nursing management intra operative

THE GOAL of perioperative or intraoperative nursing practiceis to assist patients and their families to achieve a level of well-ness equal to or greater than that which they had prior to theprocedure (Association of periOperative Registered Nurses[AORN], Perioperative Nursing Data Set (PNDS-2007). Themost important role of the perioperative nurse is to be a patientadvocate. The essence of the advocacy in the perioperative roleis defined as protection, communication (giving a voice), doing,comfort, and caring.

Advocacy is described as an act of informing and supportingthe individuals so that they may make the best decisions possiblefor themselves. It is also speaking up for someone who is unable tospeak for himself. Advocacy is a critical issue for surgical patientswho are unconscious or sedated and unable to make decisions re-lated to their care. Protecting patients from harm is the essence ofthe advocacy role of nurses, and it is a critical component for pa-tients whose family members are not readily accessible and whoseonly possible advocate is the nurse. This is often the case for thepatient having surgery. Many perioperative issues involve advo-cacy. These may include helping patients who are uninformed orhave not given adequate consent for surgical procedures, con-fronting an incompetent colleague, pressing for more analgesia for

618

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PTER

Outcome-Based Learning ObjectivesAfter 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.

Krista BrechtKrisna Ogerio

Donna StanbridgeDanielle Vigeant

Suzanne Watt

With contributions by:Jane Ashley

Kathleen Osborn

a patient in pain, or supporting the patient’s view toward prolong-ing life with extraordinary treatment or technology.

Surgical patients can be compromised by stress, diseaseprocess, and sedation or general anesthesia, and they trustthat a perioperative nurse will advocate in their best interestto ensure their privacy, dignity, rights, and safety.

The nurse must accept accountability for nursing actions thatsafeguard the rights of the surgical patients. Perioperative nursesact as patient advocates by protecting, and they must be able toquickly and accurately identify advocacy issues and be ready tointervene on behalf of their patients. In recent years, the accep-tance of a conceptual model for patient care, published byAORN, has helped to distinguish the relationship of variouscomponents of nursing practice and the effect on patient out-comes (Beyea, 2000) (Figure 26–1 �).

Guidance for Professional PracticeThe practice of perioperative nursing is guided by its own pro-fessional organization, the Association of periOperative Regis-tered Nurses, as well as the Centers for Disease Control and

Intraoperative Nursing

26

CHAPTER 26 Intraoperative Nursing 619

Prevention (CDC) and the Joint Commission. AORN defines itsmission as follows: “to promote safety and optimal outcomes forpatients undergoing operative and other invasive procedures byproviding practice support and professional development oppor-tunities to perioperative nurses.” AORN is composed of approxi-mately 41,000 perioperative registered nurses in the United Statesand abroad who manage, teach, and practice perioperative nurs-ing; who are enrolled in nursing education; and who are engagedin perioperative research (AORN, 2007a). This professional orga-nization has developed a conceptual framework and vocabularycalled the Perioperative Nursing Data Set (PNDS). The data setaddresses the domains of safety, physiological responses, behav-ioral responses of the patient and family, and the environment ofthe perioperative setting within the health system.

The CDC’s mission is to promote health and quality of life bypreventing and controlling disease, injury, and disability. It alsoinfluences perioperative practice. In 1999, the CDC issuedguidelines for the prevention of surgical infection. Additionally,it reflected the mission statement of the Joint Commission tocontinuously improve the safety and quality of care provided tothe public through the provision of health care accreditationand related services that support performance improvement inhealth care organizations (Joint Commission, 2007). The JointCommission is an independent, not-for-profit organization thatis the United States’ predominant accrediting body charged withmaintaining and improving health care delivery. The JointCommission’s comprehensive accreditation process evaluatesan organization’s compliance with its standards and other ac-creditation requirements. Joint Commission accreditation isrecognized nationwide as a symbol of quality that reflects an or-ganization’s commitment to meeting certain performance stan-dards. To earn and maintain the Joint Commission’s Gold Sealof Approval, an organization must undergo an on-site survey by

a Joint Commission survey team at least every 3 years. A com-plete discussion of the Joint Commission is presented inChapter 3 .

Surgical TeamSuccessful surgery relies on the interplay of many individualsworking as a team, complementing each other’s skills and respon-sibilities. This multidisciplinary team includes the surgeon andassistants, anesthesiologist and assistants, the nursing team, andsupport staff. Each of these professionals is responsible for specificfunctions and plays a role in supporting the other groups. Thisoverlap of responsibilities ensures the safety of patients while theyare in a most vulnerable situation of not being able to give anypersonal input. The roles of each member are described next.

SurgeonThe surgeon heads the surgical team and is responsible for mak-ing decisions related to the surgical procedure. Depending on theprocedure, an assistant might be required. This assistant could beanother surgeon, physician, resident in a university teaching hos-pital, or the registered nurse first assistant. The surgeon is respon-sible for performing the procedure and for coordinating the team.

An expanded role for perioperative nurses is that of registerednurse first assistant (RNFA). The RNFA collaborates with thesurgeon and performs the role of first assistant during the oper-ation. This role includes handling tissue, providing exposure, us-ing instruments, suturing the wound, and providing hemostasis.The role of an RNFA is highly specialized and demanding. In2008, AORN approved a policy statement that defines the RNFArole, scope of practice, and qualifications.

Anesthesia Care ProviderThe anesthesiologist is a health care provider who specializes inthe administration of anesthetic agents and provides care to alle-viate pain and promote relaxation. This professional is responsi-ble for maintaining the airway; monitoring and ensuring gasexchanges, respiration, and circulation; estimating and replacingblood and fluid losses; administering medications to maintain he-modynamic stability; managing care in the event of a physiologi-cal crisis; and constantly communicating with the surgical andnursing team. The anesthesiologist heads the anesthesia team andmight be assisted by a respiratory therapist, anesthesia resident orfellow in a university teaching hospital, or a certified registerednurse anesthetist (CRNA). As Chapter 1 discussed, the CRNAis an advance practice nurse, educated with a master’s degree froman accredited nurse anesthesia educational program. CRNAs ad-minister anesthesia and anesthesia-related care in four gen-eral categories: (1) preanesthetic preparation and evaluation;(2) anesthesia induction, maintenance, and emergence; (3) post-anesthesia care; and (4) perianesthetic and clinical support func-tions. The CRNA works under the supervision of theanesthesiologist. In a large study examining morbidity associatedwith anesthesia, researchers found several factors that signifi-cantly reduce the risk of anesthesia. Among these are the directavailability of an anesthesiologist during surgery, the presence ofa consistent anesthesia care provider throughout the case, and thepresence of an anesthetic nurse (Arbous et al., 2005).

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FIGURE 26–1 � Perioperative patient-focused model.AORN (2008). The PNDS Model. Retrieved on July 2, 2008 from http://www.aorn.org/PracticeResources/PNDSAndStandardizedPerioperativeRecord/PNDSModel/.

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PatientPatientPatient

InterventionsInte

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Structural ElementsInter

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Report CardsNursin

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620 UNIT 5 Nursing Management of the Surgical Patient

NursesThe perioperative nurse’s primary role in the operating room(OR) is that of the circulating nurse. Most states have taken legisla-tive measures in order to ensure the presence of a registered nursein the circulator role in the OR for every surgical procedure. Thecirculating nurse’s duties are performed outside the sterile fieldand encompass responsibilities of nursing care managementwithin the OR. The circulating nurse observes the surgical teamfrom a broad perspective and assists the team to create and main-tain a safe, comfortable environment for surgery. The circulatingnurse communicates patient care needs to each member of thesurgical team, facilitating a united effort while being the patientadvocate whose actions are dedicated to ensuring that the patient’srights and wishes are respected and carried out.

The scrub nurse works directly with the surgeon within thesterile field passing instruments, sponges, and other itemsneeded during the surgical procedure. The sterile field is the areaclosely surrounding the OR table. Surgical team members whowork within the sterile field perform a surgical scrub of theirhands and arms with special disinfecting solution and, in addi-tion to the regular surgical attire, don a sterile gown and gloves.This role can also be performed by other personnel than an RN,in which case the person is then called a scrub technician. Otherroles for RNs are team leader, assistant head nurse, head nurse ornurse manager, nurse educator, and clinical nurse specialist.

As with any specialty, the perioperative nursing assessment isthe first step in providing individualized care for perioperativepatients. The nursing process serves as a guide to make perioper-ative nursing assessments comprehensive and holistic in nature.The focus is aimed at promoting and maintaining wellness aswell as identifying and preventing illness (Hurley & McAleavy,2006). These assessments provide valuable information to theentire perioperative team. The nursing care plans that are devel-oped based on the assessment data are utilized to ensure conti-nuity of care during each phase of the individual’s perioperativeexperience. The assessment provides a baseline against which in-formation about the individual’s stability can be measured andmonitored at any stage of her perioperative experience.

Perioperative Nursing EducationGiven that most nursing programs offer limited or no operatingroom experience in their curricula, nurses initiating a career inthe OR get their perioperative education either at the hiring in-stitution or by enrolling in a postgraduate or fellowship periop-erative program. It is estimated that a minimum of 3 to 6months of instruction is required to adequately educate nurseswith no previous OR experience depending on the OR’s activi-ties (AORN, 2007a). Programs may include the surgical envi-ronment, aseptic technique, perioperative assessment,anesthesia, positioning the surgical patient, sterilization and dis-infection, surgical instruments, safety considerations, patientteaching, teamwork, scrubbing and circulating, and woundhealing and hemostasis (AORN, 2007a). In addition to didacticmodules, nurses are often instructed through a cognitive ap-prenticeship model in the OR in which they take on increasinglycomplex responsibilities over time.

Health PromotionPatient teaching for the intraoperative patient is usually done ina preadmission testing clinic or the day before the surgery in a

patient general surgical unit. Once in the preoperative area, thepatient is normally anxious and stressed and assumes a passiverole as the recipient of technical care. The perioperative nurseperforms the preoperative assessment of patients in the holdingarea. The responsibilities of the perioperative nurse in this set-ting are to verify the appropriate data have been obtained, assessthe patient for readiness both physically and emotionally, andreinforce teaching as needed. This information is the basis forplanning the patient’s individualized perioperative care.

The use of the nursing process emphasizes a patient-centeredapproach; health promotion in the perioperative arena has be-come more evident as perioperative nurses have gained greatsatisfaction from knowing that they are part of a team commit-ted to an individual patient with an individualized outcome. Asillustrated through the PNDS (p. 624), this framework enablesperioperative nurses to shift from a task-oriented role to that ofproviding a holistic view of the patient. Therefore, even if thenurse’s main role is still to ensure patient safety throughout a pa-tient’s surgical experience, the nurse is now able to demonstratethe caring aspect of perioperative nursing by participating in apreoperative assessment of the patient.

Surgical AreasPatients needing surgery go to the operating room for a surgicalprocedure after having been admitted to the hospital on the sameday as surgery, unless an extensive work-up or in-hospital treat-ments or tests are required prior to surgery. Patients also access theoperating room emergently through the emergency department.The practice of same-day admission has become popular for bothfinancial reasons and because evidence suggests that surgical-siteinfection rates are reduced when the preoperative stay is reduced(Nichols, 2001).

Prior to being admitted to the surgical setting, the patient donsa gown and cap. Surgical-site skin preparation includes a baselineassessment, cleaning of the surgical site and surrounding area,hair removal, and application of an antiseptic agent when re-quired. Traditionally hair removal was extensive and often per-formed the day prior to surgery. Research studies have revealedthat hair removal does not reduce the incidence of surgical-siteinfections (SSIs). In fact, today, hair removal is instead performedto improve access to surgical site, improve the field of view, or perthe institution’s policy or surgeon’s preference (Evidence-basedpractice information sheets, 2003; Niel-Weise, Willie, & van denBroek, 2005). Should hair removal be indicated, care needs to betaken to maintain skin integrity and minimize injury. The re-moval is ideally done outside of the surgical suite as close to thesurgery time as possible (AORN, 2007b). There is some evidencethat use of hair clippers is superior to use of a razor, but more re-search is needed (Niel-Weise et al., 2005).

Presurgical or Preoperative Holding AreaThe surgical area typically has a presurgical or preoperativeholding area next to the operating rooms. The preoperativeholding area is a semirestricted area usually just inside of the sur-gical area. This area provides a quiet, calm transition area for thepatient to wait immediately before surgery. It provides a shieldfrom the sights and sounds of the busy surgical suite and allowspersonnel to interview the patient and verify the documenta-


tion. Equipment should be readily available in the preoperativeholding area for patient care and monitoring. This includes oxy-gen, suction, electrocardiogram machine, pulse oximetry, and ablood pressure cuff; an emergency medical cart and defibrillatorshould be nearby (Bailey, McVey, & Pevreal, 2005; Sullivan, 2000).

In the holding area, the nurse must verify that all the relevantdocuments and studies (films, scans, etc.) are available prior tothe start of the procedure, that they have been reviewed and areconsistent with each other, and with the patient involved. Teamconsensus about the intended patient, procedure, and site and asapplicable implant is also needed. This verification should occurbefore the patient leaves the preoperative area and enters theprocedure/surgical room.

