INTRAOPERATIVE PHASE At the end of the discussion, the student will be able to:

1. Describe the interdisciplinary approach to the care of care of the patient during surgery.

2. Describe the principles of surgical asepsis. 3. Describe the various nursing roles as well as the role of the

surgical team during the intraoperative phase perioperative nursing. 4. Identify the types, effects of surgery and anesthesia. 5. Identify the surgical risk factors and nursing interventions to

reduce those risks. 6. Identify the use of the nursing process for optimizing patient

outcomes during the intraoperative phase.

Reference: Medical-Surgical Nursing by Brunner and Suddarth 10th Edition Volume 1 (Chapter 19)

Nursing care focuses on the client's emotional well-being, safety, positioning, maintaining surgical asepsis and controlling the environment.

Surgical team is a group of highly trained and educated professionals who coordinate their efforts to assure the welfare and safety of the patient.

INTRAOPERATIVE NURSING CARE Second phase of the Perioperative Nursing Known as " Operating Room Nursing " Basic Nursing Responsibilities during Intraoperative :

1. Maintain safety and prevent injury. 2. Promote wound healing and prevent infection. 3. Monitoring of Physiologic Responses 4. Documentation of Intraoperative Care 5. Moving and Transportation of Patients from Operating Room to

PACU

Intraoperative – begins when the client enters a surgical suite and ends with admission in the recovery area.

– “During” surgery; begins when the patient is transferred onto the OR table and ends with admission to the PACU.

Members of the surgical team group of highly trained and educate individuals who must worked together as a coordinated team for the welfare and safety of the client undergoing operative and other invasive procedure.

1. Surgeon

2. Anesthesiologist

3. Circulating Nurse

4. Scrub person or surgical technologist

5. Assisstant

      Surgeon – heads and makes the major decision concerning the course of the surgery such as whether to remove an organ or amputate limb. He should be alert at all times to reports from the anesthesiologist provided concerning the changing physiologic needs of the client undergoing the stress of surgery.

      Anesthesiologist: Alleviate pain, promote relaxation and medication specialist.

1. Maintain the clients’ airway.2. Ensure that client has an adequate gas exchange.3. Infuse blood, fluids and medication to maintain hemodynamic

stability.4. Monitor circulation and respiration, estimation of blood loss and fluid

loss.5. Alert surgeon for complication.        Circulating Nurse:1. Checks that all equipment is working properly before surgery.2. Ensures sterility of instrument for surgery.3. Assist with the positioning of the client.4. Perform skin prep on the client.5. Alert team members to any break in sterile techniques. 6. Assist the anesthesiologist with monitoring vital function such as urine

output and blood loss.7. Label specimens.8. Coordinates activities with other department such as x-ray and

pathology.9. Document the care provided.

6. Ensure that staff conversation traffic kept to a minimum.7. Promote smooth and safer function in the OR by bringing needed supplies

and medication to the operating table.8. Sponge, sharp and instrument count.9. Removing unneeded items or specimens.

      Scrub person Before surgeon arrives:a. Do a complete scrub according to the institutional procedure.b. Gown and glove from a surface separate from the intended sterile field.c. Drape tables as necessary according to institutional policy.d. Count sponges, surgical needles and other sharps and instrument with the

circulator according to established institutional policy and procedure.e. Arrange instrument and accessory items on the mayo stand for making and

opening the initial incision.

Classification of Instrument:1. Cutting or Dissecting – knives and scissors.2. Grasping and Folding – Tissue forcep.3. Clamping and Occuluding – Hemostatic forceps and clamps.4. Exposing – retractors.5. Suturing – needle holder.

  After surgeon and assistant scrub: a.       Gown and glove the surgeon and assistant as soon after they

enter the room. b.      Assist in draping the patient according to routine procedure. c.       Bring the mayo stand into position over the patient after draping

is completed.

During Surgical procedure:a.       Pass the knife to the surgeon and a hemostat to the assistant.b.      Hand up sterile towels or lap sponges if requested for covering skin

at the incision edges.c.       Watch the field and try to anticipate the surgeon and the assistant

needs.d.      Pass instrument in a decisive and position manner.e.       Keep two lap sponges or tapes in the field. f.        Save and care for all tissue specimens according to policy and

procedure.g.       Maintain sterile technique. Watch for any breaks. 

