Concept on Surgery:

Intra-Operative CareMa. Tosca Cybil A. Torres, RN

The Surgical Team

• Surgeon• surgical assistant• anesthesiologist or the certified RN

anesthetist (CRNA)• Circulating nurse• scrub nurse

Members of the Surgical Team

• Surgeon and surgical assistantSurgeon is a physician who assumes responsibility for the surgical procedure and any surgical judgments about the client.

Surgical Assistant – might be another surgeon or a physician’s assistant, nurse, or surgical technologist.

• Anesthesia ProvidersAnesthesiologist is a physician who specializes in giving anesthetic agent.A certified registered nurse anesthetist (CRNA) is a registered nurse with additional credentials who delivers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist

The anesthesia provider monitors the client during surgery by assessing and monitoring the following:

• The level of anesthesia (i.e.bispectal analysis)• Cardiopulmonary function (Using

electrocardiographic [ECG] monitoring, pulse oximetry, arterial blood gas [ABG]

• Vital signs• Intake and output

Circulating nurse

Also known as circulator Coordinates, oversees, and is involved in the

client’s nursing care in the OR. Monitors traffic in the room Assess the amount of urine and blood loss. Reports findings to the surgeon and

anesthesia provider Ensures that the surgical team maintains

sterile technique and a sterile field

Anticipates the client’s and surgical team’s needs, providing supplies and equipments as needed.

Communicates information regarding the client’s status with family members during long or unique procedures.

Documents care, events, interventions, and findings.

Informs the post-anesthesia care unit of the client’s estimated time of arrival.

Scrub nurse

Sets up the sterile field, drapes the client, and hands sterile supplies, sterile equipment, and instruments to the surgeon.

Maintains an accurate count of sponges, sharps, instruments, and amounts of irrigation fluid and drugs used.

Actual assist of the scrub nurse1. Pass instruments in a decisive manner2. With the tip of the instrument visible and hand is free, the handle is

placed in the surgeon’s waiting hand 3. The instrument should be slapped firmly into the palm of the

surgeon in proper position for use4. If the surgeon is in the same side of the table and on the left side,

use your right hand to pass the instrument5. If the surgeon is on the same side and on the right side, use your

left hand to pass the instrument.

Tips: Don’t reach behind a member of a sterile team, go around him Pass another member of the sterile team back to back

Specialty nurse1. Educated in a particular type of surgery

and is responsible for nursing care specific to clients needing that type of surgery.

2. Assess, maintains, and recommends equipment, instruments, and supplies used in the specialty.

3. May act as the scrub nurse of circulating nurse.

Preparation of the Surgical suite and team safety

The Surgical Environment

♦ Because the intraoperative patient’s risk for serious infection is great, prophylactic antibiotics may be prescribed and given within 2 hours of the initial incision. External precautions include surgical asepsis, which depends on the strict control of the EV. ♦ Strict dress codes are necessary in the surgical department to provide infection control within the OR suites, reduce cross-contamination between the surgery department and other hospital units or departments and promote both personnel and client health and safety.

♦ To help decrease microbes, the area in the surgical department is divided into three (3) areas:

a. Unrestricted zone – permit access by those in the hospital uniforms or street clothes. These areas may also allow limited access for communicating with OR personnel.

b. Semirestricted zone – require scrub attire, including a scrub suit, shoe covers, and cap or hood. Hallway, work areas, and storage areas are considered seirestricted.

c. Restricted zone – are located within OR. Personnel wear masks, sterile gowns and gloves in addition to appropriate scrub attire. The entire surgical attire is changed between procedures or whenever it becomes soiled or wet.

The Surgical Scrub – is performed to render hands and arms as clean as possible in preparation for a procedure.

1. The surgeon, all assistants and the scrub nurse performs a surgical scrub after putting on a mask and before putting on a sterile gown and gloves

2. A surgical antimicrobial solution is used for the surgical scrub.

The purposes are:• To remove dirt, skin oils, and transient microorganisms

from hands and forearms• To increase client safety by reducing microorganisms on

surgical personnel• To have an antimicrobial residue on the skin to inhibit

growth of microbes for several hours.

Surgical attire

1. All members of the surgical team and all OR personnel must wear scrub attire for use within the surgical suite.

2. Scrub attire is clean, not sterile.

Principles of Perioperative Asepsis

Surgical Asepsis – prevents the contamination of surgical wounds. It is the absence of microorganisms in the surgical environment to reduce the risk for infection

Basic Guidelines for Maintaining Surgical AsepsisGeneral– Sterile surfaces or articles may touch other sterile surfaces

or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated.

– If there is any doubt about the sterility of an area or an article, it is considered unsterile and contaminated.

– Whatever is sterile for one patient can be used for this patient only. Unused sterile supplies must be discarded or resterilized if they are to be used again.