When the operating room suite is ready to receive the patient,the patient is asked to empty the bladder to prevent incontinenceor overdistention because an overly full bladder can hinder accessto the surgical site and predispose the patient to inadvertent sur-gical bladder injury. Urinary catheterization is performed in theOR as necessary (Iorio et al., 2005). The nurse accompanies thepatient to the operating room where the patient will be placed onthe operating table and prepared for surgery.

Preoperative Operating Room ChecklistThe preoperative checklist is a tool for continuing the patient as-sessment. On it, allergies are documented as per facility policy.Accurate documentation of height and weight is important forproper dosage calculation of the anesthetic agents. The periop-erative nurse ensures that the results of all laboratory, radi-ographic, and diagnostic tests are on the patient’s chart.

Any abnormal results are documented and reported to thesurgical team as well as any special needs, concerns, or instruc-tions especially with regard to cultural or spiritual beliefs, phys-ical impairments or limitations, and psychosocial conditions.For example, advise the surgical team whether the patient is amember of Jehovah’s Witnesses and does not accept blood prod-ucts or whether the patient is hard of hearing and does not havehis hearing aid (Hurley & McAleavy, 2006). Showing respect forpatients’ spiritual beliefs, psychosocial conditions, and physicallimitations facilitates rapport and trust that enable nurses to un-derstand the important role these factors play in how peoplecope with fear and anxiety related to their perceived periopera-tive experience.

The perioperative nurse also notes the medical diagnosis,previous surgical experience, patient’s physical appearance,visual skin assessment, medical devices accompanying the pa-tient or indwelling medical devices, and any prostheses, jewelry,dentures, and/or capped teeth. The nurse also ensures that pre-scribed preoperative medications have been taken by the patientand any medications that have been ordered to be given justprior to surgery such as antibiotics are documented on the chartaccompanying the patient. The NPO status of the patient is alsoconfirmed by the nurse to assess any potential risk of aspiration.All relevant information is communicated to the surgical team.

Operating RoomSurgery may involve the removal, repair, drainage, replacement,or exploration of body tissue or organs. The operating room orsuite is where the surgery will be performed. This room is arestricted area where the team of health care professionals wears

attire that was donned in the surgery dressing room. This attire,commonly referred to as “scrubs,” includes a shirt, trousers, cap,shoe covers, and mask. Those directly involved in the surgicalprocedure will have scrubbed and will be wearing sterile gowns.

Surgical hand preparation, previously known as a “surgicalscrub,” is performed prior to participating in a surgical procedurein order to reduce the potential risk of SSI by reducing the num-ber of microorganisms on intact skin of the hands and forearms.Hand preparation considerations include use of a broad-spectrum, fast-acting, nonirritating, FDA-approved antisepticagent. Traditional scrub techniques with prolonged use of deter-gent, water, and brushes have contributed to the deterioration ofskin, sometimes leading to undesirable changes of hand skinflora and colonization. Additionally, surgical facilities are exam-ining ways to improve the use of physical resources and healthcare professionals’ time. Compared to the traditional surgicalscrub, waterless hand preparation boasts a reduction in micro-bial counts of hands, improved skin health, and reduced use oftime and resources (Larson et al., 2001). Below is a list of recom-mended surgical hand preparation practices (AORN, 2007b),and Chart 26–1 (p. 622) highlights the differences between a sur-gical scrub and hand rub preparation method:

• Do not wear artificial nails.

• Keep skin free from open lesions and breaks.

• Remove all jewelry from hands and forearms before per-forming hand hygiene.

• Use only lotions that are approved by infection control staff;lotions must be compatible with the hand antiseptic andgloves, and be stored in disposable, hands-free dispensers.

• Use a standardized hand scrub procedure that follows man-ufacturer’s written guidelines and is approved by the healthcare facility.

Due to the rapid growth of surgical technologies and innova-tion during the past decade, many operating rooms have beenrenovated or reconstructed. This has been done in part to ad-dress the abundance of equipment needed in today’s operatingrooms as well as ergonomic issues. Recent trends in surgery in-clude the move toward less invasive techniques with shorter hos-pital stays and faster recovery periods. One of the newest trendspromising to transform surgery is the intelligent OR. The intel-ligent OR incorporates advanced robotic surgical systems. Aspeech recognition robot allows the surgeon to control the op-erating bed, lighting, video displays, and other devices with sim-ple voice commands. A robotic endoscopic camera facilitatesoptimal views of the surgical field, and the robotic surgical assis-tant enables the surgeon to control precise technical movementsof a robotic arm from a console station. Robotic systems are cur-rently in use for certain cardiac procedures with plans for expan-sion on the horizon. Surgical robots make it likely that futuresurgeries could be performed at one facility with the surgeonoperating the console from a distant facility. One of the nurse’sroles in robotic surgery is to assist the surgeon at the patient’sside during the operation.

In addition digital information is becoming the standardformat for accessing patient information and images, for com-municating with other areas of the hospital or consultants, andfor conferring with other health care providers. The operating


room requires convenient real-time access to these digital dataand a way to manage the digital information acquired withinthe operating room. OR design may be categorized into threemajor areas: physical, information and communication sys-tems, and management.

To accommodate an optimal workflow and facilitate obser-vation of aseptic technique, certain physical considerations needto be taken into account, including the dimensions of the ORsuite, positions of exits and entrances, and location of supportservices. In addition, integration systems are available that per-mit the control of medical devices, lighting, and the OR bed; ac-cess to images; and the routing of all this digital information toany particular monitor for display or to one or more recordingdevices for archiving, or to pathologists or radiologists via tele-conferencing links. Control can be maintained from the surgicalfield by touch-screen or voice control interfaces, or from a nurs-ing station (Figure 26–2 �).

Intentional OR design considers the logistics of flow, main-tains versatility, optimizes the use of resources, promotes com-munication, synchronizes services, and adopts technologicaladvances while including all stakeholders in order to promote

successful adoption. The ultimate goal of surgical technologyadoption is to enhance patient care and improve patient out-comes.

Surgical table setup is specific to the procedure, facility, andsurgeon preference. Scrub tables are often standardized in orderto facilitate efficiency and changeover of staff. Instruments varyaccording to specialty and type of procedure. Figure 26–3 � dis-plays the contrast between traditional open surgery and endo-scopic instrumentation.

Other perioperative nursing responsibilities include ensuringproper instrument functionality intraoperatively through clean-ing and inspection. Inadvertent patient injury may occur due to aninstrument malfunction, resulting in an undesirable effect such astearing tissue, loss of small parts inside the patient, or improper re-processing leaving a residue of bioburden that can result in post-operative complications. The use of protocols, checklists, anddetailed documentation of OR equipment is associated with a sig-nificant decrease in perioperative patient injury (Arbous et al.,2005). The majority of surgical instruments are composed ofhigh-grade stainless steel, although advances in surgery such as ro-botics and minimally invasive surgery (MIS) have resulted in in-

CHART 26–1 Traditional and Waterless Surgical Hand Preparation

FIGURE 26–2 � Layout of a typical surgical unit. (Note: SDA=Sameday surgery, DS=day surgery)

SDA DSUnit

Holding Area

Operating roomsuite

Post AnesthesiaCare Unit

Traditional Surgical Hand Preparation Waterless Surgical Hand Preparation

1. Wash hands with soap and water.2. Use a disposable nail cleaner to clean nail beds under running water.

Discard nail cleaner after use.3. Rinse. Wash hands, then forearms, using antimicrobial-impregnated

sponge. Use the counted stroke technique or the recommendedamount of time according to the manufacturer’s instructions.

4. Rinse.5. Proceed to operating room.

Note: Step 2 is performed for the first scrub of the day or as required.

Scrub time for step 3 may vary according to product instructions from 3 to 5 minutes.

1. Wash hands with soap and water.2. Use a disposable nail cleaner to clean nail beds under running water.

Discard nail cleaner after use.3. Rinse and thoroughly dry hands and arms. Apply alcohol-based

surgical hand scrub product according to manufacturer’s instructions.4. Proceed to operating room.

Note: Step 2 is performed for the first scrub of the day or as required. Hand preparation timefor step 3 generally requires 2 minutes.

FIGURE 26–3 � Surgical instruments : (A) traditional versus (B) endoscopic.

(a)

(b)


novative discoveries of surgical materials and instruments. Surgi-cal instruments are costly and require proper maintenance andcare in order to preserve their longevity.

Patient PreparationOnce they enter the surgical suite, patients are cared for by theanesthetist, surgeons, and nurses. Members of the team ask thepatient questions, apply electrocardiogram (ECG) leads, removearms from gown, and so forth. Every effort should be made tolimit activity with the patient until she has received a generalanesthetic or been given a relaxant if warranted. For example, apatient should have the bladder catheterized following the gen-eral anesthetic whenever possible. Also, patients should be keptinformed on an ongoing basis. This will prevent and limit anxi-eties created by the already stressful surgical experience. If re-gional anesthesia is being used, the patient will remain awake;therefore, a screen is placed in front of the patient’s face. Seda-tives, hypnotics, or tranquilizers are administered in order to de-crease feelings of anxiety and provide sedation.

The perioperative nurse greets the patient on arrival by firstasking the patient his name and checks this with the patient’sidentification bracelet, chart, and hospital card using at least twoidentifiers, for example, name and date of birth. The nurse re-views the patient’s chart, the medical record, and preoperativechecklist, and ensures that the consent is signed and that all doc-umentation, preoperative procedures, and orders have beencompleted. The nurse conducts the preanesthetic assessment bylooking at the patient from a holistic viewpoint. This means rec-ognizing the individual person as a dynamic entity made up ofcomponents that are continuously interacting with one another.The perioperative nursing assessment is the first step in provid-ing individualized care to the perioperative patient. To harmo-nize care in all perioperative settings, the Perioperative NursingData Set vocabulary can be used as part of the data collectiontool (Chart 26–2, p. 624). The PNDS describes the practice ofperioperative nursing practice in four domains: safety, physio-logical responses, behavioral responses, and health care systems.The first three domains reflect phenomena of concern to peri-operative nurses and are composed of nursing diagnoses, inter-ventions, and outcomes that surgical patients and their familiesexperience. The fourth domain, the health care system, com-prises structural data elements and focuses on clinical processesand outcomes. The model is used to depict the relationship ofnursing process components to the achievement of optimal pa-tient outcomes (AORN, 2002).

Comprehensively written nursing care plans have beenspecifically adapted to the perioperative environment as clinicalpathways. Because of the fast-paced environment of the OR, pa-tients’ short lengths of stay, and the many routines, some proce-dures and protocols can be documented on a flow sheet.

Surgical ApproachesMinimally invasive surgery became widespread when the laparo-scopic cholecystectomy became a standard of surgical care in theearly 1990s. Initial reservations included the limitations of equip-ment, introduction of new instruments, and the ability of sur-geons to adapt and acquire these new surgical skills. Other

concerns included performing surgery on larger patients and thespreading of cancer cells intraoperatively. The latter concerns havebeen overcome through advances in equipment and instrumenta-tion and adaptive surgical techniques that have enabled the use oflaparoscopic gastric bypass surgery for bariatric patients.Study re-ports confirm MIS to be oncologically safe (Bonjer et al., 2007).The laparoscopic cholecystectomy will be used to illustrate the dif-ferences between MIS and open surgery. Open surgery involves anincision under the rib cage on the right side of approximately 15to 38 cm (6 to 15 in.) in order to allow surgeons access with theirhands to perform surgery.

Laparoscopic removal of the gallbladder involves several smallincisions, usually four, that are one-quarter to one-half inch insize. Trocars or ports (tubes with valves) are then inserted throughthese small incisions in order to provide imaging through a tele-scope attached to a camera for viewing on a monitor while otherports are accessed for instruments used to perform the surgery. Toprovide space to view and perform surgery, the abdomen is in-flated with gas (usually carbon dioxide). Carbon dioxide is usedbecause it is readily accessible, inexpensive, does not supportcombustion when using surgical energy sources, and is easily ab-sorbed and excreted by the body through the circulatory and res-piratory system. In addition, the smaller incisions available withMIS require the use of finer instruments as shown in Figure26–3b � (p. 622) resulting in less surgical trauma and immuno-suppression than open surgery (Boo et al., 2007).

Advantages of a laparoscopic surgery over open surgery in-clude less scarring, quicker recovery, shorter hospitalization,faster return to normal activities (work), fewer problems withincisions, less pain, and less use of opioids, which reduces thenegative secondary effects associated with opioid use. Often pa-tients undergoing laparoscopic surgery will be discharged thesame day as surgery, whereas open surgery procedures can re-quire 3 to 5 days of hospitalization. The intraoperative cost ofMIS surgery is often more, but is offset by the reduced hospitalstay and quicker recovery (Noblett & Horgan, 2007).

Many patients complain of discomfort similar to muscle achein the shoulder area following laparoscopic surgery. This is areferred pain and is due to the distention of the diaphragm,which results from the insufflation of the abdomen with gas

that is required for laparoscopic procedures. The discomfort usuallysubsides within 24 to 48 hours postoperatively.

The Future of Surgery: Natural OrificeTranslumenal Endoscopic SurgeryNatural Orifice Translumenal Endoscopic Surgery (NOTES) is theexploration of methods to perform surgery through any of thebody’s natural orifices (e.g., oral, rectal, urethral, vaginal). NOTESattempts to further minimize the effects of surgery through a to-tally noninvasive technique.

