects seen with these agents (Hoffer.

San Francisco: Greenwich Medical Media. Provide warm blankets during recovery period. Monitor for hypotension. J. Halothane (Fluothane) Isoflurane (Forane) Monitor for hypotension. Retrieved April 26. Minimal metabolization by the liver. Succinylcholine is known to trigger malignant hyperthermia in susceptible individuals. 30 to 60 seconds. In M. A. Recovery from neuromuscular blocking agents after surgery is evidenced by the patient’s ability to breathe on her own and hold her head upright as well as the presence of a strong hand grasp. Requires a higher degree of liver metabolization than other agents. When used with other inhalants. Causes increase in heart rate and hypotension. Care of the patient in surgery (pp. NJ: Pearson Prentice Hall. Fair degree of muscle relaxation. Increases heart rate and triggers arrhythmias. A rapid-acting neuromuscular blocking agent is administered before intubation to paralyze the muscles of the jaw and vocal cords making placement of the endotracheal tube easier. Low incidence of postoperative nausea and vomiting. May lower the threshold for seizures. Philadelphia: Mosby. Nursing Responsibility Monitor for hypotension. T. (2002). Rapid induction and recovery of anesthesia. Werder ( Contraindicated in patients with seizure disorders. In L. (2005). the anesthesia care provider monitors the effects of muscle relaxant drugs with a peripheral nerve stimulator. (2004). eliminating postoperative myalgia. Upper Saddle River. L. Nondepolarizing agents work by blocking the depolarizing action of acetylcholine at the motor end plate of the neuromuscular junction.). Physiology of the cardiovascular effects of general anesthesia in the elderly. Perioperative nursing (pp. Meeker & J. Very rapid emergence. M. Can cause hypotension.asahq. but there are disadvantages to the drug. or pyridostigmine. L. Another advantage is that these agents can be antagonized or reversed with the administration of neostigmine. depolarizing and nondepolarizing. Rothrock (Eds. Josephson. Monitor for premature ventricular contractions. it reduces the concentration of other agent. 203–238). Muscle fasciculations do not occur with these drugs. Thompson.). Causes increase in heart rate and decrease in blood pressure. Does not produce muscle relaxation. ventricular tachycardia. The drug is broken down by the plasma enzyme cholinesterase. Has a strong odor precluding its use for induction of anesthesia. Induction and maintenance of anesthesia. M. 2004. Maintenance of anesthesia. Very rapid induction and recovery (3–4 minutes faster than Isoflurane).. Continuous muscle contractions and fasciculations are followed by flaccid paralysis of the muscles. During surgery. Rapid induction and emergence but less than that of isoflurane. Weak stimulation of secretions. Good degree of muscle relaxation. edrophonium.. Shields & H. May cause coughing if used for induction. Muscle Relaxants Muscle relaxants (neuromuscular blocking agents) primarily affect skeletal muscle and they are used in surgery to facilitate endotracheal intubation and to provide optimal operating conditions. Hypotension can be unpredictable and severe if concomitant use of antihypertensive agents. Disadvantages and Side Effects Must be heated to vaporize. Causes postoperative shivering. J. from the ASA Syllabus on Geriatric Anesthesiology website: http://www. htm. thereby producing muscle paralysis. Succinylcholine is a depolarizing agent and the only one in clinical use. and the effects last up to 10 minutes. Prolonged paralysis occurs in individuals with insufficient amounts of cholinesterase although this condition is rare. The depolarization of muscle cells causes a transient increase in serum potassium that can produce cardiac dysrhythmia. and ventricular fibrillation with use of epinephrine. Faster induction and recovery than enflurane or halothane. Muscle fasciculation (twitching) leads the patient to complain of muscle soreness postoperatively. Muscle relaxation is used throughout the surgery to facilitate dissection of tissue. 79–105). & Holland. Often succinylcholine is used for intubation because it works very quickly and wears off quickly. Anesthesia. Use of reversal agents reduces the risk of morbidity associated with anesthesia . Increases heart rate and decreases blood pressure. Hoffer. Good degree of muscle relaxation. D. Nitrous oxide Sevoflurane (Ultane) Sources: Adams. Enflurane (Ethrane) Maintenance of anesthesia. Pharmacology for nurses: A pathophysiological approach. Ebert. The drug has a strong affinity for acetylcholine receptor sites and once it attaches to the site causes continuous depolarization of the motor end plate. Anaesthesia. The onset of paralysis is quick with intravenous administration. There are two types of neuromuscular blocking agents. Induction and maintenance of anesthesia. Minimal metabolization by the liver. (1999).626 UNIT 5 Nursing Management of the Surgical Patient PHARMACOLOGY Summary of Anesthetic Gases Used During Surgery Agent Desflurane (Suprane) Action and Advantages Maintenance of anesthesia.

Monitor sedation postoperatively. Sodium methohexital (Brevitol) May cause abnormal muscle movements. Patient should be recumbent during administration. Barbiturate used for induction and maintenance of anesthesia. CNS depressant used for induction of anesthesia. Prolonged effect. Rapid onset and short duration make it a good choice for short surgical procedures. Narcotic used for induction. Nursing Responsibility Good anesthetic for patients with asthma or cardiovascular disease. Metabolized by the liver. Premedicate with anticholinergic agent to reduce secretions. Opioid Analgesics Alfentanil (Alfenta) Causes respiratory depression. Used for induction of general anesthesia and for conscious sedation. Fewer postoperative nausea and vomiting than other agents. May increase heart rate and blood pressure. reassuring environment for recovery.CHAPTER 26 Intraoperative Nursing 627 PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia Used During Surgery Agent Action and Advantages Disadvantages and Side Effects Suppresses cortisol secretion. May cause hypotension and tachycardia. Ultrashort acting with onset in 10–20 seconds and duration of 20–30 minutes. Monitor blood pressure. Provide a quiet. calm. Slower induction than with barbiturates. Prepare patient for amnesia. Monitor blood pressure. (continued) . amnesiac. Can cause anaphylaxis and laryngospasm. Propofol (Diprivan) Abnormal muscle movement. Depresses CNS causing sedation and hypnosis. Thiopental sodium (Pentothal) Test dose given first. Intravenous Anesthetic Etomidate (Amidate) CNS depressant used for induction and maintenance of anesthesia for short procedures. Used in neurosurgery because it causes a slight decrease in intracranial pressure. Depresses respirations and increases intracranial pressure. CSN depressant used for induction and maintenance of anesthesia. Can cause bradycardia and hypotension. Bradycardia is more likely in patients who are taking a beta-blocking drug. Fewer respiratory and cardiovascular effects than other agents. and muscle relaxant properties. Diazepam (Valium) Benzodiazepine with hypnotic and amnesiac properties. Barbiturate used for induction and maintenance of anesthesia. Increases salivary secretions. May cause transient skeletal muscle movements. Used as adjunct drug in induction of anesthesia and as a preoperative medication to reduce anxiety. Ketamine (Ketalar) Midazolam (Versed) Benzodiazepine with hypnotic. More potent and with a shorter onset and quicker recovery than thiopental. Report bradycardia. Does not produce muscle relaxation. and irrational behavior. Monitor vital signs. Monitor cortisol levels and blood pressure. Monitor for respiratory depression. Hypotension occurs in some patients. Metabolized in the liver. Nausea and vomiting common. and laryngospasm. Hypnotic effect but no analgesia. and balanced anesthesia. anxiolytic. Recovery can be prolonged. Monitor airway to prevent aspiration. Cautious use in patients with allergies to eggs. analgesia. Hiccups may persist postoperatively. Onset is 60 seconds with duration of 3–5 minutes. Rapid onset with minimal excitation during induction. Associated with emergence reactions including hallucinations. May supplement nitrous oxide anesthesia. May cause hypotension and tachycardia. Depresses respiratory and circulatory function. dissociative feelings. May cause hypotension. Postoperative nausea and vomiting. Monitor heart rate and blood pressure. coughing.