• Personnel– Scrubbed personnel remain in the area of the

surgical procedure; if a scrubbed person leaves the room, that person’s sterile status is lost. To return to surgery, this person is required to go though the procedure of scrubbing, gowning, and gloving.

– Only a small part of a scrubbed person’s body is considered sterile: from front waist to the shoulder area; forearms and gloves. Therefore, the gloved hands must be kept in front between the shoulder and waistline.

– The circulating nurse and any unscrubbed personnel remain at a safe distance to avoid contamination of any sterile area.

• Draping– During draping of a table or patient, the sterile

drape is held well above the surface to be covered and is positioned from front to back.

– Only the top of the patient or table that is draped is considered sterile; drapes hanging over the edge are not regarded as sterile.

– Sterile drapes are kept in position by the use of clips or adherent material; drapes are not moved during the surgical procedure.

– A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. Such a drape must be replaced.

• Delivery of Sterile Supplies– Packages are wrapped or sealed in such a way that

they can be opened easily without risk of contaminating contents.

– Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that sterility of the object or fluid remains intact.

– Edges of wrappers covering sterile supplies or outer lips of bottles or flasks containing sterile solution are not considered sterile.

– The unsterile arm of the circulating nurse must not extend over a sterile area. Sterile articles are to be draped onto the sterile field, a reasonable distance from the edge of the sterile area.

• Solutions

Sterile solutions are poured from a point high enough to prevent accidental touching of the sterile receiving cup or basin, but not so high as to produce splashing.

Positioning Factors to Consider in Positioning the Patient in the OR table

1. The patient should be in as comfortable position as possible, whether asleep or awake.

2. The operative area must be adequately exposed.3. The vascular supply should not be obstructed by an

awkward position or undue pressure on a part.4. There should be no interference with the patient’s

respiration as a result of the pressure of the arms on the chest or constriction of the neck or chest caused by the gown.

5. Nerves must be protected from undue pressure. 6. Precautions for patient safety must be observed,

particularly with thin, elderly, or obese patients.7. The patient needs gentle restraint before induction, in case

of excitement.

Common Surgical positionsdorsal recumbent- for abdominal surgery such

as bowel resection; chest surgery such as mastectomy

Trendelenburg- for abdominal/ pelvic surgery as the intestines are displaced into the upper abdomen

Dorsal lithotomy- for vaginal and rectal surgery

Prone- for spinal or back surgery

Kraske/ jack knife- for hemorrhoids or proctologic

Reverse trendelenburg- for gall bladder or biliary tract procedure

Neurosurgical sitting- for intra cranial procedures

Anesthesia

• Is an induced state of partial or total loss of sensation, occurring with or without loss of conscience.

Purposes of Anesthesia

• To produce muscle relaxation • To produce analgesia• To produce artificial sleep or to cause loss of

consciousness• To block transmission of nerve impulses• To suppress reflexes

Selection of anesthesia is influenced by the following:

• Type and duration of the procedure• Area of the body having surgery• Safety issues to reduce injury, such as airway

management• Whether the procedure is an emergency• Options for management of pain after surgery• How long it has been since the client ate, had any

liquids, or any drugs• Client position needed for the surgical procedure

Classification:

• General anesthesia• Local or regional anesthesia

General anesthesia• Is a reversible loss of consciousness induced by

inhibiting neuronal impulses in several areas of the central nervous system

• General anesthetics are agents that block the pain stimulus at the cortex

Produces a state of the ff: Analgesia Amnesia Unconsciousness characterized by loss of reflexes and

muscle tone

Stages of General anesthesia

Stage 1 (analgesia and sedation, relaxation)Description1. Begins with induction and ends with loss of

consciousness2. Client feels drowsy and dizzy, has a reduced

sensation to pain and is amnesic3. Hearing is exaggerated

Nursing Intervention1. Close operating room doors, dim the lights,

and control traffic in the operating room2. Position client securely with safety belts

Stage 2 (Excitement, delirium)Description• Characterized by struggling, shouting, laughing,

singing or crying--- maybe prevented if anesthetic is administered smoothly and quickly

• Client may have irregular breathing, increased muscle tone, and involuntary movement of the extremities during this stage

• Laryngospasm or vomiting may occur• Pupils dilate but contract if exposed to light

Nursing Intervention 1. Avoid auditory and physical stimuli2. Protect the extremities3. Assist the anesthesiologist or CRNA with

suctioning as needed4. Stay with client.