AnesthesiaAdvances in anesthesia, such as improvements in airway devices,use of quickly reversible inhalation agents, and selection ofshort-acting anesthetic agents, have improved patient outcomes(Arbous et al., 2005; Tarrac, 2006). Anesthesia needs to accom-plish several things. It must produce sleep (hypnosis), lack of


CHART 26–2 Perioperative Nursing Data Set

Code Diagnosis/Intervention/Outcome Yes No Comments

X29I26I126I60I65I66I59I64

Diagnosis: Risk of Injury related to transfer and transportIntervention: Confirms identity before the operative or invasive procedure.Intervention: Verifies operative procedure.Intervention: Identifies baseline tissue perfusion.Intervention: Identifies physiological barriers to communication.Intervention: Identifies physiological status.Intervention: Identifies baseline cardiac function.Intervention: Identifies physical alterations that may affect procedure-specific positioning.Outcomes: Verbalizes comfort related to transfer/transport.

X4I13I27I30I57I85I101

I106I56I50

Diagnosis: Risk for Anxiety related to knowledge deficit and stress of surgeryIntervention: Assesses coping mechanisms based on psychological status.Intervention: Provides continuity of care.Intervention: Develops individualized plan of care.Intervention: Identifies and reports philosophical, cultural, and spiritual beliefs and values.Intervention: Minimizes the length of invasive procedure by planning care.Intervention: Provides care to each individual in a manner that preserves and protects the patient’s autonomy,dignity, and human rights.Intervention: Provides instruction based on age and identified need.Intervention: Explains expected sequence of events.Intervention: Evaluates response to instructions.Outcomes: Verbalizes/indicates decreased anxiety, ability to cope, understanding of procedure and sequence ofevents. Questions answered.

X38I24I51I61I69I71I108I16I54

Diagnosis: Risk for Acute/Chronic PainIntervention: Collaborates in initiating patient-controlled analgesia.Intervention: Evaluates response to medication.Intervention: Identifies cultural and value components related to pain.Intervention: Implements alternative methods of pain control.Intervention: Implements pain guidelines.Intervention: Provides pain management instructions.Intervention: Assesses pain control.Intervention: Evaluates response to pain management interventions.Outcome: Demonstrates adequate pain management.

X28I3I21I22I94I31

Diagnosis: Risk for InfectionIntervention: Administers care to invasive device sites.Intervention: Assesses susceptibility for infections.Intervention: Classifies surgical wound.Intervention: Performs skin preparation.Intervention: Dresses wound at completion of procedure.Outcomes: Patient’s surgery performed using aseptic technique and in a manner to prevent cross contamination.

X29I11I39I72I73I77I93I84I112

Diagnosis: Risk for InjuryIntervention: Applies safety devices.Intervention: Evaluates for signs and symptoms of injury to skin and tissue.Intervention: Implements protective measures to prevent injury due to electrical sources.Intervention: Implements protective measures to prevent injury due to laser sources.Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical sources.Intervention: Performs required counts.Intervention: Manages specimen handling and disposition.Intervention: Records devices implanted during the operative or invasive procedure.Outcome: Patient is free from signs and symptoms of physical injury.

X40I38I39I77

Diagnosis: Risk for Injury: PositioningIntervention: Applies safety devices.Intervention: Evaluates for signs and symptoms of injury to skin and tissue.Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical devices.Outcome: Patient is free from signs and symptoms of physical injury.


CHART 26–2 Perioperative Nursing Data Set—Continued

Association of periOperative Registered Nurses. (2002). PNDS Resources. AORN. Retrieved June 29, 2008 from http://www.aorn.org/PracticeResources/PNDSAndStandardizedPerioperativeRecord/PNDSResources/.

Code Diagnosis/Intervention/Outcome Yes No Comments

X30I19I20I79I103I67I63I30I104I105

Diagnosis: Deficient KnowledgeIntervention: Assesses readiness to learn based on physiological status.Intervention: Assesses readiness to learn based on psychological status.Intervention: Includes family and support persons in the preoperative teaching.Intervention: Provides information and explains Patient Self-Determination Act.Intervention: Identifies psychological barriers to communication.Intervention: Identifies individual values and wishes concerning care.Intervention: Develops individualized plan of care.Intervention: Provides instruction about prescribed medications.Intervention: Provides instruction about wound healing and wound care.Outcome: Patient demonstrates knowledge of the physiological responses to the operative or other invasiveprocedure.

awareness and recall (amnesia), freedom from pain (analgesia),and muscle relaxation. A variety of anesthetic agents can pro-duce these effects. The anesthesia care provider considers the pa-tient and selects the agent or a combination of agents that willproduce the best anesthesia with the fewest negative effects forthe patient.

Inhalation AgentsInhalation agents are frequently used for anesthesia becausethey are fast acting and easily controlled. Anesthetic agents passthrough a vaporizer and are mixed with oxygen. The patient in-hales the vapors into the lungs. The gas crosses the alveolarmembrane, dissolves in the blood, and is carried to body tissuesvia circulation where it attaches to receptor sites on the cells toproduce its effects, primarily depression of the central nervoussystem (CNS). Frequently, a mixture of gases is used to maintainanesthesia.

A number of theories have been proposed to explain how in-haled anesthetic agents work, but no single theory explains thevarious effects seen with these agents (Hoffer, 1999). The effects ofanesthesia diminish as the gas is washed out of the lungs with100% oxygen and the remainder is metabolized by the liver. ThePharmacology Summary box (p. 626) lists the advantages, the sideeffects, and implications of commonly used anesthetic gases.

Intravenous AgentsA variety of intravenous (IV) agents are used to induce andmaintain anesthesia. The Pharmacology Summary box (p. 627)lists common intravenous medications used for anesthesia or asadjuncts to anesthesia. Induction of anesthesia may be accom-plished with the administration of a sedative hypnotic or anxi-olytic drug. Common drugs include barbiturates such asthiopental sodium (Pentothal) and sodium methohexital(Brevital). These drugs cause rapid, short-acting depression ofthe CNS (sedative hypnotic), but they have limited analgesic ef-fects. A smaller test dose is initially given to make sure the patienttolerates the mediation without reaction. These drugs quickly(within seconds) produce sedation and unconsciousness. Bothdrugs can cause respiratory and cardiovascular depression.

Nonbarbiturate drugs that depress the CNS may also be usedto induce anesthesia. Etomidate (Amidate) produces rapid hyp-nosis but with less effect on the respiratory and cardiovascularsystems than the barbiturate drugs. This makes it an attractive al-ternative for use with high-risk patients. Etomidate suppressescortisol secretion causing hypotension. These effects are not sig-nificant in short procedures but can be an issue in longer surger-ies. Etomidate is used primarily in short procedures. Ketaminehydrochloride (Ketalar) is a fast-acting CNS depressant thatcauses profound anesthesia but little skeletal muscle relaxation. Itis associated with a difficult emergence phase that is characterizedby hallucinations and disassociative feelings (feeling separatefrom the environment). The patient who is recovering from keta-mine will do better in a quiet, supportive environment. Propofol(Diprivan) is a rapid-acting hypnotic that causes minimal excita-tion effects during induction. Risk of the patient’s vomiting orthrashing during induction is reduced.A test dose is initially givento test for allergy. Propofol is metabolized rapidly so it does notaccumulate in the blood when used to maintain anesthesia.Patients emerge from propofol quite quickly during the recoveryperiod.

Other IV medications used in anesthesia include benzodi-azepines and opioid analgesics. Examples of benzodiazepinesinclude midazolam (Versed), lorazepam (Ativan), and di-azepam (Valium). The benzodiazepines are antianxiety agentsthat also have hypnotic, sedative, and muscle relaxant effects.Midazolam is sometimes used to induce anesthesia but thesedrugs are more commonly used as premedication to reduce thepatient’s anxiety because they have an amnesic effect. Benzodi-azepines are used in combination with other drugs to produceconscious sedation or as adjuncts to regional anesthesia toproduce sedation and muscle relaxation. Opioids are used inanesthesia for their analgesic effect. Common medications in-clude morphine sulfate, fentanyl citrate (Sublimaze), sufen-tanil, and alfentanil. Fentanyl is more potent than morphineand is the most commonly used analgesic in anesthesia. Theopioid analgesics have good cardiovascular stability but causerespiratory depression.

Sources: Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: A pathophysiological approach. Upper Saddle River, NJ: Pearson Prentice Hall; Ebert, T. J. (2004). Physiology ofthe cardiovascular effects of general anesthesia in the elderly. Retrieved April 26, 2004, from the ASA Syllabus on Geriatric Anesthesiology website: http://www.asahq.org/clinical/geriatrics/phy.htm; Hoffer, J. L. (1999). Anesthesia. In M. Meeker & J. Rothrock (Eds.), Care of the patient in surgery (pp. 203–238). Philadelphia: Mosby; Thompson, A. M. (2002). Anaesthesia. In L. Shields & H.Werder (Eds.), Perioperative nursing (pp. 79–105). San Francisco: Greenwich Medical Media.

PHARMACOLOGY Summary of Anesthetic Gases Used During SurgeryAgent Action and Advantages Disadvantages and Side Effects Nursing Responsibility

Desflurane (Suprane) Maintenance of anesthesia. Veryrapid emergence.Good degree of muscle relaxation.

Must be heated to vaporize.Causes increase in heart rate and decrease in blood pressure.Has a strong odor precluding its usefor induction of anesthesia. Maycause coughing if used for induction.

Monitor for hypotension.

Enflurane (Ethrane) Maintenance of anesthesia.Good degree of muscle relaxation.

May lower the threshold for seizures.Increases heart rate and decreasesblood pressure.

Monitor for hypotension.Contraindicated in patients withseizure disorders.

Halothane(Fluothane)

Maintenance of anesthesia. Rapidinduction and emergence but lessthan that of isoflurane.Low incidence of postoperativenausea and vomiting.

Fair degree of muscle relaxation.Increases heart rate and triggersarrhythmias.Requires a higher degree of livermetabolization than other agents.Causes postoperative shivering.

Can cause hypotension. Monitor forpremature ventricular contractions,ventricular tachycardia, and ventricularfibrillation with use of epinephrine.Provide warm blankets during recoveryperiod.

Isoflurane (Forane) Induction and maintenance ofanesthesia. Faster induction andrecovery than enflurane orhalothane.Minimal metabolization by the liver.

Causes increase in heart rate andhypotension. Hypotension can beunpredictable and severe ifconcomitant use of antihypertensiveagents.Weak stimulation of secretions.

Monitor for hypotension.

Nitrous oxide Rapid induction and recovery ofanesthesia.When used with other inhalants, itreduces the concentration of otheragent.

Does not produce muscle relaxation.

Sevoflurane (Ultane) Induction and maintenance ofanesthesia. Very rapid induction andrecovery (3–4 minutes faster thanIsoflurane).Minimal metabolization by the liver.


Muscle RelaxantsMuscle relaxants (neuromuscular blocking agents) primarily af-fect skeletal muscle and they are used in surgery to facilitate en-dotracheal intubation and to provide optimal operatingconditions. A rapid-acting neuromuscular blocking agent is ad-ministered before intubation to paralyze the muscles of the jawand vocal cords making placement of the endotracheal tube eas-ier. Muscle relaxation is used throughout the surgery to facilitatedissection of tissue. During surgery, the anesthesia care providermonitors the effects of muscle relaxant drugs with a peripheralnerve stimulator. Recovery from neuromuscular blocking agentsafter surgery is evidenced by the patient’s ability to breathe on herown and hold her head upright as well as the presence of a stronghand grasp. There are two types of neuromuscular blockingagents, depolarizing and nondepolarizing.

Succinylcholine is a depolarizing agent and the only one inclinical use. The drug has a strong affinity for acetylcholine recep-tor sites and once it attaches to the site causes continuous depo-larization of the motor end plate. Continuous musclecontractions and fasciculations are followed by flaccid paralysis of

the muscles. The onset of paralysis is quick with intravenous ad-ministration, 30 to 60 seconds, and the effects last up to 10 min-utes. Often succinylcholine is used for intubation because it worksvery quickly and wears off quickly, but there are disadvantages tothe drug. The depolarization of muscle cells causes a transient in-crease in serum potassium that can produce cardiac dysrhythmia.Muscle fasciculation (twitching) leads the patient to complain ofmuscle soreness postoperatively. Succinylcholine is known totrigger malignant hyperthermia in susceptible individuals. Thedrug is broken down by the plasma enzyme cholinesterase. Pro-longed paralysis occurs in individuals with insufficient amountsof cholinesterase although this condition is rare.

Nondepolarizing agents work by blocking the depolarizingaction of acetylcholine at the motor end plate of the neuromus-cular junction, thereby producing muscle paralysis. Muscle fasci-culations do not occur with these drugs, eliminatingpostoperative myalgia. Another advantage is that these agentscan be antagonized or reversed with the administration ofneostigmine, edrophonium, or pyridostigmine. Use of reversalagents reduces the risk of morbidity associated with anesthesia

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to AnesthesiaUsed During Surgery

Agent Action and Advantages Disadvantages and Side Effects Nursing Responsibility

Intravenous AnestheticEtomidate (Amidate) CNS depressant used for induction

and maintenance of anesthesia forshort procedures. Hypnotic effect butno analgesia.Fewer respiratory and cardiovasculareffects than other agents.Onset is 60 seconds with duration of3–5 minutes.

