Intraoperative

Phase
Chapter 15
 LEARNING OUTCOMES
On completion of this chapter, the learner will be able to:
1. Describe the roles of the surgical team members during the
intraoperative phase of care.
2. Identify adverse effects of surgery and anesthesia.
3. Describe ways to decrease the risk of surgical site infections.
4. Compare types of anesthesia with regard to uses, advantages,
disadvantages, and nursing responsibilities.
5. Use the nursing process to optimize patient outcomes during the
intraoperative period.
 Intraoperative Phase
• The intraoperative phase begins when the patient is transferred onto the OR bed
and ends with admission to the Post operative care unit.

• The surgical team:

 The patient
 Anesthesiologist (physician) or certified registered nurse anesthetist
 Nurses (scrub or circulating)
 Surgical technicians
 The surgeon and surgical assistant
The patient
1. Patient’s preparedness
2. The risks from surgery
3. Patient while under anaesthesia, lost his ability to
communicate subjects the intraoperative patient to
possible injury.
 Nursing care
• Provide for the safety and well-being of the patient
• Coordinate the OR personnel
• Perform scrub and circulating activities
• Monitor and prevent injury (such as patient position, environmental
hazards).
• Provides the patient with information and reassurance, continuing the care
initiated by preoperative nurses.
• Protect the patient’s dignity and interests while the patient is under
anesthesia.
• Maintain surgical standards of care, identifying risks, and minimizing
complications.
 The Circulating Nurses
• A qualified registered nurse, works in collaboration with
surgeons, anesthesia providers, and other health care
providers to plan the best course of action for each patient
• Verify consent
• Ensure cleanliness, proper temperature, humidity,
appropriate lighting, safe function of equipment, and the
availability of supplies and materials.
• Ensure that the second verification of the surgical
procedure and site takes place and is documented (time-out
checklist)
 The Circulating Nurses
• Identify patients correctly
• A team debriefing session, led by the circulating nurse,
often follows the completion of surgery to identify
potential problems
• Monitor the activities of the surgical team and documents
specific activities.
• Assess the patient for signs of injury and implementing
appropriate interventions.
• Monitor aseptic practices.
• Implement fire safety precautions.
 The Scrub Nurses
• The registered nurse, licensed practical nurse, or surgical
technologist (or assistant) performs the activities of the
scrub role, including:
- Performing hand hygiene
- Setting up the sterile equipment, tables, and sterile field
- Preparing sutures, ligatures, and special equipment
- Assisting the surgeon and the surgical assistants during the
procedure
 The Scrub Nurses

• Count all needles, sponges, and instruments with the circulating

nurse to be sure that they are accounted for and not retained as a
foreign body in the patient.
• Standards call for all sponges used in surgery to be visible on x-
ray and for sponge counts to take place at the beginning of
surgery and twice at the end (when wound closure begins and
again as the skin is being closed).
• Apply label on tissue specimens obtained during surgery.
• Tissue specimens obtained during surgery are labeled by the
person in the scrub role
 Safety and Infection Prevention
• The Surgical Environment:
1. The surgical suite is behind double doors
2. access is limited to authorized
3. The OR is considered a restricted area
4. In the OR environment, microbial contamination can occur through an
airborne or contact route
5. ORs are designed with laminar flow ventilation to circulate particles away
from the patient and surgical field.
6. Personnel also follow strict aseptic practices, including hand scrubbing,
machine and room cleaning, sterile supply and instrumentation use, and
limited movement.
 Safety and Infection Prevention
• Surgical Attire:
• To help decrease microbes, the surgical area is divided
into three zones:
1. The unrestricted zone, where street clothes are allowed
2. The semi-restricted zone, where attire consists of scrub
clothes and caps
3. The restricted zone, where scrub clothes, shoe covers,
caps, and masks are worn
Principles of Surgical Asepsis and
Sterile Technique
• Surgical asepsis: prevents the contamination of surgical
wounds.
• Sterile technique: implies that the area is free of living
microorganisms.
• The patient’s natural skin flora or a previously existing
infection may cause postoperative SSI.
• Rigorous adherence to the principles of sterility by OR
personnel is basic to preventing SSIs
 Principles of Surgical Asepsis and
Sterile Technique
• Environmental Controls:
- Floors and horizontal surfaces are cleaned between cases with
detergent, soap, and water or a detergent germicide.
- All equipment that comes into direct contact with the patient
must be sterile
- Sterilized linens, drapes, and solutions are used
- Instruments are cleaned and sterilized in a unit near the OR.
- A room temperature of 20° to 24°C, humidity between 30%
and 60%, and positive pressure relative to adjacent areas are
maintained.
 Health Hazards Associated with the Surgical
Environment
• Faulty equipment, improper use of equipment, exposure to
toxic substances, surgical plume (smoke generated by
electrosurgical cautery), as well as infectious waste, cuts,
needlestick injuries, and lasers are some of the associated
hazards in the surgical environment
• A retained object can cause wound infection or disruption
• Adherence to policies and procedures for minimizing
exposure to body fluids and reducing the dangers
associated with hazards
Health Hazards Associated with the Surgical
Environment