Stage 3 ( Operative anesthesia, surgical anesthesia)

1. Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital function

2. Pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed

3. The jaw is relaxed, and there is quite, regular breathing.

4. The client cannot hear5. Sensations are lost

Nursing Intervention1. Assist the anesthesiologist or CNRA with

intubation2. Place patient into operative position3. Prep the clients skin over the operative site as

directed.Rationale1. Providing assistance helps promote smooth

intubation and prevent injury

2. Performing procedures as soon as possible promotes time management to minimize total anesthesia time for the client.

Stage 4 (Danger)Description1. Begins with depression of vital function and ends with

respiratory failure, cardiac arrrest, and possible death2. Respiratory muscles are paralyzed; apnea occurs3. Pupils are fixed and dilated.

Nursing Intervention1. Prepare for and assist in treatment of cardiac and /or

pulmonary arrest2. Document occurrence in the client’s chart.Rationale1. Teamwork and preparedness help decrease injuries

and complications, and promote the possibility of a desired outcome for the client

Administration of General AnesthesiaInhalation-a. Gaseous Agent – nitrous oxide is the

most common used agent and is usually given with oxygen. It is colorless, odorless gas that provides analgesia

b. Volatile agents – liquid agents vaporized for inhalation. O2 is the carrier, flowing over or bubbling through the liquid in the vaporizer system on the anesthesia machine.

Intravenous injection- administered through a vein. The patient feels a simple, pleasant and rapid induction. Unconsciousness generally ocurs about 30 seconds to 1 minute after the initial IV adminstration.

1. Barbiturates – it acts rapidly, causing unconsciouness within 30 seconds. Ex: Thiopental Na ( Penthotal Na)

2. Ketamine (Ketalar) – ketamine is a dissociative anesthetic agent. Rapid onset of a trancelike, analgesic state occur. Often used for diagnostic and short surgical procedures.

3. Propofol (Diporivan) – is a short acting anesthetic agent. Hypnosis occurs in less than 1 minute from the time of injection. The drug is eliminated rapidly and the client becomes responsive within 8 minutes after the infusion ends.

Adjuncts to General anesthetic Agents• Sedatives – common drugs in the class include midazolam

(Dormicum) and diazepam (Valium). All have hypnotic, sedative, muscle relaxant, and amnesic effects

• Opioid analgesics (narcotics)– common opioid analgesic enhance anesthesia include morphine sulfate, meperidine, fentanyl and sufentanil

• Neuromuscular Blocking Agents – are used to relax the jaw and vocal cords immediately after induction so that the endotracheal tube can be placed. This is used to provide continued muscle relaxation. Ex: Succinylcholine

Local anesthesia• Injection of a solution containing anesthetic into the tissues

at the planned incision site.• Briefly disrupts sensory nerve impulse transmission form a

specific body area or region.

Advantages:

• Simple, economical, and nonexplosive• Equipment needed is minimal • Post operative recovery is brief• Undesirable effects of GA are avoided• Ideal for short and superficial surgical procedures

Types of Local anesthesia

1. Topical anesthesia – topical agents are applied directly to the area of skin or mucous membrane surfaced to be anesthetized

2. Local infiltration – is the injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion.

Regional Anesthesia

A form of local anesthesia in which an anesthetic agent in injected around the nerves so that the area supplied by the nerves is anesthetized.

The patient receiving RA is awake and aware of his surroundings unless medications are given to produce mild sedation or to relieve anxiety.

Administration of Regional AnesthesiaSpinal Anesthesia- produces a

nerve block in the subarachnoid space by introducing a local anesthetic at the lumbar level, usually between L4 and L5.

• Autonomic nerve fibers are the first affected and the last to recover

Spinal anesthesia blocks the following in order: 1.Touch2.Pain 3.Pressure 4.motor

Common drugs used in SA• Procaine (Novocaine) • Lidocaine (Xylocaine)• Bupivacaine (Mercaine)

Advantages

• Eliminates the need for expensive equipments and drugs

• Relatively safe method of anesthesia • Provides excellent method of anesthesia • Does not cloud the patient’s consciousness or

alertness• Useful for patients with respiratory or cardiac

problems

Complications

• Hypotension • Headache• Post op paralysis • Nausea and vomiting • Urine retention

Epidural Anesthesia

• A commonly used conduction block by injecting a local anesthetic into the epidural space that surrounds the dura matter of the spinal cord

• Blocks sensory, motor, and autonomic functions

• Have much higher doses • All the complications in the SA can be

observed except headache

Local conduction blocks

• Brachial plexus block- produces anesthesia of the arn

• Para vertebral anesthesia- produces anesthesia of the nerves supplying the chest, abdominal wall and extremities

• Transsacral (caudal) block – produces anesthesia of the perineum and occasionally the lower abdomen

Common medications used in local/regional anesthesia

• Severe respiratory and circulatory problems• Disturbs or suppress all physiologic function (GI motility,

renal function may fail entirely)• Metabolic activities slows and becomes disturbed• Dangerous neurologic changes (elderly may suffer CVA-

Anoxia due to airway obstruction and may lead to convulsion and cerebral tissue ischemia)