Suppresses cortisol secretion.Postoperative nausea and vomiting.May cause transient skeletal musclemovements.Metabolized in the liver.

Good anesthetic for patients withasthma or cardiovascular disease.Used in neurosurgery because itcauses a slight decrease inintracranial pressure.Monitor cortisol levels and bloodpressure.

Diazepam (Valium) Benzodiazepine with hypnotic andamnesiac properties.Used as adjunct drug in induction ofanesthesia and as a preoperativemedication to reduce anxiety.

May cause hypotension andtachycardia.Prolonged effect.

Monitor sedation postoperatively.

Ketamine (Ketalar) CNS depressant used for induction ofanesthesia.May supplement nitrous oxideanesthesia.Fewer postoperative nausea andvomiting than other agents.

Increases salivary secretions.Does not produce muscle relaxation.May increase heart rate and bloodpressure.Depresses respirations and increasesintracranial pressure.Associated with emergence reactionsincluding hallucinations, dissociativefeelings, and irrational behavior.Recovery can be prolonged.

Premedicate with anticholinergicagent to reduce secretions.Provide a quiet, calm, reassuringenvironment for recovery.Monitor heart rate and blood pressure.Monitor airway to prevent aspiration.

Midazolam (Versed) Benzodiazepine with hypnotic,amnesiac, anxiolytic, and musclerelaxant properties.Used for induction of generalanesthesia and for conscioussedation.

Slower induction than withbarbiturates.May cause hypotension andtachycardia.

Prepare patient for amnesia.Monitor for respiratory depression.

Propofol (Diprivan) CSN depressant used for inductionand maintenance of anesthesia.Rapid onset with minimal excitationduring induction.

Abnormal muscle movement.May cause hypotension.

Monitor blood pressure.Cautious use in patients with allergiesto eggs.

Sodium methohexital(Brevitol)

Barbiturate used for induction andmaintenance of anesthesia.More potent and with a shorter onsetand quicker recovery thanthiopental.

May cause abnormal musclemovements, coughing, andlaryngospasm.Hypotension occurs in some patients.Hiccups may persist postoperatively.

Patient should be recumbent duringadministration.Monitor blood pressure.

Thiopental sodium(Pentothal)

Barbiturate used for induction andmaintenance of anesthesia.Depresses CNS causing sedation andhypnosis.Ultrashort acting with onset in 10–20 seconds and duration of20–30 minutes.

Depresses respiratory and circulatoryfunction.Can cause anaphylaxis andlaryngospasm.Metabolized by the liver.

Test dose given first.

Opioid AnalgesicsAlfentanil (Alfenta) Narcotic used for induction,

analgesia, and balanced anesthesia.Rapid onset and short duration makeit a good choice for short surgicalprocedures.

Causes respiratory depression.Can cause bradycardia andhypotension.Bradycardia is more likely in patientswho are taking a beta-blocking drug.Nausea and vomiting common.

Monitor vital signs.Report bradycardia.


(continued)

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to AnesthesiaUsed During Surgery—Continued


Fentanyl(Sublimaze)

Narcotic used as adjunct for inductionto anesthesia and for analgesiasupplement.The drug of choice for epiduralanalgesia.Short acting.Causes less nausea and vomitingthan morphine.

Causes sedation and respiratorydepression.May also cause bradycardia andhypotension.

Monitor vital signs.Watch for signs of respiratorydepression.

Morphine sulfate Narcotic used as premedication andfor postoperative analgesia.Long-lasting effect.

Causes respiratory depression.Histamine release causes peripheralvasodilation and hypotension.Nausea and vomiting common.

Monitor vital signs.

Sufentanil (Sufenta) Narcotic used for analgesicsupplement in balanced anesthesia.More potent than fentanyl. Has aquicker onset and shorter recoverythan fentanyl.Not associated with histamine releaseso there is less hypotensive effect.

Prolonged respiratory depression. Monitor vital signs.Watch for signs of respiratorydepression.

Depolarizing Muscle RelaxantsSuccinylcholine Depolarizing neuroblocking agent

with high affinity for acetylcholinereceptor sites.Produces muscle relaxation andparalysis.Used to facilitate endotrachealintubation and to produce skeletalmuscle relaxation for short surgicalprocedures.Short-acting agent with onset in30–60 seconds and duration ofseveral minutes.

Causes muscle fasciculations,bradycardia, and respiratorydepression.May precipitate malignanthyperthermia in susceptibleindividuals.

Monitor vital signs.Maintain airway and clear secretions.Patient may complain of musclesoreness postoperatively.

Nondepolarizing Muscle Relaxants—IntermediateMivacurium(Mivacron)

Intermediate, nondepolarizing musclerelaxant used for endotrachealintubation and to produce relaxationof skeletal muscles for surgery.Effect lasts 15–20 minutes.

Transient hypotension andbradycardia.Metabolized by plasmacholinesterase.


Vecuronium(Norcuron)

Intermediate, nondepolarizing musclerelaxant used for endotrachealintubation and to produce relaxationof skeletal muscles for surgery.Effect lasts 20–40 minutes.

Metabolized by the liver.Causes respiratory depression.Minimal cardiovascular effects.

Monitor for delay of recoverypostoperatively.

Nondepolarizing Muscle Relaxants—Long ActingTubocurarine Long-acting, nondepolarizing muscle

relaxant used for maintenance ofrelaxation during surgery.Muscle relaxant effects last 30–40minutes.

Causes histamine release withhypotension.Increases bronchial and salivarysecretions.

Monitor blood pressure and airwayuntil full recovery from drug.Observe for residual muscleweakness.

Metocurine(Metubine)

Long-acting, nondepolarizing musclerelaxant used for maintenance ofrelaxation during surgery.Muscle relaxant effects last 30–90minutes.

Hypotension, increased salivarysecretions, and respiratorydepression.

Monitor blood pressure and airwayuntil full recovery.May take several hours for completeneuromuscular recovery.


Sources: Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: A pathophysiological approach. Upper Saddle River, NJ: Pearson Prentice Hall; Ebert, T. J. (2004). Physiology ofthe cardiovascular effects of general anesthesia in the elderly. Retrieved April 26, 2004, from the ASA Syllabus on Geriatric Anesthesiology website: http://www.asahq.org/clinical/geriatrics/phy.htm; Hoffer, J. L. (1999). Anesthesia. In M. Meeker & J. Rothrock (Eds.), Care of the patient in surgery (pp. 203–238). Philadelphia: Mosby; Thompson, A. M. (2002). Anaesthesia. In L. Shields & H.Werder (Eds.), Perioperative nursing (pp. 79–105). San Francisco: Greenwich Medical Media.

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to AnesthesiaUsed During Surgery—Continued


Pancuronium(Pavulon)

Long-acting, nondepolarizing musclerelaxant used for maintenance ofrelaxation during surgery.Muscle relaxant effects last 30–60minutes.

Tachycardia, hypertension, andpremature ventricular contractions.


AnticholinergicsAtropine Anticholinergic agent used to

decrease salivary and respiratorysecretions, to treat bradycardiaand/or hypotension, and to reversemuscle relaxants.

Tachycardia, hypertension, urinaryretention, and dry mouth.May cause cardiac arrhythmias.

Monitor heart rate and blood pressure.Heart rate is best indicator ofresponse to the drug.

Glycopyrrolate(Robinul)

Anticholinergic agent used todecrease salivary and respiratorysecretions and to reverseneuromuscular block.

Tachycardia, urinary retention, and drymouth.Fewer problems with cardiacarrhythmias than atropine.

Monitor heart rate.


(Arbous et al., 2005). Reversal drugs cause bradycardia, which istreated with atropine or glycopyrrolate. Nondepolarizing agentsare divided into intermediate acting and long acting. Intermediate-acting agents have a quick onset, 60 seconds or less, and last 25 to40 minutes. Examples of intermediate-acting nondepolarizingagents are vecuronium, atracurium, and mivacurium. Longeracting nondepolarizing muscle relaxants also have a rapid onsetbut last 45 to 60 minutes. Examples include pancuronium,metocurine, and tubocurarine.

Complications of General AnesthesiaThe majority of patients experience general anesthesia withoutproblems except for the complaint of a sore throat from the endo-tracheal tube. Other problems that may occur with intubation aredamage to teeth or dental work and trauma to the vocal cords.Complications that arise from general anesthesia include hypoxia,hypotension, hypertension, cardiac dysrhythmia, residual muscleparalysis, hypothermia, and malignant hyperthermia.

A drop in body temperature is common during surgery.Anesthesia interferes with the physiological mechanisms ofthermoregulation. This effect combined with environmentalfactors such as the ambient temperature in the OR, the exposureof body cavities, and the administration of cold solutions (e.g.,blood products, IV fluids) or irrigants leads to a reduction incore body temperature. Studies show the most significant dropin body temperature occurs during the first hour of anesthesia(Hasankhani, Mohammadi, Moazzami, Mokhtari, & Nagh-gizadh, 2007; Sessler & Todd, 2000; Wagner, 2006). Monitoringbody temperature and using warming devices during surgery(e.g., blankets, thermal drapes, fluid warmers) is imperative(Hasankhani et al., 2007; Wagner, 2006). Research supports theuse of forced-air warming blankets as the most effective methodof preventing or treating hypothermia (American Society of

PeriAnesthesia Nurses, 2001). Some suggest that using a forced-air warming blanket for 30 minutes prior to surgery helps pre-vent intraoperative hypothermia and improve patient outcomes(Bitner, Hilde, Hall, & Duvendack, 2007).

Malignant HyperthermiaMalignant hyperthermia (MH) is a rare but life-threateningcomplication of anesthesia. The predisposition for MH is genet-ically transmitted by an autosomal dominant trait. It is thoughtthat MH is triggered by the medications or agents used in gen-eral anesthesia with the most common being succinylcholine orone of the inhalant anesthetics. Other factors such as stress,trauma, fatigue, or muscle injury may play a role in increasingsusceptibility to the condition or in modifying the patient’s re-sponse to the condition. Malignant hyperthermia occurs mostcommonly during induction of anesthesia although it may pre-sent anytime during the surgery or early postoperative period.

Malignant hyperthermia is not well understood. With MH,calcium levels within skeletal muscle cells increase, although thereasons for this are not known. The elevation in intracellularcalcium activates muscle rigidity and spasm and a hypermeta-bolic state. The increase in cellular metabolism leads to an in-crease in carbon dioxide production (hypercarbia) and ametabolic acidosis. As the process continues, the patient be-comes hypoxic, hyperthermic, and develops dysrhythmias andhypotension. Muscle breakdown with the release of myoglobinsleads to myoglobinuria and an increased risk of renal failure.Damaged muscle cells release intracellular potassium and crea-tinine phosphokinase (CPK) into the circulation.

The presentation of MH is variable. Early signs are masseterspasm (contracture of jaw), sinus tachycardia, and an increase inexpiratory carbon dioxide levels. The anesthesia provider firstsuspects MH by the rise in the patient’s expired CO2, which is


monitored throughout the surgery. An end-tidal carbon dioxidelevel that is two to three times normal is the earliest and most de-finitive sign of MH (Redmond, 2001). Other signs are rigor ofmuscles, hypoxemia evidenced by a drop in oxygen saturation,and tea-colored urine, indicating the presence of myoglobins.Laboratory blood tests results show metabolic acidosis and in-creases in serum calcium, potassium, and creatinine phosphoki-nase. Hyperthermia is a late sign and temperature elevations canbe extreme with increases of 1 to 2 degrees every few minutes.Other late signs are cardiac dysrhythmia and hypotension.

Malignant hyperthermia can be fatal. The key to treatment isearly recognition of the syndrome, immediate discontinuationof the triggering agent, administration of dantrolene sodium toproduce muscle relaxation, and providing supportive care. Fol-lowing emergency treatment, the patient is monitored in the in-tensive care unit for 24 hours or longer because a smallpercentage of patients experience a reoccurrence of MH (Red-mond, 2001). Chart 26–3 summarizes the management of thepatient with malignant hyperthermia.

Other ComplicationsOther adverse events or complications may occur in the oper-ating room as a result of the surgical procedure. Examples in-clude such things as bleeding with excessive blood loss orinadvertent injury to surrounding organs or tissues. Intraoper-ative complication rates depend on the surgery, the type ofanesthesia, and the patient’s physical status. In studies of com-plications associated with various procedures (e.g., abdominal,spinal, orthopedic, and urologic), 3% to 4% of patients experi-ence intraoperative complications (Rampersaud et al., 2006;Tarrac, 2006).

Regional AnesthesiaRegional anesthesia is a general classification of anesthesia thatincludes spinal and epidural anesthesia, peripheral nerve blocks,Bier blocks, and local anesthesia. The common feature of alltypes of regional anesthesia is the local injection of a medicationto block the transmission of sensory impulses from that area tothe brain, thus, effectively blocking the sensation of pain. Re-gional anesthesia has some advantages over general anesthesia.Usually, regional anesthesia does not depress respirations so thepatient is at lower risk of postoperative respiratory complica-tions. This makes regional anesthesia a good choice for patientswith severe cardiopulmonary disease. Patients who receive a re-gional anesthetic usually experience less postoperative nauseaand vomiting.