Produces muscle relaxation and paralysis. Metabolized by the liver. Causes muscle fasciculations. May take several hours for complete neuromuscular recovery. Metabolized by plasma cholinesterase. Depolarizing Muscle Relaxants Succinylcholine Depolarizing neuroblocking agent with high affinity for acetylcholine receptor sites. Patient may complain of muscle soreness postoperatively. and respiratory depression. Watch for signs of respiratory depression. Nursing Responsibility Monitor vital signs. Narcotic used for analgesic supplement in balanced anesthesia. Disadvantages and Side Effects Causes sedation and respiratory depression. Minimal cardiovascular effects. Histamine release causes peripheral vasodilation and hypotension. bradycardia. Monitor blood pressure and airway until full recovery from drug. Causes less nausea and vomiting than morphine. Nondepolarizing Muscle Relaxants—Intermediate Mivacurium Intermediate. Short acting. Vecuronium (Norcuron) Intermediate. Causes histamine release with hypotension. Morphine sulfate Causes respiratory depression. increased salivary secretions. Sufentanil (Sufenta) Monitor vital signs. Hypotension. Transient hypotension and bradycardia. Long-lasting effect. nondepolarizing muscle relaxant used for endotracheal intubation and to produce relaxation of skeletal muscles for surgery. Monitor vital signs.628 UNIT 5 Nursing Management of the Surgical Patient PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia Used During Surgery—Continued Agent Fentanyl (Sublimaze) Action and Advantages Narcotic used as adjunct for induction to anesthesia and for analgesia supplement. The drug of choice for epidural analgesia. Monitor for delay of recovery postoperatively. Used to facilitate endotracheal intubation and to produce skeletal muscle relaxation for short surgical procedures. Has a quicker onset and shorter recovery than fentanyl. Watch for signs of respiratory depression. Increases bronchial and salivary secretions. Muscle relaxant effects last 30–90 minutes. Not associated with histamine release so there is less hypotensive effect. Causes respiratory depression. nondepolarizing muscle relaxant used for maintenance of relaxation during surgery. Observe for residual muscle weakness. Narcotic used as premedication and for postoperative analgesia. More potent than fentanyl. May precipitate malignant hyperthermia in susceptible individuals. and respiratory depression. nondepolarizing muscle (Mivacron) relaxant used for endotracheal intubation and to produce relaxation of skeletal muscles for surgery. Nausea and vomiting common. Metocurine (Metubine) Long-acting. Nondepolarizing Muscle Relaxants—Long Acting Tubocurarine Long-acting. Monitor vital signs. . Maintain airway and clear secretions. Effect lasts 15–20 minutes. May also cause bradycardia and hypotension. Muscle relaxant effects last 30–40 minutes. Monitor vital signs. Effect lasts 20–40 minutes. Monitor blood pressure and airway until full recovery. Prolonged respiratory depression. Short-acting agent with onset in 30–60 seconds and duration of several minutes. nondepolarizing muscle relaxant used for maintenance of relaxation during surgery.

Hall. Complications that arise from general anesthesia include hypoxia. A drop in body temperature is common during surgery. M. the exposure of body cavities. Early signs are masseter spasm (contracture of jaw). and the administration of cold solutions (e. (2005). hyperthermic. San Francisco: Greenwich Medical Media. 2007.. Disadvantages and Side Effects Monitor heart rate and blood pressure. from the ASA Syllabus on Geriatric Anesthesiology website: http://www. and last 25 to 40 minutes. Examples of intermediate-acting nondepolarizing agents are vecuronium. Anesthesia interferes with the physiological mechanisms of thermoregulation. 2004. Wagner. and dry mouth. Some suggest that using a forcedair warming blanket for 30 minutes prior to surgery helps prevent intraoperative hypothermia and improve patient outcomes (Bitner. & Holland. to treat bradycardia and/or hypotension. 203–238). thermal drapes. and to reverse muscle relaxants. J. Examples include pancuronium. Philadelphia: Mosby. and premature ventricular contractions. T. Other factors such as stress. Rothrock (Eds. The presentation of MH is variable. and malignant hyperthermia. & Duvendack.). Hilde. Retrieved April 26. Meeker & J. The increase in cellular metabolism leads to an increase in carbon dioxide production (hypercarbia) and a metabolic acidosis. This effect combined with environmental factors such as the ambient temperature in the OR. The predisposition for MH is genetically transmitted by an autosomal dominant trait. Intermediateacting agents have a quick onset. J. NJ: Pearson Prentice Hall. D. Nursing Responsibility Monitor vital signs. 2006). htm. Care of the patient in surgery (pp. May cause cardiac arrhythmias. (2004). The elevation in intracellular calcium activates muscle rigidity and spasm and a hypermetabolic state. 2000. 60 seconds or less. cardiac dysrhythmia. As the process continues. Malignant Hyperthermia Malignant hyperthermia (MH) is a rare but life-threatening complication of anesthesia. 2001). IV fluids) or irrigants leads to a reduction in core body temperature. trauma. Nondepolarizing agents are divided into intermediate acting and long acting. The anesthesia provider first suspects MH by the rise in the patient’s expired CO2.g. Studies show the most significant drop in body temperature occurs during the first hour of anesthesia (Hasankhani. hypertension. Glycopyrrolate (Robinul) Tachycardia. residual muscle paralysis. hypertension. (Arbous et al. Complications of General Anesthesia The majority of patients experience general anesthesia without problems except for the complaint of a sore throat from the endotracheal tube. Hoffer. 79–105). Mokhtari. Heart rate is best indicator of response to the drug.asahq. fluid warmers) is imperative (Hasankhani et al. Research supports the use of forced-air warming blankets as the most effective method of preventing or treating hypothermia (American Society of PeriAnesthesia Nurses. and an increase in expiratory carbon dioxide levels.. In M. fatigue. which is . the patient becomes hypoxic.. 2005). L. Pharmacology for nurses: A pathophysiological approach. With MH.. Thompson. and develops dysrhythmias and hypotension. Wagner. Fewer problems with cardiac arrhythmias than atropine. It is thought that MH is triggered by the medications or agents used in general anesthesia with the most common being succinylcholine or one of the inhalant anesthetics. Moazzami. hypothermia. urinary retention. Ebert. In L. atracurium. metocurine. Perioperative nursing (pp. 2007). Werder (Eds. Other problems that may occur with intubation are damage to teeth or dental work and trauma to the vocal cords. Malignant hyperthermia is not well understood. Sessler & Todd.. Monitoring body temperature and using warming devices during surgery (e. and tubocurarine. Muscle breakdown with the release of myoglobins leads to myoglobinuria and an increased risk of renal failure. Shields & H. Monitor heart rate. (1999). Damaged muscle cells release intracellular potassium and creatinine phosphokinase (CPK) into the circulation. Reversal drugs cause bradycardia.g. blankets. hypertension. Upper Saddle River. urinary retention. blood products. and mivacurium. although the reasons for this are not known. (2002). M. Mohammadi. Malignant hyperthermia occurs most commonly during induction of anesthesia although it may present anytime during the surgery or early postoperative period. Anaesthesia. nondepolarizing muscle relaxant used for maintenance of relaxation during surgery.CHAPTER 26 Intraoperative Nursing 629 PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia Used During Surgery—Continued Agent Pancuronium (Pavulon) Action and Advantages Long-acting.. Anticholinergic agent used to decrease salivary and respiratory secretions and to reverse neuromuscular block. 2007.). Sources: Adams. 2006). Anticholinergic agent used to decrease salivary and respiratory secretions. Muscle relaxant effects last 30–60 minutes. Anticholinergics Atropine Tachycardia. & Naghgizadh. which is treated with atropine or glycopyrrolate. A. Longer acting nondepolarizing muscle relaxants also have a rapid onset but last 45 to 60 minutes. and dry mouth. Josephson. Physiology of the cardiovascular effects of general anesthesia in the elderly. or muscle injury may play a role in increasing susceptibility to the condition or in modifying the patient’s response to the condition. sinus tachycardia. L. calcium levels within skeletal muscle cells increase. hypotension. Anesthesia.