• Corneal abrasions--- blinking and tearing may be suppressed

• Lip and tongue injuries• Vocal cord damage• Peripheral nerve injury• Abscess formation, tissue necrosis, and /or gangrene

NURSING PROCESS FOR THE INTRAOPERTIVE PERIOD

AssessmentClassify the client’s physical status for anesthesia:• Mild disturbance (eg, mild cardiac disease, mild

diabetes mellitus)• Severe systemic disturbance (eg, poorly controlled

diabetes mellitus, pulmonary complications)• Life-threatening systemic disease (eg, severe renal or

cardiac disease)• Moribund, with little chance of survival (eg, rupture

aortic aneurysm)

Assess the client’s record for appropriate documentation including• Current signed consent form• Completed history and physical assessment record• Recent laboratory and diagnostic reports• Evaluation of the client’s overall physiologic, emotional and

psychologic statusSpecifically ask the client about any known allergies.Verify client identification and that the correct surgery is

scheduled.Assess for special surgical considerations (eg, locations

where an electric grounding plate can be safely placed on the clients, avoiding areas where metal or a prosthesis is present) and precautions (eg, shielding with a lead apron if radiation is involved, if the client is pregnant).

Assess the client’s risk for accidental hypothermia or malignant hypothermia during anesthesia administration and surgery. Be sure that antidotal supplies are readily available in an emergency.

Possible Nursing Diagnoses

• Risk for fluid volume deficit or excess• Risk for hypothermia or hyperthermia• Risk for infection• Risk for altered tissue perfusion: cardiac,

respiratory, and peripheral • Risk for injury

Planning and Outcome Identification.

The major goals for the client during the intra-operative period may include:

• maintenance of fluid balance• maintenance of normothermia • prevention of infection • adequate tissue perfusion • absence of injury.

Implementation

Promote measures that maintain adequate fluid and electrolyte balance.• Monitor intake and output accurately• Assess the client for dehydration to include skin turgor

and mucous membranes.• Assess the client for circulatory overload to include

breath sounds, peripheral edema and jugular vein distention• Monitor pertinent electrolyte values.

Promote measures that maintain the client’s normal temperature of 36.6 C to 37.5 C (98 F to 99F)• Ensure that OR temperature is between 25 C and 26.6 C

78 F to 80F).• Warm all intravenous and irrigating solutions• Monitor the client’s temperature continuously.• Remove all wet gowns and drapes promptly and

replace with dry to prevent heat loss.

Promote measures that decrease risk of infection.• Maintain sterile procedures and techniques during

surgery.• Apply sterile dressings to all wounds.• Non-scrubbed personnel refrain form touching or

contaminating anything that is sterile.

Promote measures that ensure adequate tissue perfusion in the client during surgery.• Assess the client’s vital signs continuously.• Assess the client’s respiratory status, and assist with

mechanical ventilation.• Assess the client’s cardiovascular status.• Assess the client’s peripheral vascular status.

Ensue the client’s safety in the OR• Set room temperature and humidity to prevent hypothermia.• Remove any potential contaminants• Curtail unnecessary room traffic.• Keep room noise and talk at a minimum• Recheck electrical equipment for proper operations• Make sure that necessary equipment and supplies are available• Ensure that instruments, sutures and dressings are ready.• Count and record sutures, needles, instruments, and sponges• Make sure that staff call the client by name and provide

individualized attentions.• Assist in transferring the client to the OR table.• Cove the client with a warm blanket, and attach the safety strap.• Remain at the client’s side during anesthesia induction• Verify proper client positioning to protect nerves, circulation,

respiration, and skin integrity. Always pad pressure areas.• Ensure that newly requested items are quickly supplied to the

anesthesia or scrub team by the circulating nurse

Perform other actions as appropriate.• Act in the role of client advocate, providing privacy and

protection from harm• Follow established procedures and protocols.• Document all OR care.• Help coordinate health team activities.• Promote ethical behaviors (eg, respect, confidentiality).• Monitor blood, fluid and other drainage output.• Maintain a quiet, relaxing atmosphere. Remember, the

client can hear.• Apply grounding pad.

Outcome evaluation• The client maintains adequate fluid balance as evidenced

by elastic skin turgor, moist buccal mucosa, and no peripheral edema or jugular vein distention, and the electrolyte status remains within normal limits.

• The client maintains satisfactory body temperature between 96F and 100F on completion of surgery.

• The client shows no signs or symptoms of systemic or wound infection

• The client show safely in the PACU and exhibits adequate cardiac, respiratory and peripheral circulation.

• The client remains free of any operative injury from electrical, chemical or physical hazards related to surgery.

• The client remains free form injury linked to positioning during surgery, as evidenced by no complaints of numbness, paralysis, or abrasions.