Regional anesthesia can be used for any number of surgeries.It is commonly used for repair of inguinal hernia, transurethralresection of the prostate, gynecologic procedures, and arthro-scopies and other orthopedic surgeries including repair of hipfractures in the elderly. Typically, patients scheduled for regionalanesthesia are premedicated in the holding area with an antianx-iety agent to produce mild to moderate sedation. Opioid anal-gesics may be administered to reduce the pain associated with theinsertion of needles and the administration of numbing agents.

Spinal AnesthesiaSpinal anesthesia, also called intrathecal anesthesia, is the injec-tion of a local anesthetic into the subarachnoid space and directlyinto the cerebrospinal fluid (CSF). The anesthetic blocks nervefibers (i.e., sensory, motor, and sympathetic) at the level of thespinal cord. Spinal anesthesia effectively blocks motor and sen-sory nerves so that the patient cannot move the affected area(temporary paralysis) or feel pain, touch, temperature, or pres-sure. The spinal needle is inserted between the 2nd and 3rd lum-bar vertebrae (L2–L3) or the 3rd and 4th vertebrae (L3–L4). Forinsertion, the patient is placed in a sitting position or in a side-lying position with their head and knees flexed (i.e., fetal posi-tion). A spinal needle is inserted in the intervertebral spacethrough the dura mater and into the subarachnoid space. Specialspinal needles called pencil point needles enter the dura mater byseparating the fibers rather than cutting them, reducing the riskof a CSF leak after the needle is removed.

Commonly, spinal anesthesia includes the administration oflocal anesthetics such as lidocaine, bupivacaine (Marcaine), orchloroprocaine combined with an opioid analgesic such as fen-tanyl or preservative-free morphine. The medication may bemixed with a dextrose solution to create a hyperbaric solution(i.e., a solution that is heavier than CSF). Once a hyperbaric so-lution is injected into the CSF, it travels by gravity. The anesthe-siologist may have the patient sit for a few minutes to create ablock in the lower extremities or place the patient supine withthe head tilted slightly downward to create a higher block. After10 to 15 minutes, the block sets and does not extend further.

Epidural AnesthesiaEpidural anesthesia is the injection of a local anesthetic into theepidural space. The epidural space is located adjacent to thedura mater and contains fat, tissue, and blood vessels. Anestheticinjected into the epidural space affects nerve roots as they leavethe spinal cord and some medication diffuses across the duramater into the subarachnoid space and the CSF. The anesthetic

CHART 26–3 Management of the Patientwith Malignant Hyperthermia

• Immediately discontinue triggering agent.

• Stop surgery if possible. Otherwise, deepen anesthesia with opioids,sedatives, nondepolarizing muscle relaxants.

• Hyperventilate with 100% oxygen.

• Administer a bolus of dantrolene sodium (Dantrium) 2 to 3 mg/kgintravenously with additional bolus doses up to 10 mg/kg untildecreased signs of hypercarbia.

• Administer cooling devices: Apply cooling blanket, use iced normalsaline intravenously, lavage open body cavities with iced saline.

• Hydrate with intravenous normal saline.

• Maintain a urine output greater than 2 mL/kg per hour. Administerfurosemide and/or mannitol if urine output is less than goal.

• Treat metabolic acidosis with intravenous sodium bicarbonate if itdoes not self-correct with treatment.

• Treat hyperkalemia with intravenous sodium bicarbonate, 10 units ofregular insulin with dextrose intravenously.

• Treat cardiac arrhythmia if it does not self-correct with treatment. Donot use calcium channel blockers.

• Continue to monitor vital signs, oxygen saturation, electrocardiogram,urine output, arterial blood gases, and blood chemistry.

• Transfer to Intensive Care Unit for postoperative care.

Redman, M.C. (2007). Malignant hyperthermia: Perianesthesia recognition, treatment, andcare. Retrieved on July 2, 2008 from http://www.aspan.org/EdCeMalHyper.htm#head11.


spreads in both directions (i.e., cephalad and caudad) from thesite of the injection, and positioning has less effect on movementof the medication than it does with spinal anesthesia.

The same medications used in spinal anesthesia are used inepidural anesthesia, but the concentration of the drugs is greaterbecause they must diffuse across several layers of tissue. The on-set of epidural anesthesia is slower than that of spinal anesthe-sia. A test dose of lidocaine with epinephrine is injected to makesure that the needle is correctly placed in the epidural space andnot in the subarachnoid space or in a vein. If the needle is mis-takenly in a vein, the test dose produces transient tachycardia; ifit is in the subarachnoid space, it produces mild numbness. Fre-quently, an epidural catheter remains in place after the opera-tion to provide postoperative pain control. Caudal anesthesia isthe administration of a local anesthetic into the epidural space,but the approach is through the caudal canal in the sacrumrather than through the lumbar vertebrae.

Complications of Spinal or Epidural Anesthesia Spinal anesthesiamay be complicated by the development of headache, hypoten-sion, and meningitis. Spinal headache or post–dural punctureheadache (PDPH) is a common postoperative complaint. PDPHis caused by the leaking of CSF through the hole in the dura (e.g.,the puncture site). The loss of CSF causes irritation of meningealnerves and vessels (Hyderally, 2002). Because PDPH develops orworsens when the patient moves to an upright position, patientsmay be restricted to bed rest for the first 8 to 24 hours postopera-tively to reduce the incidence of spinal headache. When headachedevelops, it is located in the occipital area and resolves in 1 to 3days. Patients who develop a headache are treated with hydrationand analgesics. The patient is placed on bed rest with the head ofthe bed maintained at less than 30 degrees to reduce CSF leak.PDPH that does not resolve quickly or that produces an intolera-ble headache may be treated with a “blood patch.” The anesthesi-ologist injects 5 to 10 mL of autologous blood into the epiduralspace at the site of puncture to seal the leak.

Whereas PDPH occurs postoperatively, hypotension is morelikely to occur while anesthesia is still being administered. Hy-potension is caused by vasodilation associated with the blockingof sympathetic nerves. When sympathetic nerves are blocked byanesthesia, arteries and veins lose muscle tone and the ability toconstrict. This decreases venous return from the extremities andreduces cardiac output. Hypotension can occur with both spinaland epidural anesthesia. Hypotension is avoided with the admin-istration of fluid volume usually normal saline. Medications withstrong alpha-adrenergic stimulation effects, such as ephedrine orphenylephrine, are used to prevent or treat hypotension.

Spinal anesthesia is associated with a low risk of asepticmeningitis. When it does occur, signs develop within the first 24hours after surgery (Hyderally, 2002). The patient presents withthe typical signs of meningitis, fever, headache, nuchal rigidity,and photophobia.

Peripheral Nerve BlocksA peripheral nerve block is the injection of a local anestheticinto or around a nerve plexus to produce anesthesia of a selectedarea. The major advantage of a nerve block is that anesthesia isconfined to the area of the surgery and does not have a systemiceffect. Long-acting local anesthetics used in the nerve block pro-vide extended control of pain postoperatively. The local anes-

thetic blocks motor, sensory, and sympathetic nerves. Fre-quently, epinephrine is administered with the local anesthetic.Epinephrine causes vasoconstriction of the area and decreasesvascular uptake of the medication, thus prolonging the effect ofthe local anesthetic. The duration of the block depends on thechoice of anesthetic, the volume and concentration of the drug,and the site being injected. Frequently, nerve blocks are admin-istered by anesthesia in the holding area because they may takeanywhere from 5 to 30 minutes to take effect.

A nerve block can be performed in a number of different sites.For example, an interscalene or axillary block of the brachialplexus is done for surgeries on the shoulder, forearm, or elbow.Surgery on the lower leg may be accomplished using a femoral orsciatic block. Peripheral nerve blocks are used alone or in combi-nation with general anesthesia. When used with general anesthe-sia, the amount of general anesthesia can be reduced.Complications that can occur with nerve blocks includehematoma at the site of the block, nerve damage, and toxicityfrom systemic absorption of local anesthetic. Other, specific com-plications depend on the site where the block is administered.

Peripheral nerve blocks may be performed as outpatient sur-geries. Patients are taught that recovery of motor function occursfirst followed by recovery of sensation. Note that while the area isnumb, the patient is at risk for inadvertently injuring the area.

A Bier block is a specific type of peripheral nerve block that isadministered intravenously, but certain techniques are used totrap the anesthetic in the local area. Bier blocks may be used forsurgeries on an extremity, usually the arm. An IV catheter is in-serted in the extremity at the most distal site possible.A pneumatictourniquet is applied proximal to the surgical site and inflatedhigher than the patient’s systolic blood pressure. When the localanesthetic (lidocaine) is injected intravenously, the obstruction ofblood by the tourniquet prevents it from leaving the surgical area.At the completion of the surgery, the tourniquet is intermittentlydeflated so that the lidocaine enters the patient’s general circula-tion slowly, preventing a toxic reaction to the anesthetic.

Nursing ManagementThe verification process consists of information gathering and ver-ification, which begins with the determination to do the procedureand continues through all settings and interventions involved inthe preoperative preparation of the patient, up to and includingthe time-out (discussed later) just before the start of the procedure.

AssessmentThe nurse asks the patient to confirm the procedure to be com-pleted, the surgical site, and the surgeon. The nurse verifies thisinformation with the surgical consent form, a site verificationform per organization policy, and the operating room schedule.In some cases, especially when there is a left or right side in-volved in the procedure, the correct area for surgery is markedon the patient. Per the AORN (2008) correct site surgery posi-tion statement, a comprehensive approach is needed in eachhealth care delivery system to prevent wrong site surgery. In2003 AORN and the American College of Surgeons developednational guidelines that are to be used with every patient havingsurgery to eliminate inadvertently operating on the wrong sur-gical site (see the National Guidelines box, p. 632).


Nursing DiagnosesThe actual and potential nursing diagnoses related to surgeryinclude:

1. Stress, Overload

2. Surgical Recovery Delayed

3. Fear

4. Infection, Risk for

5. Pain, Acute.

PlanningTo provide the safest and least stressful experience for the patient,planning is essential. Planning for the surgical experience typicallybegins with the admission to the hospital. A comprehensive planthat organizes the care of the patient and family will facilitate thesurgical process. The plan includes preoperative, intraoperative,and postoperative management and teaching. Communication isas essential part of executing the plan. Each hospital has specificforms that are used to guide the nurse through the process.Chapter 25 includes an example of a preoperative checklist.

Outcomes and Evaluation ParametersThe desired outcome for patients having surgery is that the pa-tient safely transitions through the entire process. Evaluation pa-rameters include: airway is maintained, oxygen levels are withinnormal limits, pain is managed and any postoperative complica-tions are effectively mitigated or controlled as much as possible.

Interventions and RationalesThe nurse must communicate pertinent information to the anes-thesia team. Information may include allergies, lab/test results,skin condition, NPO status, sensory/mobility impairments, phys-ical particularities, restrictions to jaw and neck range of motion,history of drug use including herbal medication, anticoagulantsheld for number of days, implanted electronic devices (IEDs),

88

other implants, previous anesthesia/surgery history, artificial orloose teeth, previous surgery, comorbidities, particular patient re-quests, or any other information deemed crucial to intraoperativepatient care.Although this verification takes place in the same-dayadmission unit or the surgical unit, many ORs have developed apresurgical checklist to ensure that all pertinent information is re-viewed and communicated.

Preventing Wrong Site SurgeryWhen a procedure involves a left/right distinction, multiplestructures (such as finger and toes), or multiple levels (such asspinal procedures), the intended site must be marked so that themark will be visible after the patient has been prepped anddraped. The purpose is to identify unambiguously the intendedsite of incision or insertion. The mark must be made using amarker that is sufficiently permanent to remain visible after theskin preparation. The Joint Commission (2004) recommendsthat the method and the type of marking should be consistentthroughout the organization and that the person doing themarking should be the one doing the procedure. Marking musttake place with the patient involved and aware.

Exemptions to the marking procedure may include single-organ cases, interventional cases where the point of insertionis not predetermined (such as cardiac catheterization), teethextractions (although the involved tooth should be

documented), and premature infants, for whom the mark may cause apermanent tattoo.

As the patient’s advocate, the perioperative nurse should com-municate with all members of the surgical team to verify the cor-rect surgical site. Individual facility policy should clearly delineatethe role and responsibility of the health care provider and otherteam members in marking and verifying the correct surgical site.The 2006 statistics on sentinel events from the Joint Commissionidentify wrong site surgery as the second most reported sentinelevent, accounting for 13% of reported sentinel events (Beyea,

NATIONAL GUIDELINES AORN Guidelines for Eliminating Wrong Site Surgery

The following guidelines are supported by both AORN and the American College of Surgeons.

1. Verify that the correct patient is being taken to the operating room. This verification can be made with the patient or the patient’s designatedrepresentative if the patient is underage or unable to answer for him/herself.

2. Verify that the correct procedure is on the operating room schedule.

3. Verify with the patient or the patient’s designated representative the procedure that is expected to be performed, as well as the location of theoperation.

4. Confirm the consent form with the patient or the patient’s designated representative.

5. In the case of a bilateral organ, limb, or anatomic site (for example, hernia), the surgeon and patient should agree and the operating surgeonshould mark the site prior to giving the patient narcotics, sedation, or anesthesia.

