INTRAOPERATIVE

PHASE

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Goals

ｷ Asepsis
ｷ Homeostasis
ｷ Safe Administration of
Anesthesia
ｷ Hemostasis

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The Surgical Team

ｷ The Patient
ｷ The Anesthesiologist or
Anesthetist
ｷ The Surgeon
ｷ Scrub Nurse
ｷ Circulating Nurse
ｷ RNFA ( Reg.Nurse First Assistant )
ｷ Surgical Technologists

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Surgeon

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Responsibilities
• Primary responsible for the preoperative medical history
and physical assessment.

• Performance of the operative procedure according to the

needs of the patients.
• The primary decision maker regarding surgical technique
to use during the procedure.
• May assist with positioning and prepping the patient or
may delegate this task to other members of the team

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First Assistant to the Surgeon

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Anesthesiologist

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 Responsibilities

• Selects the anesthesia, administers it, intubates the

client if necessary, manages technical problems
related to the administration of anesthetic agents,
and supervises the client’s condition throughout the
surgical procedure.

• A physician who specializes in the administration and

monitoring of anesthesia while maintaining the
overall well-being of the patient.

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Scrub Nurse

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Responsibilities
• May be either a nurse or a surgical technician.
• Reviews anatomy, physiology and the surgical procedures.
• Assists with the preparation of the room.
• Scrubs, gowns and gloves self and other members of the
surgical team.
• Prepares the instrument table and organizes sterile equipment
for functional use.
• Assists with the drapping procedure.
• Passes instruments to the surgeon and assistants
by anticipating their need.
• Counts sponges, needles and instruments.
• Monitor practices of aseptic technique in self and
others.
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Circulating Nurse

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Responsibilities
• Must be a registered nurse who, after additional
education and training, specialized in perioperative
nursing practice.
• Responsible and accountable for all activities occurring
during a surgical procedure including the management of
personnel equipment, supplies and the environment
during a surgical procedure.
• Patient advocate, teacher, research consumer, leader
and a role model.
• May be responsible for monitoring the patient during
local procedures if a second perioperative nurse is not
available.

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Very defined activities during surgery:

• Ensure all equipment is working properly.

• Guarantees sterility of instruments and supplies.
• Assists with positioning.
• Monitor the room and team members for breaks in the sterile
technique.
• Handles specimens.
• Coordinates activities with other departments, such as
radiology and pathology.
• Documents care provided.
• Minimizes conversation and traffic within the operating room
suite.

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Medical vs. Surgical Asepsis

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Medical vs. Surgical Asepsis

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Principles of Surgical Asepsis
(Sterile Technique)

• Sterile object remains sterile only when touched by

another sterile object
• Only sterile objects may be placed on a sterile field
• A sterile object or field out of range of vision or an
object held below a person’s waist is contaminated

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Principles of Surgical Asepsis
(Sterile Technique)

• When a sterile surface comes in contact with a wet,

contaminated surface, the sterile object or field
becomes contaminated by capillary action
• Fluid flows in the direction of gravity
• The edges of a sterile field or container are
considered to be contaminated (1 inch)

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Common Surgical Incision
Incision Site
Butterfly
Limbal
Halstead / Elliptical
Subcostal
Paramedian
Transverse
Rectus
McBurney
Pfannenstiel
Lumbotomy
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Position During Surgery

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Position During Surgery

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Position During Surgery

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Position During Surgery

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Position During Surgery
Supine ( Dorsal Recumbent )
-
Abdominal,extremity,vascular,ch
est,neck,facial,ear
breast surgery

Positioning Techniques
• Patient lies flat on back with arms either extended on arm boards
or placed along side of body.
• Small padding placed under patient’s head,neck and under
knees
• Vulnerable pressure points should be padded.
• Safety strap applied 2 in. above knees.
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 Prone Position
- Surgeries involving posterior surface of the body (
spine,
neck,buttocks and lower extremities )
Positioning Techniques
• Chest rolls or bolster are placed on operating table prior to
positioning
• Foam head rest, head turned to side or facing downward
• Patient’s arms are rotated to the padded armboards that face
head, bringing them through their normal range of motion.
• Padding for knees and pillow for lower extremities to prevent
toes from touching mattress.
• Safety strap applied 2 in. above the knees

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Trendelenburg Position
- Surgeries involving lower abdomen, pelvic organ when
there is a need to tilt abdominal viscera away from the
pelvic area.

Positioning Techniques
• Patient is supine with head lower than feet.
• Shoulder braces should not be used as they may cause damage
brachial plexus.
• When patient is returned to supine position, care must be taken
move leg section slowly, then the entire table to level position.
• Modification of this position can be used for hypovolemic
shock.
• Extremity position and safety strap are the same as for supine.
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Reverse Trendelenburg Position
- Upper abdominal, head, neck and facial surgery

Positioning Technique
• Patient is supine with head higher than feet.
• Small pillow under neck and knees.
• Well - padded footboard should be used to prevent slippage to
foot of the table.
• Anti embolic hose should be used if position is to be maintained
for an extended period of time.
• Patient should be returned slowly to supine position.