Regional anesthesia has some advantages over general anesthesia. also called intrathecal anesthesia. or pressure. effectively blocking the sensation of pain. An end-tidal carbon dioxide level that is two to three times normal is the earliest and most definitive sign of MH (Redmond. The common feature of all types of regional anesthesia is the local injection of a medication to block the transmission of sensory impulses from that area to the brain. 2006). 3% to 4% of patients experience intraoperative complications (Rampersaud et al. This makes regional anesthesia a good choice for patients with severe cardiopulmonary disease. The anesthesiologist may have the patient sit for a few minutes to create a block in the lower extremities or place the patient supine with the head tilted slightly downward to create a higher block.htm#head11.e. Regional Anesthesia Regional anesthesia is a general classification of anesthesia that includes spinal and epidural anesthesia. • Stop surgery if possible. Spinal anesthesia effectively blocks motor and sensory nerves so that the patient cannot move the affected area (temporary paralysis) or feel pain. and providing supportive care. Epidural Anesthesia Epidural anesthesia is the injection of a local anesthetic into the epidural and sympathetic) at the level of the spinal cord. treatment. and local anesthesia. temperature. the block sets and does not extend further. CHART 26–3 Management of the Patient with Malignant Hyperthermia • Immediately discontinue triggering agent.e. and care. Other late signs are cardiac dysrhythmia and hypotension. The anesthetic Other Complications Other adverse events or complications may occur in the operating room as a result of the surgical procedure. abdominal. Anesthetic injected into the epidural space affects nerve roots as they leave the spinal cord and some medication diffuses across the dura mater into the subarachnoid space and the CSF. and tea-colored urine. immediate discontinuation of the triggering agent. After 10 to 15 minutes. reducing the risk of a CSF leak after the needle is removed. bupivacaine (Marcaine).g. Do not use calcium channel blockers. potassium. • Transfer to Intensive Care Unit for postoperative care. Administer furosemide and/or mannitol if urine output is less than goal. and urologic). Special spinal needles called pencil point needles enter the dura mater by separating the fibers rather than cutting them. Tarrac. sedatives. or chloroprocaine combined with an opioid analgesic such as fentanyl or preservative-free morphine. is the injection of a local anesthetic into the subarachnoid space and directly into the cerebrospinal fluid (CSF). A spinal needle is inserted in the intervertebral space through the dura mater and into the subarachnoid space. Hyperthermia is a late sign and temperature elevations can be extreme with increases of 1 to 2 degrees every few minutes. Redman. nondepolarizing muscle relaxants. and the patient’s physical status. • Hyperventilate with 100% oxygen. administration of dantrolene sodium to produce muscle relaxation. In studies of complications associated with various procedures (e. lavage open body cavities with iced saline. oxygen saturation. and blood chemistry. deepen anesthesia with opioids. 10 units of regular insulin with dextrose intravenously. Once a hyperbaric solution is injected into the CSF. The anesthetic blocks nerve fibers (i. arterial blood gases. • Maintain a urine output greater than 2 mL/kg per hour. spinal. 2001). Laboratory blood tests results show metabolic acidosis and increases in serum calcium. Spinal Anesthesia Spinal anesthesia. It is commonly used for repair of inguinal hernia. the patient is monitored in the intensive care unit for 24 hours or longer because a small percentage of patients experience a reoccurrence of MH (Redmond. Opioid analgesics may be administered to reduce the pain associated with the insertion of needles and the administration of numbing agents.aspan. hypoxemia evidenced by a drop in oxygen saturation.. • Continue to monitor vital signs. Other signs are rigor of muscles. Usually. spinal anesthesia includes the administration of local anesthetics such as lidocaine. Examples include such things as bleeding with excessive blood loss or inadvertent injury to surrounding organs or tissues. M. patients scheduled for regional anesthesia are premedicated in the holding area with an antianxiety agent to produce mild to moderate sedation.630 UNIT 5 Nursing Management of the Surgical Patient monitored throughout the surgery.. the patient is placed in a sitting position or in a sidelying position with their head and knees flexed (i. and creatinine phosphokinase. • Treat cardiac arrhythmia if it does not self-correct with treatment. • Treat metabolic acidosis with intravenous sodium bicarbonate if it does not self-correct with treatment. . Commonly. Chart 26–3 summarizes the management of the patient with malignant hyperthermia. • Hydrate with intravenous normal saline. touch. • Administer cooling devices: Apply cooling blanket. Bier blocks. and blood vessels. fetal position).. Intraoperative complication rates depend on the surgery. 2008 from http://www. it travels by gravity. transurethral resection of the prostate. The medication may be mixed with a dextrose solution to create a hyperbaric solution (i. the type of anesthesia. motor. (2007). sensory. regional anesthesia does not depress respirations so the patient is at lower risk of postoperative respiratory complications. use iced normal saline intravenously. Regional anesthesia can be used for any number of surgeries. The epidural space is located adjacent to the dura mater and contains fat. • Treat hyperkalemia with intravenous sodium bicarbonate. peripheral nerve blocks. thus..C.e. Retrieved on July 2. gynecologic procedures. • Administer a bolus of dantrolene sodium (Dantrium) 2 to 3 mg/kg intravenously with additional bolus doses up to 10 mg/kg until decreased signs of hypercarbia. electrocardiogram. and arthroscopies and other orthopedic surgeries including repair of hip fractures in the elderly. urine output. 2001). Malignant hyperthermia: Perianesthesia recognition. Malignant hyperthermia can be fatal. indicating the presence of myoglobins. a solution that is heavier than CSF).. The spinal needle is inserted between the 2nd and 3rd lumbar vertebrae (L2–L3) or the 3rd and 4th vertebrae (L3–L4). For insertion. Patients who receive a regional anesthetic usually experience less postoperative nausea and vomiting. orthopedic. Following emergency treatment. tissue. The key to treatment is early recognition of the syndrome. Typically. 2006. Otherwise.