6. If the patient is scheduled for multiple procedures that will be performed by multiple surgeons, all the items on the checklist must be verified foreach procedure that is planned to be performed.

7. Conduct a final verification process with members of the surgical team to confirm the correct patient, procedure, and surgical site.

8. Ensure that all relevant records and imaging studies are in the operating room.

9. If any verification process fails to identify the correct site, all activities should be halted until verification is accurate.

10. In the event of a life- or limb-threatening situation, not all of these steps may be followed.

Source: Carney, B. Evolution of Wrong Site Surgery Prevention Strategies. AORN, Volume 83, Issue 5, pp. 1115–1122.


2000). Although it is the surgeon’s role to diagnose a patient’s needfor surgery and to delineate the surgical site, verifying the surgicalsite at the time of surgery is the responsibility of perioperativenurses and every member of the health care team (AORN, 2008).To this effect, the Joint Commission has issued regulations and isendorsing the Universal Protocol as part of the 2007 National Pa-tient Safety Goals (Joint Commission, 2007).

The goal of the universal protocol is to prevent wrong site,wrong procedure, and wrong person surgery. The JointCommission’s national guidelines to prevent wrong sitesurgery are based on the consensus of experts from the

relevant clinical specialties and professional disciplines and is endorsed bymore than 40 professional medical associations and organizations. Theactive involvement of the team and the patient or patient’s representativeand effective communication among all members of the operating roomteam are important for success.

Surgical Time-OutSafety initiatives that address communication issues such as thetime-out are designed to promote correct site surgery. The time-out checklist has been adopted from the aviation industrymodel and requires surgical team members to cease all other ac-tivities in order to actively, verbally, and mutually verify infor-mation such as the correct patient, correct surgery, correctsite/side, correct patient position, and possibly additional infor-mation such as prophylactic medications being administered atthe appropriate time prior to surgery. Figure 26–4 � shows asample of a time-out checklist.

Wrong site surgery may be the result of operating on the wrongpatient or performing the wrong procedure, but most commonlyit is the result of operating on the wrong site/side; for example, theleft hand is operated on instead of the right (Joint Commission,2007). Although rare, the consequences of wrong site surgery can

FIGURE 26–4 � AORN guidelines for verifying the correct surgical site.AORN. (2008). AORN position statement. Retrieved on July 2, 2008 from http://www.aorn.org/PracticeResources/AORNPositionStatements/PositionCorrectSiteSurgery/.

Guidelines for Implementing JCAHO Universal ProtocolTo Promote Correct Site Surgery

In the case of pediatric patients and patients unable to verifyinformation for themselves, the RN identifies the patient’s

legal guardian and verifies with them the following protocol.

PREOPERATIVE VERIFICATION

“TIME OUT”

DOCUMENTATION of “TIME OUT”

DISCREPANCIES/ISSUES

When marking the siteDO NOT USE:

The letter X or the word NODo NOT mark the Non-Operative Site

According to AORN standards, the patient isidentified by the circulating RN when the patient

enters the OR suite. The procedure and surgical siteare validated at this time as well.

Takes place in the procedure/OR room, after the patient isprepped and draped and it involves the ENTIRE TEAM.

All team members must verbally verify their agreement on:

SITE MARK:

2 Patient Identifiers Must be Used (for example)*

Should indicate the following was verified:

Confirm and Verify

• Ask patient to state their full name.

• Patient’s name on their ID band, date of birth, and otherdocuments that correspond with the patient’s responses.

• The patient’s room number is not an acceptable patient identifier:

PATIENT RESPONSES MUST MATCH:MARKED SITE * ID BAND * CONSENTS * RADIOLOGIC EXAMS *

SCHEDULED PROCEDURE

• Ask patient to state their date of birth.

• Medical record number. • The name of the patient.

Procedure does not start until patient verification & missinginformation is completed and agreed upon by all team members.

• The procedure to be performed.

• Correct patient.• Correct site and side.

• Agreement to procedure.• Correct patient position.

• Implants and/or special equipment or special requirements available.

Facility determined identifiers should be used.*

**

***

Remove the mark at the end of procedure, especially forpatients returning for subsequent procedures (e.g., trauma).If operating physician does not mark site, an individual identifiedby facility policy with knowledge of the patient and plannedprocedure to be performed may mark the site.

• The site of the procedure, including laterality, implant to be usedand radiologic exams, if applicable.

Validate site mark after draping or confirm ID band with theprocedure written on it if used in cases of exemption.

• Consents.• Availability of implant if required.• Availability of blood if ordered.

• Radiologic exams (x-ray, CT scan, MRI, etc.).

• 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,

prior to patient entering the OR suite. ***

• Mark site(s) with patient participation (e.g., verbal confirmation orvisual pointing).

• Use an additional mechanism for identifying site(s) exempt frommarking according to facility policy and JCAHO guidelines (Forexample, an ID band with the procedure written on it is an alternativefor site marking. When possible the ID band should be verified duringthe time out phase similar to the site mark).

• Ask patient to state their planned procedure anddocument it in the patient’s own words.

All issues resolved are documented in the medical record.

If a disagreement is not resolved, follow your facility policy andnotify your manager or administrator.


FIGURE 26–5 � Sample of intraoperative nursing documentation.

Room #: ASA: Pt. in room: Anes. start:

Procedure start: Procedure finish: Pt. out of room: Anes. finish:

This record is a sample only. Clinical records should be customized to incorporate data fields that represent the setting, facility, procedure, and patient.Reproductions and variations are encouraged, provided credit is given to AORN.

Addressograph

(Patient Information:name, age, gender, medical record number, date)

Structural Data:

Nursing Data Elements - Preoperative:

AORN SAMPLE Patient Record(Facility Name and Address)

Operating Room Progress Notes Surgeon 1:

Surgeon 2:

Circulating nurse 1:

Circulating nurse 2:

Assistant 1:

Assistant 2:

Circ. 1 relief:

Time in: Time out:

Time in: Time out:

Circ. 2 relief:

Anesthesia care provider 1:

Anesthesia care provider 2:

Scrub 1:

Scrub 2:

Laser operator:

Other authorized personnel:

Scrub 1 relief:

Time in: Time out:

Time in: Time out:

Scrub 2 relief:

Anesthesia type:

General

Local block, Type:

Op Dx:

Op Dx:

Procedure(s):

Other:

MAC Spinal

Risk for injury related to transfer and transport (X29):Risk for anxiety related to knowledge deficit andstress of surgery (X4):

Risk for acute/chronic pain (X38, X74):

ID confirmed

Preoperative checklist reviewed/evaluated

Allergies verifiedConsent verified Site verified

Procedure verifiedLatex allergy: Yes No

Sensory impairment: No limitations Hearing

Musculoskeletal status: No limitations

Prosthetics/Assistive devices: Hearing aid Glasses

Paralysis Traction

Language barrier Sight

NPO verified

Alert/orientedAsleep

DrowsyUnresponsive

Sedated

HighDVT/PE risk: Med. LowTracheotomyRespiratory: Intubated Chest tubeRegular Labored Other findings

DisorientedOther:

Psychosocial status:Calm/relaxed

Provided instruction based on age and identifiedneeds (I106).Communicated patient concerns to appropriatemembers of health care team (I128).

Explained sequence of events and preoperativeroutine (I56).

Evaluated response to instructions (I50).

Instructed on use of pain scale

Outcomes:Verbalizes/indicates decreased anxiety, ability tocope, understanding of procedure and sequence ofevents. Questions answered.Demonstrates adequate pain management.Verbalizes comfort related to transfer/transport.

Location:Pain assessment (0-10):

CryingAnxiousRestless

Talkative

Transfer to suite via:

StretcherIsolette

W/CCrib

Bed

Other:

Prosthetics:AICD

Peripheral edema:Cardiopulmonary status:

Yes Location:No

CoolDry

WarmMoist

IntactBody jewelry removed

Tattoos:

Time:

Epidural


be devastating and warrant improved systems that promote effec-tive communication such as the time-out initiative.

Intraoperative Patient RecordMost facilities have an intraoperative patient record, like thatshown in Figure 26–5 �, that is used to record intraoperative in-formation. In addition, perioperative nurses may chart informa-tion in the nurse’s notes when warranted. For example,information may include personnel involved, length of surgery,

position and accessories implemented, wound classification,anesthesia classification, and monitoring devices to name a few.

Protecting the Patient from InfectionSurgical-site infections are the third most frequently reportedtype of iatrogenic (hospital-acquired) infection (Engemann etal., 2003). Preventing and minimizing associated risks of SSI arefundamental perioperative nursing diagnoses of the surgical pa-tient. According to Nichols (2001), the most critical factor in

Intraoperative Structural Data:

Intraoperative Nursing Data:

Postprocedure Assessment/Evaluation:

Implants/Prosthesis: Time Medication Dosage Route Initials

OR medications:

Yes No Exp. Date:

Risk for infection (X28):Skin Pre-op intact Other:

Surgical clippers:

Apply safety strap to:Apply grounding pad Site:Electrosurgical unit #:Setting: Coag: Cut:

Bipolar #:

Sequential stockings:

Counts: Sponge Needles Instruments1st count:

2nd count:3rd count:

CorrectCorrectCorrectUnresolvedN/A



Yes No Other: Unit #:

Laser Type: Unit #: Settings: Time:Safety measures implemented Operator:

Tourniquet checked & applied

Surgeon notified of counts Yes NoIf counts unresolved, X-ray taken:

#: Site: Applied by:Inflated: Deflated: Pressure:

Risk for impaired skin integrity (X50):

Risk for injury (X29):

Position for surgery: Supine Prone Mod. lithotomy Jackknife

Lt. lateral Rt. lateral Other:

Other:Positioned by:

Signature: If no, explain:

Pad bony prominences: Elbows Heels Arms tucked/padded

Positioning devices: Chest roll Shoulder roll Axillary roll

Pillow/wedge Stirrups Leg holder

Risk for hypothermia (X26):Apply warming blanket #:

Outcomes: Patient’s surgery performed using aseptic technique and in a manner to prevent cross-contamination (O10).Skin remains smooth, intact, non-reddened, non-irritated, free of bruising (O5, O2, O8).Core body temperature remains in expected range (O12).

Warm IV fluid

Temp setting:

Applied by:

Drains/tubes (size/type/site):

Packing (size/type/site):Cast (type/site):Dressing (type/site):

Warm irrigationOther:

OR drainage amount:

Wound classification:1-Clean 3-Contaminated

2-Clean/contaminated 4-Dirty

Other:

Skin prep By:

Povidone-iodine Chlorhexidine

Area:

Urinary catheter:(size/type/site):OR output: Inserted by:

Blood products: Yes No X-rays: Yes NoBlood band #:

Unit #: Start time: Finish time:Unit #: Start time: Finish time:

Blood recovery: Yes No Gonadal ThyroidUnit #:CCs reinfused:

Unit #: Start time: Finish time:

Site:

Pathology specimens:Yes NoRoutine:

Type: #:Yes NoFrozen section:

#:

Yes NoCultures:#:Comments:

Other:

Protective devices:

Grafts: Yes No

Type:Donor site:Recipient site:

Manufacturer:

Irrigation:

Type:

Amount:

Type:Size:Lot/Serial #:

EKG Oximeter NIAPB Temp monitor (other than those given by anesthesia care provider)


postoperative infection is the sound judgment and proper prac-tice of the surgical team in addition to the general health anddisease state of the patient. It is for this reason that perioperativenurses have become quite expert in the areas of aseptic tech-nique and sterile conscience. Surgical aseptic practice is basedon the premise that most infections are caused by exogenous or-ganisms or organisms that are external from the body.

Asepsis is the absence of infectious organisms. In the OR asep-tic techniques are practices that minimize contamination due tomicroorganisms. Frequently aseptic techniques and practicesare criticized for being ritualistic in nature and lacking in scien-tific rigor, but until empiric evidence demonstrates a techniqueis otherwise unnecessary or ineffective, basic aseptic principlesshould be observed.

There are no sterilization processes that completely eliminateall microorganisms. The best technologies to date can only limitand reduce the presence of microbial life such as bacteria,viruses, fungi, and spores to an acceptable sterility assurancelevel. It is for this reason that nurses and surgical team membersin the OR need to continually monitor the surgical field and de-velop strategies to minimize patient risk. An example may in-clude inspecting sterile packaging, delivering items using properaseptic technique, and ensuring items have been appropriatelysterilized.

SSIs may also be predicted based on the surgical wound clas-sification. The CDC publishes norms for SSI rates based on cer-tain indicators, including wound classification (see the NationalGuidelines box). The CDC data provide benchmarks for healthcare professionals to evaluate their SSI rates so they can furtherinvestigate the problem and implement initiatives should therates be unusually high.

The purpose of surgical wound classification is to track andlearn the cause of infections in order to prevent futureincidence. This information is generally recorded on thepatient’s intraoperative record.

Over time, surgical team members will in fact develop a surgi-cal conscience. Surgical conscience is defined as “An inner com-mitment to strictly adhere to aseptic practice, to report any break

in aseptic technique, and to correct any violation whether or notanyone else is present or observes the violation. A surgical con-science mandates a commitment to aseptic practice at all times”(Spry, 2005). This allows personnel to function in a more efficientand safe manner.