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 Lithotomy
- Perineal, vaginal, rectal surgeries; combined abdominal
vaginal procedure

Positioning Techniques
• Patient is placed in supine position with buttocks near lower break
in the table ( sacrum are should be well padded )
• Feet are placed in stirrups, stirrups height should not be
excessively high or low, but even on both sides.
• Knee brace must not compress vascular structures or nerves in
the popliteal space.
• Pressure from metal stirrups against upper inner aspect of
thigh
and calf should be avoided.
• Legs should be raised and lowered slowly and simultaneously
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 Modified Fowler ( Sitting Position )
- Otorhinology (ear and nose ), neurosurgery

Positioning Techniques
• Patient is supine, positioned over the upper break in the
table
• Backrest is elevated, knees flexed
• Arms rest on pillow, placed in lap; safety strap 2 in. above the
knees.
• Slow movement in and out of position must be used to prevent
drastic changes in blood volume movement.
• Anti embolic hose should be used to assist venous return.
• When using special neurologic headrest, eyes must be
protected.
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Jack Knife Position
- Rectal procedures, sigmoidoscopy and colonoscopy

Positioning Techniques
• Table is flexed at center break
• All precautions taken with prone position are taken with
Jack knife position.
• Table strap applied over thighs

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ANESTHESIA

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• State of “Narcosis”
• Anesthetics can produce muscle relaxation, block transmission
of pain nerve impulses and suppress reflexes.
• It can also temporary decrease memory retrieval and recall.
The effects of anesthesia are monitored by considering the
following parameters:
- Respiration
- O2 saturation
- CO2 levels
- HR and BP
- Urine output

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Types of Anesthesia

 General Anesthesia
 Regional Anesthesia
 Balanced Anesthesia

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Types of Anesthesia
1. General Anesthesia

ｷ reversible state consisting of complete loss of

consciousness and sensation.
ｷ protective reflexes such as cough and gag are
lost
ｷ provides analgesia, muscle relaxation
and
sedation.
ｷ produces amnesia and hypnosis.
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Techniques used in General Anesthesia
A. Intravenous Anesthesia

ｷ This is being administered intravenously

and extremely rapid.
ｷ Its effect will immediately take place after
thirty minutes of introduction.
ｷ It prepares the client for smooth
transition to the
surgical anesthesia.
B. Inhalation Anesthesia

ｷ This comprises of volatile liquids or gas

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Stages of General Anesthesia based on
Guedel’s Classification

ﾘ Stage 1: Analgesia/Disorientation.
ﾘ Stage 2: Excitement / Delirium.
ﾘ Stage 3: Surgical Anesthesia
ﾘ Stage 4: Overdose/Stage of Danger

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Stages of General Anesthesia based on
Guedel’s Classification

ﾘ Stage 1: Analegesia/Disorientation.

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Stages of General Anesthesia based on
Guedel’s Classification

ﾘ Stage 2: Excitement / Delirium.

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Stages of General Anesthesia based on
Guedel’s Classification

ﾘ Stage 3: Surgical Anesthesia

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Stages of General Anesthesia based on
Guedel’s Classification

ﾘ Stage 4: Overdose/Stage of Danger

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2. Regional Anesthesia

ｷ temporary interruption of the transmission of

nerve impulses to and from specific area or region
of the body.

ｷ achieved by injecting local anesthetics in

close proximity to appropriate nerves.

ｷ reduce all painful sensation in one region of the

body without inducing unconsciousness.

ｷ agents used are lidocaine and bupivacaine.

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Techniques used in Regional Anesthesia:

A. Topical Anesthesia

ｷ applied directly to the skin and mucous

membrane, open skin surfaces, wounds and burns.
ｷ readily absorbed and act rapidly
ｷ used topical agents are lidocaine and
benzocaine.

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B. Spinal Anesthesia ( Subarachnoid block )

ｷ local anesthetic is injected through lumbar

puncture,
between L2 and S1

ｷ anesthetic agent is injected into subarachoid

space surrounding the spinal cord.

- Low spinal, for perineal/rectal areas

- Mid spinal T10 ( below level of
umbilicus) for hernia repair and
appendectomy.
-High spinal T4 ( nipple line ), for CS
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C. Epidural Anesthesia
ｷ achieved by injecting local anesthetic into epidural
space by way of a lumbar puncture.
ｷ result similar to spinal analgesia
ｷ agents use are chloroprocaine, lidocaine and bupivacaine.

D. Peripheral Nerve Block

ｷ achieved by injecting a local anesthetic to anesthetize
the surgical site.
ｷ agents use are chloroprocaine, lidocaine and
bupivacaine.

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 E. Intravenous Block ( Beir block )

ｷ often used for arm,wrist and hand

procedure
ｷ an occlusion tourniquet is applied
to the extremity to prevent
infiltration and absorption of the
injected IV agents beyond the
involved extremity.

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 F. Caudal Anesthesia
ｷ Is produced by injection of
the local anesthetic into the
caudal or sacral canal

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 G. Field Block Anesthesia
ｷ The area proximal to a planned
incision can be injected and
infiltrated with local anesthetic
agents.

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Complications and Discomforts of Anesthesia

ｷ Hypoventilation - inadequate ventilatory

support after paralysis of respiratory muscles.
ｷ Oral Trauma
ｷ Malignant Hyperthermia - uncontrolled
skeletal muscle contraction
ｷ Hypotension - due to preoperative hypovolemia
or
untoward reactions to anesthetic agents.
ｷ Cardiac Dysrhythmia - due to preexisting
cardiovascular compromise, electrolyte imbalance or
untoward reaction to anesthesia.
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ｷ Hypothermia - due to exposure to a cool ambient OR
environment and loss of thermoregulation capacity
from anesthesia.
ｷ Peripheral Nerve Damage - due to improper
positioning of patient or use of restraints.
ｷ Nausea and Vomiting
ｷ Headache

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END OF SLIDE