Caudal anesthesia is the administration of a local anesthetic into the epidural space. are used to prevent or treat hypotension. When it does occur. The nurse verifies this information with the surgical consent form. up to and including the time-out (discussed later) just before the start of the procedure. headache. The patient is placed on bed rest with the head of the bed maintained at less than 30 degrees to reduce CSF leak. and the surgeon. and sympathetic nerves.” The anesthesiologist injects 5 to 10 mL of autologous blood into the epidural space at the site of puncture to seal the leak. PDPH is caused by the leaking of CSF through the hole in the dura (e. it produces mild numbness. but certain techniques are used to trap the anesthetic in the local area. Epinephrine causes vasoconstriction of the area and decreases vascular uptake of the medication. Per the AORN (2008) correct site surgery position statement. and positioning has less effect on movement of the medication than it does with spinal anesthesia. and meningitis. the correct area for surgery is marked on the patient. Bier blocks may be used for surgeries on an extremity. Long-acting local anesthetics used in the nerve block provide extended control of pain postoperatively. the puncture site). sensory. Frequently. Nursing Management The verification process consists of information gathering and verification. such as ephedrine or phenylephrine. hypotension. When used with general anesthesia. a comprehensive approach is needed in each health care delivery system to prevent wrong site surgery. A pneumatic tourniquet is applied proximal to the surgical site and inflated higher than the patient’s systolic blood pressure.. If the needle is mistakenly in a vein. nuchal rigidity. hypotension is more likely to occur while anesthesia is still being administered. the volume and concentration of the drug. 2002). At the completion of the surgery.g. Note that while the area is numb. Patients who develop a headache are treated with hydration and analgesics. The same medications used in spinal anesthesia are used in epidural anesthesia. nerve blocks are administered by anesthesia in the holding area because they may take anywhere from 5 to 30 minutes to take effect. p. especially when there is a left or right side involved in the procedure. Assessment The nurse asks the patient to confirm the procedure to be completed. For example. which begins with the determination to do the procedure and continues through all settings and interventions involved in the preoperative preparation of the patient. When sympathetic nerves are blocked by anesthesia. it is located in the occipital area and resolves in 1 to 3 days. Patients are taught that recovery of motor function occurs first followed by recovery of sensation. fever. but the approach is through the caudal canal in the sacrum rather than through the lumbar vertebrae. arteries and veins lose muscle tone and the ability to constrict.. and the site being injected. or elbow. Hypotension is avoided with the administration of fluid volume usually normal saline. the obstruction of blood by the tourniquet prevents it from leaving the surgical area. epinephrine is administered with the local anesthetic. Surgery on the lower leg may be accomplished using a femoral or sciatic block. if it is in the subarachnoid space. This decreases venous return from the extremities and reduces cardiac output. forearm. the patient is at risk for inadvertently injuring the area. Peripheral Nerve Blocks A peripheral nerve block is the injection of a local anesthetic into or around a nerve plexus to produce anesthesia of a selected area. When headache develops. PDPH that does not resolve quickly or that produces an intolerable headache may be treated with a “blood patch. cephalad and caudad) from the site of the injection. and photophobia. Spinal headache or post–dural puncture headache (PDPH) is a common postoperative complaint. An IV catheter is inserted in the extremity at the most distal site possible. When the local anesthetic (lidocaine) is injected intravenously. a site verification form per organization policy. Hypotension can occur with both spinal and epidural anesthesia. and toxicity from systemic absorption of local anesthetic. In some cases. the surgical site.e. but the concentration of the drugs is greater because they must diffuse across several layers of tissue. 632). and the operating room schedule. Medications with strong alpha-adrenergic stimulation effects. A test dose of lidocaine with epinephrine is injected to make sure that the needle is correctly placed in the epidural space and not in the subarachnoid space or in a vein. Hypotension is caused by vasodilation associated with the blocking of sympathetic nerves. The major advantage of a nerve block is that anesthesia is confined to the area of the surgery and does not have a systemic effect. The duration of the block depends on the choice of anesthetic. Complications that can occur with nerve blocks include hematoma at the site of the block. the tourniquet is intermittently deflated so that the lidocaine enters the patient’s general circulation slowly. The onset of epidural anesthesia is slower than that of spinal anesthesia.CHAPTER 26 Intraoperative Nursing 631 spreads in both directions (i. The patient presents with the typical signs of meningitis. patients may be restricted to bed rest for the first 8 to 24 hours postoperatively to reduce the incidence of spinal headache. Spinal anesthesia is associated with a low risk of aseptic meningitis. Frequently. 2002). Frequently. usually the arm. . In 2003 AORN and the American College of Surgeons developed national guidelines that are to be used with every patient having surgery to eliminate inadvertently operating on the wrong surgical site (see the National Guidelines box. Because PDPH develops or worsens when the patient moves to an upright position. Peripheral nerve blocks are used alone or in combination with general anesthesia. Whereas PDPH occurs postoperatively. an epidural catheter remains in place after the operation to provide postoperative pain control. Peripheral nerve blocks may be performed as outpatient surgeries. an interscalene or axillary block of the brachial plexus is done for surgeries on the shoulder. A nerve block can be performed in a number of different sites. specific complications depend on the site where the block is administered. preventing a toxic reaction to the anesthetic. the amount of general anesthesia can be reduced. nerve damage. Other. signs develop within the first 24 hours after surgery (Hyderally. A Bier block is a specific type of peripheral nerve block that is administered intravenously. the test dose produces transient tachycardia. The loss of CSF causes irritation of meningeal nerves and vessels (Hyderally. The local anes- thetic blocks motor. thus prolonging the effect of the local anesthetic. Complications of Spinal or Epidural Anesthesia Spinal anesthesia may be complicated by the development of headache.

and postoperative management and teaching. Evolution of Wrong Site Surgery Prevention Strategies. all activities should be halted until verification is accurate.or limb-threatening situation. Confirm the consent form with the patient or the patient’s designated representative. Although this verification takes place in the same-day admission unit or the surgical unit. procedure. not all of these steps may be followed. pp. Each hospital has specific forms that are used to guide the nurse through the process. physical particularities. interventional cases where the point of insertion is not predetermined (such as cardiac catheterization).632 UNIT 5 Nursing Management of the Surgical Patient NATIONAL GUIDELINES AORN Guidelines for Eliminating Wrong Site Surgery The following guidelines are supported by both AORN and the American College of Surgeons. intraoperative. Stress. 2. oxygen levels are within normal limits. teeth extractions (although the involved tooth should be documented). Source: Carney. This verification can be made with the patient or the patient’s designated representative if the patient is underage or unable to answer for him/herself. 8 As the patient’s advocate. Information may include allergies. sensory/mobility impairments. lab/test results. Planning To provide the safest and least stressful experience for the patient. or anesthesia. planning is essential. the intended site must be marked so that the mark will be visible after the patient has been prepped and draped. 4. The mark must be made using a marker that is sufficiently permanent to remain visible after the skin preparation. and surgical site. or any other information deemed crucial to intraoperative patient care. Acute. or anatomic site (for example. AORN. A comprehensive plan that organizes the care of the patient and family will facilitate the surgical process. 5. Interventions and Rationales The nurse must communicate pertinent information to the anesthesia team. The purpose is to identify unambiguously the intended site of incision or insertion. Verify with the patient or the patient’s designated representative the procedure that is expected to be performed. The plan includes preoperative. implanted electronic devices (IEDs). 4. 6. sedation. as well as the location of the operation. previous surgery. 5. pain is managed and any postoperative complications are effectively mitigated or controlled as much as possible. The 2006 statistics on sentinel events from the Joint Commission identify wrong site surgery as the second most reported sentinel event. Verify that the correct patient is being taken to the operating room. Chapter 25 includes an example of a preoperative checklist. 3. hernia). multiple structures (such as finger and toes). Marking must take place with the patient involved and aware. If any verification process fails to identify the correct site. all the items on the checklist must be verified for each procedure that is planned to be performed. Conduct a final verification process with members of the surgical team to confirm the correct patient. In the event of a life. other implants. Issue 5. B. 10. limb. particular patient requests. for whom the mark may cause a permanent tattoo. 9. and premature infants. Preventing Wrong Site Surgery When a procedure involves a left/right distinction. Communication is as essential part of executing the plan. If the patient is scheduled for multiple procedures that will be performed by multiple surgeons. 2. 7. artificial or loose teeth. Nursing Diagnoses The actual and potential nursing diagnoses related to surgery include: 1. Risk for Pain. Planning for the surgical experience typically begins with the admission to the hospital. Evaluation parameters include: airway is maintained. the surgeon and patient should agree and the operating surgeon should mark the site prior to giving the patient narcotics. Overload Surgical Recovery Delayed Fear Infection. anticoagulants held for number of days. 3. Individual facility policy should clearly delineate the role and responsibility of the health care provider and other team members in marking and verifying the correct surgical site. Outcomes and Evaluation Parameters The desired outcome for patients having surgery is that the patient safely transitions through the entire process. The Joint Commission (2004) recommends that the method and the type of marking should be consistent throughout the organization and that the person doing the marking should be the one doing the procedure. Volume 83. 8. 1115–1122. comorbidities. the perioperative nurse should communicate with all members of the surgical team to verify the correct surgical site. Exemptions to the marking procedure may include singleorgan cases. many ORs have developed a presurgical checklist to ensure that all pertinent information is reviewed and communicated. 1. Ensure that all relevant records and imaging studies are in the operating room. skin condition. NPO status. history of drug use including herbal medication. accounting for 13% of reported sentinel events (Beyea. . previous anesthesia/surgery history. restrictions to jaw and neck range of motion. Verify that the correct procedure is on the operating room schedule. In the case of a bilateral organ. or multiple levels (such as spinal procedures).