During closure:

a.       Count sponges, sharps and instrument with the circulation when the surgeon begins the closure of the wound in accordance with established count procedure.

b.      Clear the mayo stand as time permits leaving a knife handle with blade, tissue forceps, suture, scissors, four hemostats and two Alli’s forceps.

c.       Have a clean, saline-moistened sponge ready to wash blood from the area surrounding the incision as skin closure is completed.

d.      Have dressings ready.

PRINCIPLES OF STERILE TECHNIQUE       Infection is a serious postoperative complication that may

become life threatening for the patient OR team members must know and apply the principle of aseptic and sterile technique at all times.

Postoperative wound infection can originate in the OR from a break in technique by a team member from airborne contaminants of improperly cleaned floors, furniture, and ventilating system or from inadequate sterilized instrument and supplies.

 1. Only sterile items are used within sterile field.2. Sterile persons are gowned and gloved.3. Tables are sterile only at table level.4. Sterile person touch only sterile items or areas; unsterile person touch only

unsterile items or areas.5. Unsterile person avoid reaching over sterile field; sterile person avoid leaning

over unsterile area.6. Edges of anything that encloses sterile contents are considered unsterile.7. Sterile field is created as close as possible to time of use.8. Sterile areas are continuously kept in view.9. Sterile persons keep contact with sterile area.10. Sterile persons keep contact with sterile areas to minimum.11. Unsterile persons avoid sterile areas.12. Destruction of integrity to microbial barriers results in contamination.13. Microorganism must be kept to irreducible minimum. -         Perfect asepsis in the surgical wound is an ideal to be approached; it is

not absolute. All microorganisms cannot be eliminated but this does not obviate the necessity for strict sterile technique. It is generally agreed that:

a.       Skin cannot be sterilized. b.      Some areas cannot be scrubbed. c.       Infected areas grossly contaminated. d.      Air is contaminated by dust, droplets and shedding.

Anesthesia – means the absence of pain.

  Types or Major Classification of Anesthesia:

1. General anesthesia

2. Regional

  General Anesthesia: Best suited for surgery of the head, neck, upper torso, back, prolonged

surgical procedure. Client who are unable to lie quietly fro prolonged period of time.

Blocked pain stimulus at the cerebral cortex, drug induced depression of the CNS that is reversed either by metabolites elimination in the body or by pharmacologic means.

Stage From To Assessment Nursing Intervention

I Onset Anesthetic Administration

Loss of Consciousness

Drowsy or dizzy, may experience auditory and visual hallucination.

Close operating room doors; keep room quiet and stand by to assist client.

II Excitement Loss of consciousness

Loss of eyelid reflexes

Increase in autonomic activity irregular breathing; client may struggle.

Remain quietly at patient’s side; assist anesthetist, if needed.

III Surgical Anesthesia

Loss of eyelid reflexes

Loss of most reflexes, depression of vital function

Client is unconscious, muscles are relaxed, no blink or gag reflex

Begin preparation (if indicated) only when anesthetic indicates stage III has been reached and client is under good control.

Stages of General Anesthesia:

Types of General Anesthesia: 1.      Intravenous     rapid introduction     unconsciousness, generally occurs about 30mins.     Commonly used as an induction agent before inhalation anesthesia is

given.     Used for dental extraction, pelvic examination. 2.      Inhalation   Mixture of volatile liquid or gas and oxygen.   Given through mask or endotracheal tube.   Advantageous because of the case of administration and elimination through

respiration system.

IV Danger(death) Vital functions too depressed

Respiratory and circulatory failure

Client is not breathing, may or may not move have heart beat.

If arrest occurs, respond immediately to assist in establishing airway; provide cardiac arrest tray, drugs, syringes, long needles; assist surgeon with.

  Nitrous oxide – commonly used gas anesthesia.   IV anesthesia is often administered before the use of inhalation

anesthetics-promotes rapid transition from the conscious stage to the surgical anesthesia stage.

    1.      Rectal anesthesia – via rectal tube. 2.      Administer IV and are given mainly to facilitate intubations,

relax the muscle within the surgical field ease laryngospasm, and relax muscle for controlled ventilation.