One of the strategies employed is the creation of the sterilefield. The sterile field begins at the surgical site (incision), andextends to the rest of the patient, OR table, surgical team, scrubtable, and to a 1-foot parameter around the draped areas (Figure26–6 �). This principle is applied to application of prepping so-lutions, patient draping, room setup, and so forth. It is com-monly referred to as the clean to dirty principle.

Surgical attire, scrubbing, gowning, and gloving are all func-tions of OR aseptic technique. Figure 26–7 � shows a nurse in

NATIONAL GUIDELINES for Surgical Wound Classification

Source: Devaney, L., & Rowell K. S. (2004). Improving surgical wound classification—why it matters. AORN Journal. Retrieved on July 2, 2008 from http://findarticles.com/p/articles/mi_m0FSL/

is_2_80/ai_n6159709.

Clean wounds An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, oruninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drainedwith closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included inthis category if they meet the criteria.

Clean-contaminated wounds Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlledconditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina,and oropharynx are included in this category provided no evidence of infection or major break in technique isencountered.

Contaminated wounds Includes open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., opencardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulentinflammation is encountered are included in this category.

Dirty or infected wounds Includes old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection orperforated viscera. This definition suggests that the organisms causing postoperative infection were present in theoperative field before the operation.

FIGURE 26–6 � OR table.


proper OR attire and a surgical team member in scrub apparel,highlighting important standards and principles.

Positioning the Patient to Prevent InjuryPatient positioning in the OR is chosen to accommodate surgi-cal access, staff ergonomics, and surgical view while maintainingthe patient’s skin integrity. It is for this reason that OR tables arenarrow (ergonomic for surgeon) and firm (limits movementand allows for CPR). OR tables and accessories are designed toaccommodate a wide range of positions in order to allow for theuse of gravity to displace organs in order to provide additionalworking space, surgical access, enhanced ergonomics for profes-sionals, and prevent patient complications.

Complications secondary to positioning include compro-mised respiratory or circulatory responses, injury to nerves andmuscles, and the development of pressure ulcers. Chart 26–4 listscommon intraoperative positioning complications and potentialcauses. Nurses may review patient’s intraoperative position viathe OR record and assess any relevant patient outcomes. Of these,pressure ulcers have received much attention as a preventable in-traoperative complication. The incidence of pressure ulcers in

surgical patients ranges from 4% to a high of 45% depending onthe study (Feuchtinger, Halfens, & Dassen, 2005; Price, Whitney,& King, 2005). Researchers report conflicting data on risk factorsfor the development of pressure ulcers. However, preoperativerisk factors commonly cited across studies include age (e.g., olderpatients); presence of comorbidities particularly diabetes, hyper-tension, and vascular disorders; and poor nutritional status asmeasured by low serum albumin and anemia (Feuchtinger et al.,2005; Price et al., 2005). Further research is needed to clarify in-traoperative risk factors but those that are suggested include typeof surgery (e.g., higher risk with vascular, cardiac, thoracic, andspinal surgery), length of operation (e.g., longer surgeries), caretaken during perioperative skin preparation to reduce unneces-sary moisture collection under the skin, hypotensive episodesduring surgery reducing the blood available to tissues, and thetype of anesthetic used. Perioperative nurses need adequateknowledge of anatomy and an understanding of the physiologicaleffects of specific surgical positions. Appropriate positioning ac-cessories and excellent communication between the anesthesiateam monitoring physiological responses and the surgical teamoften requesting position changes is essential in order to preventpatient injury.

The primary objective of patient positioning for surgery is toprovide maximize exposure while ensuring patient safety.For example, proper positioning can help maintain properbody alignment and access to intravenous and anesthesiasupport devices.

Preventing the Retention of Foreign ObjectsSurgical counts are the responsibility of perioperative nurses andare performed in order to prevent patient injury due to the highrisk of retained foreign body, which can include gauzes, needles,or instruments. Retained foreign objects in patients have resultedin major injuries such as sepsis, bowel perforation, and death.Most facilities follow a legal counting procedure based on theAORN (2007b) recommended standards and practices. The de-sired patient outcome is a patient free from injury related to ex-traneous objects. It seems to be a much greater issue thanreported, leading to an initiative by health care professional or-ganizations, such as AORN,American College of Surgeons (ACS),

FIGURE 26–7 � Correct surgical attire.

CHART 26–4 Intraoperative Positioning Complications

Potential Complications Secondary to Intraoperative Positioning Potential Intervention

Decreased lung expansion due to supine position resulting incompromised respiratory effects

Position bolsters correctly to minimize compression of thorax, facilitating fulllung expansion.

Brachial plexus nerve injury Position arm correctly to ensure proper arm alignment of less than 90 degrees,supinated, and adequately padded and protected.

Circulatory obstruction due to position resulting in increased risk ofpostoperative deep vein thrombosis

Apply antiembolic stockings and sequential compression leggings. Useappropriate prophylactic anticoagulant medication administration.

Integumentary injury resulting in pressure ulcers, abrasion, andblistering

Use OR table equipment that will minimize pressure and maximize capillaryrefill. Appropriate equipment includes gel mattresses. Ensure proper lifting andsecuring of patient to prevent friction-related injuries.

Dislocation of acetabulum Ensure proper placement of stirrups and ensure that two health careprofessionals simultaneously lift, support, and place legs onto stirrupsobserving correct alignment.


and the Joint Commission, to develop improved methods of ac-counting for surgical items. One technology that is currently be-ing tested is radio-frequency identification (RFID). This involvesRF tags being implanted in surgical sponges (Figure 26–8 �). Thispermits the surgical team to pass a wand over the patient follow-ing a procedure to verify that no sponges have been left in the pa-tient (Medline, 2006).

The presence of foreign materials in the body can lead to in-fection, abscess, and other serious problems. Multiple proce-dures are in place to prevent leaving an instrument or a spongeor other material in the patient when the wound is closed.Sponges, swabs, instruments, and sharps are counted manytimes during the surgical procedure. Hospitals have writtenpolicies describing what is counted, when it is counted, whodoes the counting, where the counting is documented, and howto resolve a discrepancy in the count. To prevent a foreign objectfrom being left behind:

• All items brought to the operating room are documented.

• No items are removed from the operating room until the fi-nal count is complete and verified.

• Sponges, swabs, and other items are counted before surgery,before wound closure begins, and before skin closure begins.

• The circulating nurse and scrub nurse count items in unison.

• The circulating nurse and scrub nurse document the count inthe record.

If there is a discrepancy in the count, all personnel try to locatethe missing item. If it cannot be found, the patient may be x-rayed.Surgical instruments can be seen by x-ray and soft materials,such as surgical sponges, have a radio-opaque stripe for x-rayidentification.

Estimating Blood LossThe patient is monitored throughout the operation for blood loss.The calculation of blood loss is referred to as the estimation ofblood loss (EBL). Blood in suction containers, wound drains,chest tubes, and nasogastric tubes is measured directly at frequentintervals during the surgery. If irrigating fluid is used, it is sub-tracted from the total amount of drainage to determine theamount of actual blood loss. Blood in sponges can be approxi-

mated from their weight with 1 gram of weight being equal to1 mL of blood. Blood-soaked sponges are collected in a plastic bagand weighed. The weight of the dry sponge(s) and plastic con-tainer is subtracted from the total weight to determine blood loss.

Whether or not the patient needs a transfusion during sur-gery depends on blood loss as well as on other factors such asage, general level of health prior to surgery, history of cardiovas-cular disease, how well the patient tolerates the blood loss, andthe availability of autologous blood. Some religions, such asChristian Science and Jehovah’s Witnesses, restrict the adminis-tration of blood products.

Adult patients who are generally healthy can tolerate surgicalblood loss of up to 500 mL without the need for a transfusion.Blood loss is treated with the administration of packed red bloodcells. Chapter 23 provides a complete description of bloodadministration indications and procedures.

Latex Allergy There has been a significant increase in the number of latex aller-gies seen in the hospital, including the operating room. Some sug-gest the increase correlates with the adoption of universalprecautions and the increased use of latex gloves. Patients areasked preoperatively about the possibility of latex allergy. A latexsensitivity questionnaire can be used to identify those who have alatex allergy or who are likely to develop the allergy. A high inci-dence of latex allergy is found in people with spina bifida, patientswho have had multiple surgeries, those who work with latex prod-ucts (health care workers, dental industry workers, rubber work-ers), and those with a genetic predisposition to allergies (atopy).Patients who report allergies to kiwis, bananas, and avocados arealso at an increased risk of latex allergies due to the cross reactiv-ity of the proteins present in these fruits and latex. Blood or skintests can detect latex-specific IgE antibodies and are performedpreoperatively when latex allergy is suspected. Latex allergy is dis-cussed in detail in Chapter 60 .

It is virtually impossible to create a latex-free environment inthe operating room—although it may be possible in the futureas more products are being manufactured without latex. For pa-tients with known allergy, a latex-reduced environment is cre-ated. Elements of a latex-reduced environment in the operatingroom include (1) scheduling elective cases as the first cases of the

88

88

FIGURE 26–8 � RFID technology: (A) RF tag implanted in surgical gauze; (B) wand to detect the RF tag in surgical gauze; (C) surgical RFID detectionconsole.

(a) (b) (c)


day to minimize contact with aerosolized allergen from latexgloves, (2) using vinyl gloves rather than latex gloves, (3) usingpowder-free gloves to limit the aerosolization of latex antigens,(4) avoiding latex on the sterile field, (5) using a plastic anesthe-sia mask, (6) using a stopcock rather than the rubber port for in-jection of intravenous drugs, (7) removing the rubber cap onmedication vials rather than drawing a medication through thecap, (8) using nonlatex equipment such as blood pressure cuff,stethoscope, and electrocardiogram leads, and (9) using nonla-tex tape. Premedication of allergic patients with steroids or an-tihistamines is not recommended.

Allergic responses to latex can range from mild cases of con-tact dermatitis evidenced by a rash and urticaria to serious casesof anaphylaxis. When a latex allergy is suspected in the operat-ing room, the source of latex in direct contact with the patient isimmediately removed. Follow-up treatment includes the ad-ministration of 100% oxygen, intravenous fluids to support theblood pressure, and the administration of intravenous epineph-rine. Diphenhydramine and steroids may also be given intra-venously to attenuate the allergic response.

Postanesthesia Care UnitOnce the surgery is completed, the anesthetist and the nurse willaccompany the patient to the postanesthesia care unit (PACU)for further monitoring. Concerns along this route will focus onsafety, infection control, medication, communication, position-ing, and equipment. The PACU is where the patient will recoverfrom the anaesthetic he has received. This is an unrestricted areawhere the patient will no longer need to wear a head cover andthe nurses will wear regular uniforms. Visitors may be allowedin certain parts of the PACU under certain circumstances.

Poor communication is one of the top contributing factorsto medical errors. Therefore, nurses must strive to provide ef-fective and consistent information during patient handoff to atransition unit such as the PACU or Intensive Care Unit (ICU).It is important to give any pertinent information to the unitmembers where the transfer of responsibility for the surgicalpatient is occurring and provide an interactive communicationthat is free of interruptions and includes a systematic processof verification. Figure 26–9 � (p. 640) shows a mnemonic thathighlights the handoff principles and verification process.PACU is dicussed in detail in Chapter 27 .88

Gerontological ConsiderationsPersons 65 years of age and older, require surgical interventionsmore often than younger persons because of age-related systemchanges and comorbid conditions. Degeneration of multiplesystems such as the musculoskeletal, nervous, cardiovascular,respiratory, genitourinary, endocrine, and hematopoietic sys-tems and hearing and vision can influence intraoperative andpostoperative outcomes. Changes in pharmacokinetics resultin changes in drug absorption, distribution, metabolism, andexcretion by the body. At this stage of life, both physical andcognitive abilities may vary greatly. Appropriate age-specificinterventions should be considered for the geriatric popula-tion taking into consideration both physical, cognitive, senso-rimotor, and psychosocial factors. The GerontologicalConsiderations box highlights the special considerations forthe gerontological population.

Assess the geriatric patient’s history and general health status,in particular medications, previous surgeries, and comorbidi-ties. Promote patient warmth through warming devices and as-sess range of motion prior to patient being anesthetized in orderto ensure correct positioning accessories are available. Addi-tional padding may be necessary due to decreased adipose tissueand circulation, predisposing the patient to the development ofpressure ulcers. Efforts should be made to diminish the use oftapes that may lead to denuding of geriatric fragile thinner skin.Ensure adequate time is available to communicate clearly andslowly, keeping in mind possible hearing impairment and needfor additional processing and response time.

Hyperglycemia is known to be associated with increased sep-sis, suggesting that careful monitoring of glucose levels may bea way to reduce serious postoperative infections. Infections area major concern for all hospitalized patients, but are especiallydangerous for elderly persons. General risk factors for infectionin elderly patients are known to include frailty, chronic under-nutrition, reduced muscle mass, and poor dentition. Othermore general factors common to all age groups are diabetes, as-piration, and the presence of an indwelling urinary catheter.

Patients with postoperative cognitive dysfunction (POCD)experience deterioration in cognitive function that persists foryears after the operation. POCD may be related to brain oxy-genation during anesthesia, anesthetic agents, and hospital en-vironment (Prough, 2005).