implant to be used and radiologic exams.). and possibly additional information such as prophylactic medications being administered at the appropriate time prior to surgery. (2008). MRI. but most commonly it is the result of operating on the wrong site/side. The goal of the universal protocol is to prevent wrong site. 2008). correct patient position. • The patient’s room number is not an acceptable patient identifier: Confirm and Verify • Patient’s name on their ID band. Although rare.CHAPTER 26 Intraoperative Nursing 633 2000). follow your facility policy and notify your manager or administrator. 2007). The timeout checklist has been adopted from the aviation industry model and requires surgical team members to cease all other activities in order to actively. • Correct patient position. DOCUMENTATION of “TIME OUT” SITE MARK: • Use a permanent marker that is visible after skin is prepped and draped • Have operating physician/surgeon mark the site with his or her initials. To this effect. When possible the ID band should be verified during the time out phase similar to the site mark). . • Consents. • Radiologic exams (x-ray. • Implants and/or special equipment or special requirements available. • Agreement to procedure. and mutually verify information such as the correct patient. *** If operating physician does not mark site. the consequences of wrong site surgery can Guidelines for Implementing JCAHO Universal Protocol To Promote Correct Site Surgery When marking the site DO NOT USE: The letter X or the word NO Do NOT mark the Non-Operative Site According to AORN standards. Wrong site surgery may be the result of operating on the wrong patient or performing the wrong procedure. Validate site mark after draping or confirm ID band with the procedure written on it if used in cases of exemption. ** Remove the mark at the end of procedure.. • Ask patient to state their planned procedure and document it in the patient’s own words. * Facility determined identifiers should be used. verifying the surgical site at the time of surgery is the responsibility of perioperative nurses and every member of the health care team (AORN. and other documents that correspond with the patient’s responses. • Medical record number. All team members must verbally verify their agreement on: • The name of the patient. an ID band with the procedure written on it is an alternative for site marking. verbal confirmation or visual pointing). and wrong person surgery. PATIENT RESPONSES MUST MATCH: MARKED SITE * ID BAND * CONSENTS * RADIOLOGIC EXAMS * SCHEDULED PROCEDURE DISCREPANCIES/ISSUES Procedure does not start until patient verification & missing information is completed and agreed upon by all team members. • The procedure to be performed.g. • Correct site and side. *** • Mark site(s) with patient participation ( the left hand is operated on instead of the right (Joint Commission. if applicable. the patient is identified by the circulating RN when the patient enters the OR suite. If a disagreement is not resolved.aorn. Figure 26–4 shows a sample of a time-out checklist. including laterality. The Joint Commission’s national guidelines to prevent wrong site surgery are based on the consensus of experts from the relevant clinical specialties and professional disciplines and is endorsed by more than 40 professional medical associations and organizations. The procedure and surgical site are validated at this time as well. correct site/side.g. • Ask patient to state their date of birth. Surgical Time-Out Safety initiatives that address communication issues such as the time-out are designed to promote correct site surgery. prior to patient entering the OR suite. 2008 from http://www. In the case of pediatric patients and patients unable to verify information for themselves. for example. All issues resolved are documented in the medical record. “TIME OUT” Takes place in the procedure/OR room. Retrieved on July 2. AORN.. Should indicate the following was verified: • Correct patient. an individual identified by facility policy with knowledge of the patient and planned procedure to be performed may mark the site. after the patient is prepped and draped and it involves the ENTIRE TEAM. Although it is the surgeon’s role to diagnose a patient’s need for surgery and to delineate the surgical site. etc. trauma). verbally. especially for patients returning for subsequent procedures (e. The active involvement of the team and the patient or patient’s representative and effective communication among all members of the operating room team are important for success. • Use an additional mechanism for identifying site(s) exempt from marking according to facility policy and JCAHO guidelines (For example. wrong procedure. 2007). the Joint Commission has issued regulations and is endorsing the Universal Protocol as part of the 2007 National Patient Safety Goals (Joint Commission. AORN position statement. • The site of the procedure. FIGURE 26–4 AORN guidelines for verifying the correct surgical site. the RN identifies the patient’s legal guardian and verifies with them the following protocol. • Availability of implant if required. CT scan. PREOPERATIVE VERIFICATION 2 Patient Identifiers Must be Used (for example)* • Ask patient to state their full name. correct surgery. date of birth. • Availability of blood if ordered.

out of room: Anes. Verbalizes comfort related to transfer/transport. 1 relief: Time in: Time out: Circ. Explained sequence of events and preoperative routine (I56). Structural Data: Operating Room Progress Notes Room #: ASA: Pt. gender. Questions answered. start: (Patient Information: name. Low Chest tube Other findings Transfer to suite via: Stretcher Isolette W/C Crib Bed Alert/oriented Asleep Other: Cool Dry Tattoos: Sensory impairment: Musculoskeletal status: Prosthetics/Assistive devices: Cardiopulmonary status: Peripheral edema: Yes Location: No DVT/PE risk: Respiratory: High Tracheotomy Regular Med. Intubated Labored FIGURE 26–5 Sample of intraoperative nursing documentation. age. and patient. Communicated patient concerns to appropriate members of health care team (I128). procedure. Demonstrates adequate pain management. provided credit is given to AORN. understanding of procedure and sequence of events. in room: Anes. finish: Assistant 1: Anesthesia type: General Local block. Type: MAC Spinal Other: Epidural Assistant 2: Circulating nurse 2: Circ.634 UNIT 5 Nursing Management of the Surgical Patient Addressograph AORN SAMPLE Patient Record (Facility Name and Address) This record is a sample only. .Preoperative: Preoperative checklist reviewed/evaluated Risk for injury related to transfer and transport (X29): ID confirmed Allergies verified Latex allergy: Consent verified Yes No Drowsy Unresponsive Warm Moist No limitations Language barrier No limitations Hearing aid AICD Prosthetics: Site verified Procedure verified NPO verified Time: Sedated Disoriented Intact Body jewelry removed Hearing Sight Paralysis Glasses Traction Risk for anxiety related to knowledge deficit and stress of surgery (X4): Psychosocial status: Calm/relaxed Anxious Talkative Crying Restless Other: Provided instruction based on age and identified needs (I106). Risk for acute/chronic pain (X38. medical record number. facility. Clinical records should be customized to incorporate data fields that represent the setting. Reproductions and variations are encouraged. 2 relief: Time in: Time out: Anesthesia care provider 1: Scrub 1: Op Dx: Anesthesia care provider 2: Procedure(s): Laser operator: Op Dx: Other authorized personnel: Scrub 2 relief: Time in: Time out: Scrub 2: Scrub 1 relief: Time in: Time out: Nursing Data Elements . date) Surgeon 1: Circulating nurse 1: Surgeon 2: Procedure start: Procedure finish: Pt. X74): Instructed on use of pain scale Pain assessment (0-10): Location: Outcomes: Verbalizes/indicates decreased anxiety. Evaluated response to instructions (I50). ability to cope.