Regional Anesthesia – is useful in many clinical situations.   Types of Regional Anesthesia:1. Topical Anesthesiaa. Directly applied to the area.b. Is most often applied to the respiratory passages to eliminate laryngeal

reflexes of cough for insertion of airways before induction or during light general anesthesia or for therapeutic and diagnostic procedure such as bronchoscope or laryngoscope.

c. Ointment, solution, gel, cream or powder.d. Used for minor surgery such as rectal exam when painful hemorrhoids

are present, bronchoscope.

Local Infiltration Anesthesia

a. Involved injection of anesthesia agent such as lidocaine into the skin and subcutaneous tissue.

b. Blocks only the peripheral nerves around the area of incision.

c. Physician should not allow the needle to slip into one of the veins-it may cardiovascular collapse or convulsions.

d. Physician always aspirate before injection to ensure the needle is not in a vein.

 

2. Field Block Anesthesia

a. area proximal to the incision is injected and filtrated with local anesthetics and thereby forming a barrier between the incision and the nervous system.

3. Peripheral Nerve Block Anesthesia

a. Finger-digital nerve block

b. Entire upper arm-brachial plexus nerve block

c. Chest or abdominal wall-intercostals nerve block.

Spinal Anesthesia

a. Injecting certain local anesthesia into the subarachnoid space.

b. Autonomic nerve fibers are the first to be affected by spinal anesthesia and the last to recover.

c. Blocks the following fiber in order: touch, pain, motor, pressure, proprioceptive fibers.

d. Performed for almost any type of major procedure below the level of diaphragm.

e. Positioning:

1. Lateral position – the most common; the patient’s back is at the edge of the operative table, parallel to it. Knees are flexed into the abdomen and the head is flexed to the knees. Hips and shoulder are vertical to the table to prevent rotation of the spine.

2. Sitting Position – the patient sits on the side of the operating table with feet resting on a stool. The spine is flexed, with chin lowered to sternum, arms crossed and supported on a pillow on an adjustable table or mayo stand.

1. Prone Position – the patient lies face downward on operating table.

f. Advantage:

1. Safe

2. Provide excellent muscle relaxation.

3. Does not clouds the client with full stomach, because they will be awake to maintain their airway if they vomit.

Complication Cause Intervention Prevention

Hypotension Paralysis of the vasomotor nerve usually occurs shortly after induction of anesthesia.

Oxygen inhalation, vasoactive drugs, tredelenburg position if level of anesthesia is fixed 10 to 20 minutes after induction. Oxygen, fluids and anti-emetics.

500 to 800 ml fluid administered rapidly prior to block.

Nausea and Vomiting During abdominal surgery, because of fraction placed on various structures within the abdomen or hypotension.

Oxygen, fluids and anti-emetics

 

Headache CSF Apply tight abdominal binder. Fluids, analysis, inject 10 ml of client’s blood to plug hole.

Use very small spinal needle, administers IV and oral fluids before and after induction. Keep client flat on bed for 8 hours post op.

 Spinal Anesthesia Complication:

1. Epidural, Peridural Block – the term epidural, peridural and extradural are used synonymously.

Lumbar Approach – is a peridural block. Equipment is similar to that for a spinal with the addition of 19 gauze x 3 ½ inches long, thin walled needle with sty let with a rigid shaft and short bevel tip to minimize danger of inadvertent dural puncture. Insertion of a catheter allows repeated injection for continuous epidural anesthesia, requiring additional needles, stopcocks and plastic catheter in the set-up.

1. Caudal Anesthesia       Is an epidural sacral block. Epidural injection is through the

caudal canal, desensitizing nerves emerging from the dural sac.       Position for injection is prone with hips flexed, sacrum

horizontal, and heels turned outward to expose the injection site.       Skin and ligaments are infiltrated with local anesthetic agent

before the spinal needles is inserted.

Respiratory Paralysis If drug reaches upper thoracic and cervical cord in large amount or in heavy concentration.

Artificial Respiration Avoid extreme trendelenburg position 10-20 minutes following induction.