GERONTOLOGICAL CONSIDERATIONS for Elderly Patients Having Surgery

Physical Factors Cognitive Factors Sensorimotor Factors Psychosocial Factors

• Decreased tolerance to heatand cold

• Loss of skin tone• Declining cardiac/renal

function• Atrophy of reproductive

organs• Increased incidence of

preexisting healthconditions

• Decline dependent on pregeri-atric state and general healthand social involvement

• Decreased memory, inductivereasoning, and figural relations may occur

• Cognitive tasks may requiremore time to complete

• Decreased visual acuity• Diminished hearing• Altered tactile sensation• Changes in taste and smell• Diminished response to

stress and sensory stimuli• Decreased mobility

• Ego integrity important• Stressors: end of life, changes in

environment, increased cognitivedemands

• Death of loved ones• Concerns for general health

increase


FIGURE 26–9 � Handoff protocol to improve communication when transferring a patient from the OR to another unit.Source: Joint Commission (2008). National Patient and Safety Goals. Retrieved July 3, 2008 from http://www.jointcommission.org/NR/rdonlyres/ACA4DBF6-90FD-4400-BE7E-4C6F881E5DCD/0/08_OBS_NPSG_Master.pdf.

Introduction Introduce yourself and your role/job (include patient)

Name, identifiers, age, sex, location

Presenting chief complaint, vital signs and symptomsand diagnosis

Current status, medications, circumstances, including codestatus, level of (un)certainty, recent changes, response totreatment

Critical lab values/reports, socio-economic factors,alllergies, alerts (falls, isolation, etc.)

Co-morbidities, previous episodes, past/home medications,family history

What actions were taken or are required AND provide briefrationale

Level of urgency and explicit timing, prioritization of actions

Who is responsible (nurse/doctor/team)including patient/family responsibilities

What will happen next? Anticipated changes? What is thePLAN? Contingency plans?

Patient

Assessment

Situation

SAFETY Concerns

Background

Actions

Timing

Ownership

Next

“I PASS THE BATON”

Handoffs and Healthcare Transitionswith opportunities to ask

QUESTIONS, CLARIFY AND CONFIRM

I

P

A

A

T

O

N

S

S

B

THE

Prevention of Infection

Clinical ProblemMild perioperative hypothermia, which is common during majorsurgery, may promote surgical-wound infection by triggeringthermoregulatory vasoconstriction, which decreases subcutaneousoxygen tension. Reduced levels of oxygen in tissue impair oxidativekilling by neutrophils and decrease the strength of the healing woundby reducing the deposition of collagen. Hypothermia also directlyimpairs immune function.

Research FindingsResearch was done testing the hypothesis that hypothermia bothincreases susceptibility to surgical-wound infection and lengthenshospitalization. Good et al. (2006) report that hypothermia itself maydelay healing and predispose patients to wound infections.Maintaining normothermia intraoperatively is likely to decrease theincidence of infectious complications in patients undergoing colorectalresection and to shorten their hospitalizations.

Other research was done on prewarming of patients’ skin and itsinfluence on core hypothermia (Cooper, 2006; Vanni et al., 2003).Camus et al. (1995) found that a single hour of preoperative skinsurface warming reduced the rate at which core hypothermiadeveloped during the first hour of anesthesia.

Antibiotic AdministrationAnother measure to reduce infection in the operating room is propertiming for antibiotic administration. Antibiotic prophylaxis is beingused in a variety of surgical procedures to reduce the incidence ofsurgical-site infections. Antibiotics should be chosen on the basis oftheir effectiveness against the pathogens most likely to beencountered. Skin floras (e.g., Staphylococcus organisms) are theusual target, so first-generation cephalosporins are most oftenchosen. Preoperative prophylactic antibiotics should be administeredwithin 60 minutes before the initial incision is made to ensure thatantimicrobial levels in the tissue are adequate and maintained for theduration of the procedure (Gordon, 2006; White & Schneider, 2007). Tocomply with the recommendations of administration within 60minutes of incision, the holding area was identified as the preferredlocation (Olin, 2006).

Implications for Nursing PracticeThe latest research results have and will influence a change of practicein the perioperative setting based on evidence. In the preoperative

setting nurses can use blankets and warming to maintainnormothermia. For maintaining normothermia in the OR policies andprocedures could be implemented such as use of warming devicesunder the patient as well as the use of warm solutions. In addition thetemperature of the OR suite could be increased.

Nurses also can coordinate the timing of preoperative antibioticadministration. This will necessitate cooperation with both thesurgeon and the OR staff to determine the optimal timing of antibioticadministration.

Critical Thinking Questions

1. What nursing interventions will decrease the risk of infection?

Answer:a. Communication with surgical team for timing of antibiotic

administration.b. Institute measures to maintain normothermia throughout

surgery & PACU.c. Develop policies that ensure standards are used by all

members of the surgical team regarding warningprocedures.

Answers to Critical Thinking Questions appear in Appendix F.

ReferencesCamus,Y., Delva, E., Sessler, D., & Lienhart,A. (1995). Pre-induction skin

surface warming minimizes intraoperative core hypothermia.Journal of Clinical Anesthesia, 7, 384–388.

Cooper, S. (2006).The effect of preoperative warming on patient’s postop-erative temperatures. AORN Journal, 83(5) 1074–1076, 1079–1084.

Good, K. K., Verble, J. A., & Norwood, B. R. (2006). Postoperativehypothermia—The chilling consequences. AORN Journal, 83(5),1055–1066.

Gordon, S. M. (2006). Antibiotic prophylaxis against postoperative woundinfections. Cleveland Clinic Journal of Medicine, 73, S42–S45.

Olin, J. (2006). Multidisciplinary approach to optimizing antibiotic pro-phylaxis of surgical site infections. American Journal of Health-System Pharmacy, 63, 2312–2314.

Vanni, S. M., Braz, J. R., Modolo, N. S., Amorim, R. B., & Rodrigues, G. R.(2003). Preoperative combined with intraoperative skin surfacewarming avoids hypothermia caused by general anesthesia and sur-gery. Journal of Clinical Anesthesia, 15(2), 119–125.

White, A., & Schneider, T. (2007). Improving compliance with prophylacticantibiotic administration guidelines. AORN Journal, 85(1), 173–180.


NCLEX® REVIEW1. A preoperative patient is taken into the holding area. The

nurse will utilize this time with the patient to do which ofthe following?

1. Ensure surgical instruments are operational.

2. Clean and inspect surgical instruments.

3. Conduct an interview.

4. Insert an indwelling urinary catheter if necessary.

2. A registered nurse first assistant is scheduled to assist asurgeon with a surgical procedure. This nurse will beresponsible for:

1. Administering anesthetic agents.

2. Serving as the patient advocate.

3. Providing the surgeon with instruments.

4. Collaborating with the surgeon and suturing the woundclosed.


KEY TERMSBier block p.631circulating nurse p.620conscious sedation p.625epidural anesthesia p.630

general anesthesia p.629intraoperative p.620intrathecal anesthesia p.630malignant hyperthermia (MH) p.629

peripheral nerve block p.631regional anesthesia p.630scrub nurse p.620spinal anesthesia p.630

REFERENCESAmerican Society of PeriAnesthesia Nurses. (2001). Clinical guideline for

the prevention of unplanned perioperative hypothermia. Journal ofPeriAnesthesia Nursing, 16, 305–314.

Arbous, M., Meursing, A., van-Kleef, J., de-Lange, J., Spoormans, H.,Touw, P., et al. (2005). Impact of anesthesia managementcharacteristics on severe morbidity and mortality. Anesthesiology,102(2), 257–268.

Association of periOperative Registered Nurses. (2002). PNDS Resources.AORN. Retrieved June 29, 2008 from http://www.aorn.org/

PracticeResources/PNDSAndStandardizedPerioperativeRecord/PNDSResources/

Association of periOperative Registered Nurses. (2007a). About AORN.Retrieved February 16, 2007, from http://www.aorn.org/AboutAORN

Association of periOperative Registered Nurses. (2007b). Standards,recommended practices and guidelines. Orientation of theregistered professional nurse to the perioperative setting. Denver,CO: Author.

Association of periOperative Registered Nurses. (2008). RN FirstAssistant. AORN. Retrieved on June 29, 2008 from http://www.aorn.org/CareerCenter/CareerDevelopment/RNFirstAssistant/

Bailey, J., McVey, L., & Pevreal, A. (2005). Surveying patients as a startto quality improvement in the surgical suites holding area. Journalof Nursing Care Quality, 20(4), 319–326.

Beyea, S. (2000). Preventing surgical site infections—Guiding practicewith evidence AORN Journal. Retrieved on June 29, 2008 fromhttp:// findarticles.com/p/articles/mi_m0FSL/is_2_72/ai_64424354/pg_3

3. During the course of a surgical procedure, the patient’s heartrate increases and the blood pressure drops. The careprovider who would address these physiological changes tothe patient would be the:

1. Surgeon.

2. Anesthesiologist.

3. RNFA.

4. Scrub nurse.

4. While conducting a surgical time-out, the nurse says that thesite of surgery is the right knee whereas the left knee wasmarked as the site of the surgery. Which of the followingshould be done?

1. Operate on the right knee.

2. Operate on the left knee.

3. Ask a family member which knee is the site of surgery.

4. Stop all preparations until it can be verified which knee is thesite of surgery.

5. While an anesthetized patient is being moved to theoperating room table, the patient’s lower left leg drops andhits the side of the table. Which of the following should thenurse do?

1. Move the leg and place it on the table.

2. Examine the leg for possible or extent of injury anddocument the event.

3. Nothing because this is considered an acceptable hazard ofsurgery.

4. Elevate the leg on a pillow.

6. During a surgical procedure the patient begins todemonstrate signs of malignant hyperthermia. Which of thefollowing should be done to support this patient?

1. Administer calcium channel blockers.

2. Stop the surgery or deep the anesthesia.

3. Transfer to the PACU for postsurgical care.

4. Provide 21% oxygen.

7. During a surgical procedure the anesthesiologist directsanother care provider to change the oxygen mix beingprovided to the patient. The care provider most likely tomake this oxygen change would be the:

1. RN First Assistant.

2. Scrub nurse.

3. CRNA.

4. Respiratory therapist.

Answers for review questions appear in Appendix 5

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Bitner, J., Hilde, L., Hall, K., & Duvendack, T. (2007). A team approach tothe prevention of unplanned postoperative hypothermia: Clinicalreport. AORN Journal, 85 (5), 921–928.

Bonjer, H. J., Hop, W. C., Nelson, H., Sargent, D. J., Lacy, A. M., et al.(2007). Laparoscopically assisted vs open colectomy for coloncancer: A meta-analysis. Archives of Surgery, 142(3), 298–303.

Boo, Y. J., Kim, W. B., Kim, J., Song, T. J., Choi, S. Y., et al. (2007).Systemic immune response after open versus laparoscopiccholecystectomy in acute cholecystitis: A prospective randomizedstudy. Scandinavian Journal of Clinical & Laboratory Investigation,67 (2), 207–214.

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Evidence based practice information sheets for health professionals. Theimpact of preoperative hair removal on surgical site infection.(2003). Best Practice, 7 (2), 1–6.

Feuchtinger, J., Halfens, R., & Dassen, T. (2005). Pressure ulcer riskfactors in cardiac surgery: A review of the research literature. Heart &Lung: The Journal of Acute and Critical Care, 34(6), 375–385.

Hasankhani, H., Mohammadi, E., Moazzami, F., Mokhtari, M., &Naghgizadh, M. (2007). The effects of intravenous fluidtemperature on perioperative hemodynamic situation, post-operative shivering, and recovery in orthopaedic surgery. CanadianOperating Room Nursing Journal, 25 (1), 20–24, 26–27.

Hoffer, J. L. (1999). Anesthesia. In M. Meeker & J. Rothrock (Eds.),Care of the patient in surgery (pp. 203–238). Philadelphia:Mosby.

Hurley, C., & McAleavy, J. (2006) Preoperative assessment andintraoperative care planning. British Journal of Perioperative Nursing,16 (1), 187–194.

Hyderally, H. (2002). Complications of spinal anesthesia. The MountSinai Journal of Medicine. Retrieved June 29, 2008 from http://www.mssm.edu/msjournal/69/v69_1&2_055_056.pdf

Iorio, R., Whang, W., Healy, W. L., Patch, D. A., Najibi, S., & Appleby, D.(2005). The utility of bladder catheterisation in total hiparthroplasty. Clinical Orthopedics and Related Research, 432,148–152.

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Larson, E. L., Aiello, A. E., Heilman, J. M., Lyle, C., Cronquist, A., Stahl,A., et al. (2001). Comparison of different regimens for surgical handpreparation. AORN Journal, 73 (2), 412–432.

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Noblett, S. E., & Horgan, A. F. (2007). A prospective case-matchedcomparison of clinical and financial outcomes of open versuslaparoscopic colorectal resection. Surgical Endoscopy, 21(3),404–408.

Price, M., Whitney, J., & King, C. (2005). Development of a riskassessment tool for intraoperative pressure ulcers. Journal ofWound, Ostomy and Continence Nursing, 32 (1), 19–30.

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Sessler, D., & Todd, M. (2000). Perioperative heat balance.Anesthesiology, 92 (2), 578–596.

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nursing management intra operative

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