information may include personnel involved. explain: Patient’s surgery performed using aseptic technique and in a manner to prevent cross-contamination (O10). O2. and monitoring devices to name a few. anesthesia classification. perioperative nurses may chart information in the nurse’s notes when warranted. be devastating and warrant improved systems that promote effective communication such as the time-out initiative. lithotomy Other: Shoulder roll Jackknife Axillary roll Leg holder Arms tucked/padded Inserted by: Drains/tubes (size/type/site): OR drainage amount: Packing (size/type/site): Cast (type/site): Dressing (type/site): Risk for hypothermia (X26): Apply warming blanket #: Temp setting: Applied by: Warm IV fluid Warm irrigation Other: Postprocedure Assessment/Evaluation: Outcomes: Risk for injury (X29): Apply safety strap to: Apply grounding pad Site: Electrosurgical unit #: Bipolar #: Setting: Coag: Cut: Laser Type: Unit #: Settings: Safety measures implemented Operator: Tourniquet checked & applied #: Site: Inflated: Deflated: Pressure: Sequential stockings: Yes No Other: Counts: 1st count: 2nd count: 3rd count: Sponge Correct Correct Correct Unresolved N/A Needles Correct Correct Correct Unresolved N/A Time: Applied by: Unit #: Instruments Correct Correct Correct Unresolved N/A Yes No Surgeon notified of counts Signature: If counts unresolved. the most critical factor in . lateral Positioning devices: Chest roll Pillow/wedge Pad bony prominences: Positioned by: Elbows Other: 3-Contaminated 4-Dirty Rt. Intraoperative Patient Record Most facilities have an intraoperative patient record. intact.CHAPTER 26 Intraoperative Structural Data: EKG Manufacturer: Type: Size: Lot/Serial #: Blood products: Unit #: Unit #: Unit #: Blood recovery: Irrigation: Type: Amount: Intraoperative Nursing Data: Risk for infection (X28): Skin Pre-op intact Other: Surgical clippers: Area: Skin prep By: Povidone-iodine Other: Wound classification: 1-Clean 2-Clean/contaminated Urinary catheter: (size/type/site): OR output: Chlorhexidine Risk for impaired skin integrity (X50): Position for surgery: Supine Prone Lt. X-ray taken: If no. non-reddened. wound classification. For example. lateral Stirrups Heels Yes Start time: Start time: Start time: Yes No No Blood band #: Finish time: Finish time: Finish time: Unit #: CCs reinfused: X-rays: Yes No Oximeter Yes NIAPB No Temp monitor Intraoperative Nursing 635 OR medications: (other than those given by anesthesia care provider) Time Medication Dosage Route Initials Implants/Prosthesis: Exp. Preventing and minimizing associated risks of SSI are fundamental perioperative nursing diagnoses of the surgical patient. 2003). Skin remains smooth. that is used to record intraoperative information. like that shown in Figure 26–5 .. Date: Site: Type: Protective devices: Gonadal Thyroid Other: Grafts: Yes No Type: Donor site: Recipient site: Pathology specimens: Routine: Yes #: Frozen section: Yes #: Cultures: Yes #: Comments: No No No Mod. In addition. non-irritated. free of bruising (O5. According to Nichols (2001). Core body temperature remains in expected range (O12). Protecting the Patient from Infection Surgical-site infections are the third most frequently reported type of iatrogenic (hospital-acquired) infection (Engemann et al. O8). length of surgery. position and accessories implemented.

. genital. gowning. It is for this reason that perioperative nurses have become quite expert in the areas of aseptic technique and sterile conscience. accidental wounds.. if necessary. or uninfected urinary tracts are not entered. scrub table. OR table. Retrieved on July 2. is_2_80/ai_n6159709. and to correct any violation whether or not anyone else is present or observes the violation. Operative wounds in which the respiratory. This principle is applied to application of prepping solutions. S. genital. 2005).g. & Rowell K. and to a 1-foot parameter around the draped areas (Figure 26–6 ). This allows personnel to function in a more efficient and safe manner. including wound classification (see the National Guidelines box). basic aseptic principles should be observed. operations involving the biliary tract. In addition. alimentary. or urinary tracts are entered under controlled conditions and without unusual contamination. The CDC data provide benchmarks for health care professionals to evaluate their SSI rates so they can further investigate the problem and implement initiatives should the rates be unusually high. vagina. but until empiric evidence demonstrates a technique is otherwise unnecessary or ineffective. The sterile field begins at the surgical site (incision). The CDC publishes norms for SSI rates based on certain indicators. and ensuring items have been appropriately sterilized. Includes open. The best technologies to date can only limit and reduce the presence of microbial life such as bacteria. It is commonly referred to as the clean to dirty principle. Frequently aseptic techniques and practices are criticized for being ritualistic in nature and lacking in scientific rigor. An example may include inspecting sterile packaging. to report any break FIGURE 26–6 OR table. NATIONAL GUIDELINES for Surgical Wound Classification Clean wounds An uninfected operative wound in which no inflammation is encountered and the respiratory. drained with closed drainage. and extends to the rest of the patient. Improving surgical wound classification—why it matters. nonpurulent inflammation is encountered are included in this category. In the OR aseptic techniques are practices that minimize contamination due to microorganisms. and incisions in which acute. operations with major breaks in sterile technique (e. room setup. and oropharynx are included in this category provided no evidence of infection or major break in technique is encountered. fresh. Surgical conscience is defined as “An inner commitment to strictly adhere to aseptic practice. viruses. Over time. Asepsis is the absence of infectious organisms. clean wounds are primarily closed and. and gloving are all functions of OR aseptic technique. One of the strategies employed is the creation of the sterile field. It is for this reason that nurses and surgical team members in the OR need to continually monitor the surgical field and develop strategies to minimize patient risk. There are no sterilization processes that completely eliminate all microorganisms. alimentary. L. In addition. AORN Journal. and so forth. 2008 from http://findarticles. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. Clean-contaminated wounds Contaminated wounds Dirty or infected wounds Source: Devaney. Includes old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or perforated viscera.. A surgical conscience mandates a commitment to aseptic practice at all times” (Spry. The purpose of surgical wound classification is to track and learn the cause of infections in order to prevent future incidence. Surgical attire. surgical team. patient draping. fungi. Specifically. delivering items using proper aseptic technique.636 UNIT 5 Nursing Management of the Surgical Patient in aseptic technique. (2004). SSIs may also be predicted based on the surgical wound classification. open cardiac massage) or gross spillage from the gastrointestinal tract. scrubbing. This information is generally recorded on the patient’s intraoperative record. surgical team members will in fact develop a surgical conscience. and spores to an acceptable sterility assurance level. Figure 26–7 shows a nurse in postoperative infection is the sound judgment and proper practice of the surgical team in addition to the general health and disease state of the patient. Surgical aseptic practice is based on the premise that most infections are caused by exogenous organisms or organisms that are external from the body. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

enhanced ergonomics for professionals..CHAPTER 26 Intraoperative Nursing 637 FIGURE 26–7 Correct surgical attire.g. proper OR attire and a surgical team member in scrub apparel.g. higher risk with vascular. highlighting important standards and principles. Ensure proper lifting and securing of patient to prevent friction-related injuries. injury to nerves and muscles. Use appropriate prophylactic anticoagulant medication administration. pressure ulcers have received much attention as a preventable intraoperative complication. and poor nutritional status as measured by low serum albumin and anemia (Feuchtinger et al. 2005). Preventing the Retention of Foreign Objects Surgical counts are the responsibility of perioperative nurses and are performed in order to prevent patient injury due to the high risk of retained foreign body. OR tables and accessories are designed to accommodate a wide range of positions in order to allow for the use of gravity to displace organs in order to provide additional working space. and prevent patient complications. Retained foreign objects in patients have resulted in major injuries such as sepsis. Ensure proper placement of stirrups and ensure that two health care professionals simultaneously lift. staff ergonomics. Price. preoperative risk factors commonly cited across studies include age (e. It is for this reason that OR tables are narrow (ergonomic for surgeon) and firm (limits movement and allows for CPR). and the development of pressure ulcers. Position arm correctly to ensure proper arm alignment of less than 90 degrees. Researchers report conflicting data on risk factors for the development of pressure ulcers. care taken during perioperative skin preparation to reduce unnecessary moisture collection under the skin. Appropriate positioning accessories and excellent communication between the anesthesia team monitoring physiological responses and the surgical team often requesting position changes is essential in order to prevent patient injury.. and adequately padded and protected. 2005).g. leading to an initiative by health care professional organizations. However. 2005. or instruments. The incidence of pressure ulcers in surgical patients ranges from 4% to a high of 45% depending on the study (Feuchtinger.. 2005. and death.. Most facilities follow a legal counting procedure based on the AORN (2007b) recommended standards and practices.. surgical access. Whitney. CHART 26–4 Intraoperative Positioning Complications Potential Intervention Position bolsters correctly to minimize compression of thorax. Chart 26–4 lists common intraoperative positioning complications and potential causes. supinated. length of operation (e. Further research is needed to clarify intraoperative risk factors but those that are suggested include type of surgery (e. For example. abrasion. support. and surgical view while maintaining the patient’s skin integrity. facilitating full lung expansion. and spinal surgery). bowel perforation. and place legs onto stirrups observing correct alignment. Potential Complications Secondary to Intraoperative Positioning Decreased lung expansion due to supine position resulting in compromised respiratory effects Brachial plexus nerve injury Circulatory obstruction due to position resulting in increased risk of postoperative deep vein thrombosis Integumentary injury resulting in pressure ulcers. Positioning the Patient to Prevent Injury Patient positioning in the OR is chosen to accommodate surgical access. & King. & Dassen. thoracic. Appropriate equipment includes gel mattresses. and blistering Dislocation of acetabulum . It seems to be a much greater issue than reported. and vascular disorders. longer surgeries). which can include gauzes. Apply antiembolic stockings and sequential compression leggings. hypotensive episodes during surgery reducing the blood available to tissues. such as AORN. needles. presence of comorbidities particularly diabetes. Perioperative nurses need adequate knowledge of anatomy and an understanding of the physiological effects of specific surgical positions. Use OR table equipment that will minimize pressure and maximize capillary refill. older patients). The primary objective of patient positioning for surgery is to provide maximize exposure while ensuring patient safety. cardiac. hypertension. and the type of anesthetic used. Halfens. Price et al. proper positioning can help maintain proper body alignment and access to intravenous and anesthesia support devices. Nurses may review patient’s intraoperative position via the OR record and assess any relevant patient outcomes. Complications secondary to positioning include compromised respiratory or circulatory responses. Of these. The desired patient outcome is a patient free from injury related to extraneous objects. American College of Surgeons (ACS).