Type of Wound       Surgical Incision and Excision – the surgeon cuts through

intact tissue for the purpose of exposing or excising tissue. An incision is a cut or an opening into a tissue. An excision is the removal of a tissue.

      Traumatic Injuries – traumatic wounds are considered closed or open, simple or complicated, clean or contaminated. Wound closure is predicated on type, location, severity and extent of injury.

1. Close wounds – skin is intact in a close wound, but underlying tissue are injured. A blister filled with serum or a hematoma of blood and serum may form under epidermis. Torn ligaments and simple fractures are close wounds.

2. Open wound – the continuity of skin is broken by abrasion, laceration or penetration.

Simple wound – continuity of skin is interrupted in simple wounds, but without loss or destruction of tissue and without implantation of a foreign body. These laceration are usually caused by a sharp-edged object cutting or penetrating at a low velocity.

1. Complicated wounds – tissue is lost or destroyed by crush or burn, or a foreign body is implanted by high velocity penetration. The depth of a penetrating wound is irrigated and may be excised. Skin grafting may be required following destruction of dermis.

2. Clean wound – will heal by first intention after closure of all tissue layers and wound edges. The cosmetic care of lacerated areas is important, as is treatment to provide normal function of a part.

3. Contaminated wounds – when dirty objects penetrate skin, microorganisms multiple rapidly. Debridement is done to thoroughly wash and irrigate a wound. Devitalized tissue is removed because it acts as a culture medium. After initial debridement to remove foreign body including dirt and dead or deviated tissue, the wound may be left open to heal by second or third.

      Chronic wounds – pressure sores and decubitus ulcers may result from a comprised circulation over bony prominences for extend period of time.venous stasis or inadequate circulation in the legs may cause skin ulcer.

Mechanism of wound healingWound healing is nature’s way of restoring continuity and strength to

injured or incised tissue. When a tissue is cut, the body’s inherent defense mechanism responds immediately to begin repair.

MAINTENANCE OF SAFETY AND PREVENTION OF INJURY

  Positioning Factors a. Site of Operation b. Age and Size of Patient c. Type of Anesthetic Use d. Pain normally experience on movement Criteria for Positioning a. Maximum safety and comfort (Body Alignment). b. No interference of respiration. c. No interference with circulation. d. No pressures on nerves e. Accessibility of Operative Site f. Accessibility of Anesthetic Administration g. No undue postoperative discomfort h. Individual requirements met

Operative Positions a. Dorsal Recumbent: Coronary Bypass/ Hernia Repair

Mastectomy/Bowel Resection b. Trendelenberg : Permits displacement of intestines into upper abdomen

( Lower Abdomen Surgery or Pelvis ) c. Lithotomy: Exposes perineal and rectal areas (Vaginal repairs/D and C

and Rectal Surgery) d. Lateral (Kidney Position): Kidney/ Chest or Hip Surgery e. Prone: Posterior Chest, Trunk, Legs and at times rectal areas f. Kraske ( Jacknife ) : Hemorroidectomy Safety Measures 1. Proper identification of patient when transferring from OR table and

affirmation of operative site. 2. Table securely locked in position with application of brake. 3. Anesthesiologist guards the head at all times and head support is done. 4. Physician assumes responsibility for protecting unsplinted fracture if any

on movement. 5. If arm board is used, it must be guarded. Don't hyperextend arm or

dislodged IVF. 6. Move slowly and gently to allow circulatory adjustment. 7. If patient is on his back, ankles and les must not cross. 8. If patient is on his side, a pillow must be placed lengthwise between the

legs.

9. If patient is on prone, thorax must be relieved of pressure to facilitate respiration.

10. Adequate assistance in lifting patients and constant vigilance to prevent falls.

11. Position should not obstruct tubing’s. 12. Patient is not moved without permission from the anesthesiologist.

 Method of accounting for items put on sterile table performed by scrub nurse and

circulating nurse. a. FIRST COUNT (Person who wraps items for sterilization counts them

in standardized multiple units) b. SECOND COUNT (Circulating and Scrub Nurse count together when

packages are open before OR begins) c. THIRD COUNT (Counts are taken in 3 areas when surgeon starts

wound closure) d. FOURTH COUNT (Before incision is closed) Electrical Hazards 1. All plugs and wires are inspected for correct attachments. 2. All working equipment is checked to ensure good working order. 3. Grounding of all electrical equipment is essential for safety and prevention of

stray leakage current.