The calculation of blood loss is referred to as the estimation of blood loss (EBL). patients who have had multiple surgeries. Blood loss is treated with the administration of packed red blood cells. If it cannot be found. all personnel try to locate the missing item. it is subtracted from the total amount of drainage to determine the amount of actual blood loss. A latex sensitivity questionnaire can be used to identify those who have a latex allergy or who are likely to develop the allergy. Patients are asked preoperatively about the possibility of latex allergy. chest tubes. wound drains. general level of health prior to surgery. abscess. swabs. Latex allergy is discussed in detail in Chapter 60 . Elements of a latex-reduced environment in the operating room include (1) scheduling elective cases as the first cases of the 8 8 Estimating Blood Loss The patient is monitored throughout the operation for blood loss. before wound closure begins. the patient may be x-rayed. Sponges. where the counting is documented. and other items are counted before surgery. • No items are removed from the operating room until the final count is complete and verified. 2006). have a radio-opaque stripe for x-ray identification. Multiple procedures are in place to prevent leaving an instrument or a sponge or other material in the patient when the wound is closed. This permits the surgical team to pass a wand over the patient following a procedure to verify that no sponges have been left in the patient (Medline. (C) surgical RFID detection . to develop improved methods of accounting for surgical items. Blood or skin tests can detect latex-specific IgE antibodies and are performed preoperatively when latex allergy is suspected. such as surgical sponges. dental industry workers. (B) wand to detect the RF tag in surgical gauze. restrict the administration of blood products. a latex-reduced environment is created. The presence of foreign materials in the body can lead to infection. and the Joint Commission. • The circulating nurse and scrub nurse count items in unison. who does the counting. A high incidence of latex allergy is found in people with spina bifida. and avocados are also at an increased risk of latex allergies due to the cross reactivity of the proteins present in these fruits and latex.638 UNIT 5 Nursing Management of the Surgical Patient mated from their weight with 1 gram of weight being equal to 1 mL of blood. Hospitals have written policies describing what is counted. Some religions. history of cardiovascular disease. how well the patient tolerates the blood loss. The weight of the dry sponge(s) and plastic container is subtracted from the total weight to determine blood loss. Latex Allergy There has been a significant increase in the number of latex allergies seen in the hospital. It is virtually impossible to create a latex-free environment in the operating room—although it may be possible in the future as more products are being manufactured without latex. Blood in suction containers. and how to resolve a discrepancy in the count. those who work with latex products (health care workers. and other serious problems. For patients with known allergy. If there is a discrepancy in the count. Whether or not the patient needs a transfusion during surgery depends on blood loss as well as on other factors such as age. and before skin closure begins. and those with a genetic predisposition to allergies (atopy). Blood in sponges can be approxi- 8 8 (a) (b) (c) FIGURE 26–8 console. and sharps are counted many times during the surgical procedure. • Sponges. and nasogastric tubes is measured directly at frequent intervals during the surgery. If irrigating fluid is used. One technology that is currently being tested is radio-frequency identification (RFID). This involves RF tags being implanted in surgical sponges (Figure 26–8 ). instruments. swabs. such as Christian Science and Jehovah’s Witnesses. including the operating room. Adult patients who are generally healthy can tolerate surgical blood loss of up to 500 mL without the need for a transfusion. Surgical instruments can be seen by x-ray and soft materials. Chapter 23 provides a complete description of blood administration indications and procedures. and the availability of autologous blood. when it is counted. rubber workers). Blood-soaked sponges are collected in a plastic bag and weighed. Some suggest the increase correlates with the adoption of universal precautions and the increased use of latex gloves. • The circulating nurse and scrub nurse document the count in the record. RFID technology: (A) RF tag implanted in surgical gauze. bananas. Patients who report allergies to kiwis. To prevent a foreign object from being left behind: • All items brought to the operating room are documented.