SURGICAL ASEPSIS Ensures sterility of all instruments and supplies. Key words in Operating Room Practice (Caring, Conscience,

Discipline, and Technique)

Surgical Conscience         One's inner voice for conscientious practice of asepsis and

steriletechnique at all times.

Application of Principles of Sterile Technique 1. Preparation by sterilization of all instruments and materials use. 2. Preparation of surgical team in handling supplies and contact

with surgical wound. 3. In creation and maintenance of sterile field and preparation of

client in order to prevent wound contamination. 4. Maintenance of sterility and asepsis in the operative procedure. 5. Terminal sterilization and disinfections at conclusion of the

operation.

PROMOTION OF WOUND HEALING AND PREVENTION OF INFECTION

      Product of entrance, growth and metabolic activities and pathophysiological effects of microorganisms in living tissue.

      Classification of Infection 1. Source ( Home or Nosocomial ) 2. Etiology ( Bacterial or Nonbacterial )

PREDISPOSING FACTORS TO INFECTION       Malnutrition       Age       Obesity       Chronic Diseases       Remote Infections       Impaired Defense Mechanisms       Cardiovascular and Respiratory Determinants       Lengthy Preoperative Stay       Types of Operation       Duration of Operation       Operative Technique       Indiscriminate Use of Antibiotics

CLINICAL MANIFESTATION OF WOUND INFECTIONS       Redness, excessive swelling, and tenderness      Red streaks in the skin near the wound      Pus or other discharges from the wound      Tender lymph nodes in axillary region      Foul smell from wound      Generalized body chills      Elevated body temperature and pulse

PREVENTION OF WOUND INFECTIONS      Control of infection      Use of strict sterile techniques      Careful Operative Technique      Reduction of Environmental sources of Contamination      Thorough, Prompt Cleansing and Debridement of Traumatic Wounds      Prevention of Intraoperative Contamination of Wound      Judicious use of Prophylactic Antibiotics      Meticulous Hand washing Sterile Technique for Dressing Change

MONITORING OF PHYSIOLOGIC RESPONSES

          Body Temperature 1. Prevention of hypothermia and hyperthermia. 2. Provide blanket to minimize heat loss without causing

vasodilation which may cause bleeding. 3. Special Considerations to infants.

        Emergencies * Malignant Hyperthermia* 1. Genetic disorder characterized by uncontrolled skeletal muscle

contraction leading to fatal hyperthermia 2. Occurs in combination with succinnylcholine and halothane

anesthetics and within 30 minutes of anesthesia induction. 3. Signs and symtoms : Increase end tidal oxygen; masseter muscle

rigidity cardiac dysrhythmias; hypermetabolic rate 4. Treatment: Datrolene (Muscle relaxant)

DOCUMENTATION OF INTRAOPERATIVE CARE Time patient arrived in and departed from OR Level of consciousness or anxiety manifested by observable physical

responses Site, time started, type of needle or cannula, solutions administered

intravenously including blood products. Position and type of restraints and supports Skin condition and antiseptics Location of electrosurgical grounding and monitoring electrodes Operation performed Specimen and cultures sent to laboratory. Medications given and anesthetics used Sites and types of drains applied Type of dressing applied Unusual incident or complications

MOVING AND TRANSPORTING PATIENTS FROM O.R. TO PACU        Wiping of any excess blood, skin preparation and debris from the

patient's skin        Provide clean gown and blanket on patient.        Enough personnel for moving and transporting.        Avoid rapid movements in changing the patient's position.        Watch out for effects of anesthesia.        Careful with devices attached to patients        Provide privacy in transfer, avoid rough handling may damage fragile

skin.        Provide privacy in transfer; avoid rough handling my damage fragile

skin.        Provide warm blanket and secure safety belts and siderails.

Patients who may be transferred to ICU 1. Clients at risk of severe complications. 2. Undergone major surgery 3 Suffered cardiac or respiratory arrest during or immediately following

surgery. 4. Clients who came to surgery from Intensive Care Units NOTE: Family should be notified of patient's progress.