It is important to give any pertinent information to the unit members where the transfer of responsibility for the surgical patient is occurring and provide an interactive communication that is free of interruptions and includes a systematic process of verification. the source of latex in direct contact with the patient is immediately removed. anesthetic agents. and the administration of intravenous epinephrine. in particular medications. GERONTOLOGICAL CONSIDERATIONS for Elderly Patients Having Surgery Physical Factors • Decreased tolerance to heat and cold • Loss of skin tone • Declining cardiac/renal function • Atrophy of reproductive organs • Increased incidence of preexisting health conditions Cognitive Factors • Decline dependent on pregeriatric state and general health and social involvement • Decreased memory. Diphenhydramine and steroids may also be given intravenously to attenuate the allergic response. Gerontological Considerations Persons 65 years of age and older. This is an unrestricted area where the patient will no longer need to wear a head cover and the nurses will wear regular uniforms. When a latex allergy is suspected in the operating room. (6) using a stopcock rather than the rubber port for injection of intravenous drugs. POCD may be related to brain oxygenation during anesthesia. but are especially dangerous for elderly persons. Other more general factors common to all age groups are diabetes. positioning. The PACU is where the patient will recover from the anaesthetic he has received. require surgical interventions more often than younger persons because of age-related system changes and comorbid conditions. and figural relations may occur • Cognitive tasks may require more time to complete Sensorimotor Factors • • • • • Decreased visual acuity Diminished hearing Altered tactile sensation Changes in taste and smell Diminished response to stress and sensory stimuli • Decreased mobility Psychosocial Factors • Ego integrity important • Stressors: end of life. Patients with postoperative cognitive dysfunction (POCD) experience deterioration in cognitive function that persists for years after the operation. cardiovascular. The Gerontological Considerations box highlights the special considerations for the gerontological population. chronic undernutrition. Changes in pharmacokinetics result in changes in drug absorption. (4) avoiding latex on the sterile field. and comorbidities. and hospital environment (Prough. (3) using powder-free gloves to limit the aerosolization of latex antigens. communication. Visitors may be allowed in certain parts of the PACU under certain circumstances. nurses must strive to provide effective and consistent information during patient handoff to a transition unit such as the PACU or Intensive Care Unit (ICU). endocrine. Additional padding may be necessary due to decreased adipose tissue and circulation. both physical and cognitive abilities may vary greatly. infection control. Concerns along this route will focus on safety. intravenous fluids to support the blood pressure. Postanesthesia Care Unit Once the surgery is completed. (5) using a plastic anesthesia mask. Follow-up treatment includes the administration of 100% oxygen. Premedication of allergic patients with steroids or antihistamines is not recommended. and psychosocial factors. aspiration. sensorimotor. and poor dentition. cognitive. and electrocardiogram leads. and (9) using nonlatex tape. increased cognitive demands • Death of loved ones • Concerns for general health increase 8 8 . stethoscope. General risk factors for infection in elderly patients are known to include frailty. and excretion by the body. 640) shows a mnemonic that highlights the handoff principles and verification process. the anesthetist and the nurse will accompany the patient to the postanesthesia care unit (PACU) for further monitoring. previous surgeries. (2) using vinyl gloves rather than latex gloves. metabolism. suggesting that careful monitoring of glucose levels may be a way to reduce serious postoperative infections. respiratory. and the presence of an indwelling urinary catheter. inductive reasoning. reduced muscle mass. 2005). (7) removing the rubber cap on medication vials rather than drawing a medication through the cap. Allergic responses to latex can range from mild cases of contact dermatitis evidenced by a rash and urticaria to serious cases of anaphylaxis. distribution. Efforts should be made to diminish the use of tapes that may lead to denuding of geriatric fragile thinner skin. Degeneration of multiple systems such as the musculoskeletal. changes in environment. and hematopoietic systems and hearing and vision can influence intraoperative and postoperative outcomes. PACU is dicussed in detail in Chapter 27 . Hyperglycemia is known to be associated with increased sepsis. predisposing the patient to the development of pressure ulcers. Promote patient warmth through warming devices and assess range of motion prior to patient being anesthetized in order to ensure correct positioning accessories are available. Poor communication is one of the top contributing factors to medical errors. nervous. Assess the geriatric patient’s history and general health status. Therefore. genitourinary. At this stage of life.CHAPTER 26 Intraoperative Nursing 639 day to minimize contact with aerosolized allergen from latex gloves. Ensure adequate time is available to communicate clearly and slowly. Figure 26–9 (p. keeping in mind possible hearing impairment and need for additional processing and response time. and equipment. (8) using nonlatex equipment such as blood pressure cuff. Appropriate age-specific interventions should be considered for the geriatric population taking into consideration both physical. medication. Infections are a major concern for all hospitalized patients.

identifiers. recent changes. alerts (falls. 2008 from http://www. alllergies. medications. including code status. previous episodes. vital signs and symptoms and diagnosis Current status. prioritization of actions Who is responsible (nurse/doctor/team) including patient/family responsibilities What will happen next? Anticipated changes? What is the PLAN? Contingency plans? Actions Timing Ownership Next FIGURE 26–9 Handoff protocol to improve communication when transferring a patient from the OR to another unit. socio-economic factors.pdf.640 UNIT 5 Nursing Management of the Surgical Patient “I PASS THE BATON” Handoffs and Healthcare Transitions with opportunities to ask QUESTIONS. level of (un)certainty. past/home medications. response to treatment Critical lab values/reports. 08_OBS_NPSG_Master. etc. CLARIFY AND CONFIRM I P A S S THE Introduction Introduce yourself and your role/job (include patient) Patient Name. location Presenting chief complaint. . sex. family history What actions were taken or are required AND provide brief rationale Level of urgency and explicit timing. circumstances. age.jointcommission. National Patient and Safety Goals. Retrieved July 3. Source: Joint Commission (2008).) Assessment Situation SAFETY Concerns B A T O N Background Co-morbidities.

K. 384–388. Postoperative hypothermia—The chilling consequences.. A registered nurse first assistant is scheduled to assist a surgeon with a surgical procedure. 2003). Communication with surgical team for timing of antibiotic administration. 7. S42–S45. (2006). b.g.. In the preoperative NCLEX® REVIEW 1. R. & Schneider. Multidisciplinary approach to optimizing antibiotic prophylaxis of surgical site infections. Ensure surgical instruments are operational. Conduct an interview. Antibiotic prophylaxis against postoperative wound infections. J. 2007). Research Findings Research was done testing the hypothesis that hypothermia both increases susceptibility to surgical-wound infection and lengthens hospitalization. Insert an indwelling urinary catheter if necessary.. 83(5). This will necessitate cooperation with both the surgeon and the OR staff to determine the optimal timing of antibiotic administration.. 2. For maintaining normothermia in the OR policies and procedures could be implemented such as use of warming devices under the patient as well as the use of warm solutions. What nursing interventions will decrease the risk of infection? Answer: a. R. R. This nurse will be responsible for: 1. Nurses also can coordinate the timing of preoperative antibiotic administration. & Rodrigues. (2003). E. Good et al. so first-generation cephalosporins are most often chosen. 2. Implications for Nursing Practice The latest research results have and will influence a change of practice in the perioperative setting based on evidence. T. Hypothermia also directly impairs immune function. Camus et al. 83(5) 1074–1076.. Staphylococcus organisms) are the usual target. Journal of Clinical Anesthesia.. 2312–2314. AORN Journal. (1995) found that a single hour of preoperative skin surface warming reduced the rate at which core hypothermia developed during the first hour of anesthesia. may promote surgical-wound infection by triggering thermoregulatory vasoconstriction. Sessler. the holding area was identified as the preferred location (Olin. setting nurses can use blankets and warming to maintain normothermia. B. Vanni et al... 2006. Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen. Y. J. Good. Cleveland Clinic Journal of Medicine. References Camus. (2007). Antibiotics should be chosen on the basis of their effectiveness against the pathogens most likely to be encountered. 63. c. The effect of preoperative warming on patient’s postoperative temperatures. D. Improving compliance with prophylactic antibiotic administration guidelines. S. 2006. AORN Journal.. The nurse will utilize this time with the patient to do which of the following? 1. G. & Lienhart. Serving as the patient advocate. K.CHAPTER 26 Intraoperative Nursing 641 Prevention of Infection Clinical Problem Mild perioperative hypothermia. A preoperative patient is taken into the holding area. Braz.. Cooper. S. . 73. Preoperative prophylactic antibiotics should be administered within 60 minutes before the initial incision is made to ensure that antimicrobial levels in the tissue are adequate and maintained for the duration of the procedure (Gordon. In addition the temperature of the OR suite could be increased. AORN Journal. S.. Maintaining normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations. Pre-induction skin surface warming minimizes intraoperative core hypothermia. White & Schneider. 119–125. Administering anesthetic agents. Critical Thinking Questions 1. Modolo. 4. 173–180. (2006). Journal of Clinical Anesthesia. To comply with the recommendations of administration within 60 minutes of incision.. (2006). Preoperative combined with intraoperative skin surface warming avoids hypothermia caused by general anesthesia and surgery. M. Collaborating with the surgeon and suturing the wound closed. Amorim. White. Olin. & Norwood. 1055–1066. which decreases subcutaneous oxygen tension. S. R. J. B. 3. Develop policies that ensure standards are used by all members of the surgical team regarding warning procedures. 85(1). M. Answers to Critical Thinking Questions appear in Appendix F. (2006) report that hypothermia itself may delay healing and predispose patients to wound infections. Clean and inspect surgical instruments. Verble. Delva. (1995). Antibiotic Administration Another measure to reduce infection in the operating room is proper timing for antibiotic administration. American Journal of HealthSystem Pharmacy. A. Skin floras (e. 15(2). Vanni. Gordon. 4. (2006). N. 1079–1084. Antibiotic prophylaxis is being used in a variety of surgical procedures to reduce the incidence of surgical-site infections. A. which is common during major surgery. Institute measures to maintain normothermia throughout surgery & PACU. A. 2006). Providing the surgeon with instruments. Other research was done on prewarming of patients’ skin and its influence on core hypothermia (Cooper. 3. 2.

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