• Laser Risks
• Surgical Smoke
• Exposure to Blood and Body Fluids
 The Surgical Experience
Types of Anesthesia and Sedation
1. General Anesthesia:
- Anesthesia is a state of narcosis (severe central nervous system
depression produced by pharmacologic agents), analgesia,
relaxation, and reflex loss.
- Patients under general anesthesia are not arousable, not even to
painful stimuli.
- They lose the ability to maintain ventilatory function and require
assistance in maintaining a patent airway.
 The Surgical Experience
2. Regional Anesthesia:
A. Epidural anesthesia: injecting a local anesthetic agent into
the epidural space that surrounds the dura mater of the
spinal cord
- Epidural anesthesia blocks sensory, motor, and autonomic
functions
- Absence of headache
- A disadvantage is the greater technical challenge of introducing
the anesthetic agent into the epidural space rather than the
subarachnoid space
 The Surgical Experience
B. Spinal Anesthesia:
- A local anesthetic agent is introduced into the subarachnoid space at
the lumbar level, usually between L4 and L5
- It produces anesthesia of the lower extremities, perineum, and lower
abdomen
- To administer medication keep patient lies on the side in a knee–chest
position.
- Headache may be an aftereffect of spinal anesthesia.
- To minimize headache: hydration, small gauge needle, quite
environment, keep patient lying down.
The Surgical Experience
3. Moderate Sedation:
- Previously referred to as conscious sedation
- A form of anesthesia that involves the IV
administration of sedatives or analgesic medications
to reduce patient anxiety and control pain during
diagnostic or therapeutic procedures.
- Used for many short-term surgical procedures in
hospitals and ambulatory care centers
 The Surgical Experience
4. Local Anesthesia:
- the injection of a solution containing the anesthetic agent into the
tissues at the planned incision site.
- Advantages of LA are as follows:
It is simple, economical, and nonexplosive.
Equipment needed is minimal.
 Postoperative recovery is brief.
 Undesirable effects of general anesthesia are avoided.
It is ideal for short and minor surgical procedures.
 Potential Intraoperative Complications

•Anesthesia Awareness
•Nausea and Vomiting
•Anaphylaxis
•Hypoxia and Other Respiratory Complications
•Hypothermia
•Malignant Hyperthermia
 Anesthesia Awareness

•Refers to a patient becoming conscious of surgical

interventions while under general anesthesia and then recalling
the incident.
•Indications of the occurrence of anesthesia awareness include:
 Increase in the blood pressure
 Rapid heart rate
 Patient movement.
 Nausea and Vomiting

•If vomiting occurs:

• The patient is turned to the side, the head of the
table is lowered, and a basin is provided to collect
the vomitus.
• Suction is used.
• Administers antiemetics preoperatively or
intraoperatively to counteract possible aspiration.
 Anaphylaxis

•An anaphylactic reaction can occur in response to many

medications, latex, or other substances.
•The reaction may be immediate or delayed.
•Nurses should:
Use allergy alert sign
Use allergens free treatments and equipment.
Observe the patient for changes in vital signs and
symptoms of anaphylaxis
 Hypoxia and Other Respiratory Complications

Reasons:
•Inadequate ventilation
•Occlusion of the airway
•Inadvertent intubation of the esophagus
•Hypoxia associated with general anesthesia.
 Hypothermia

Reasons:
•Low temperature in the OR
•Infusion of cold fluids
•Inhalation of cold gases
•Open body wounds or cavities
•Decreased muscle activity
•Advanced age
•The pharmaceutical agents used
 Hypothermia

Management:
•Environmental temperature in the OR can be adjusted.
•IV and irrigating fluids are warmed to 37°C.
•Wet gowns and drapes are removed promptly and
replaced with dry materials
•Warm air blankets and thermal blankets
 Malignant Hyperthermia

•Malignant hyperthermia:
is a rare inherited muscle disorder that is chemically
induced by anesthetic agents. MH occurs because of a
genetic autosomal dominant disorder involving a mutation
on the ryanodine receptor that causes an atypical increase in
release of calcium in muscle cells
 Malignant Hyperthermia
Clinical manifestations
•Cardiac signs: tachycardia, ventricular arrhythmia, hypotension,
decreased cardiac output, oliguria, cardiac arrest.
•Respiratory signs: hypercapnia, an increase in carbon dioxide
(CO2).
•Generalized muscle rigidity and tetanus like movements in the
jaw.
•The rise in temperature is a late sign that develops rapidly
(temperature can increase 1° to 2°c every 5 minutes, and core
body temperature can exceed 42°c.
 Malignant Hyperthermia

Management:
•Reverse metabolic and respiratory acidosis
•Correct arrhythmias
•Decrease body temperature
•Provide oxygen and nutrition to tissues
•Correct electrolyte imbalance.
NURSING PROCESS- The Patient
during Surgery
• NURSING DIAGNOSES:
1. Anxiety associated with surgical or environmental concerns
2. Risk for latex allergy
3. Risk for perioperative positioning injury associated with
positioning in the OR
4. Risk for injury associated with anesthesia and surgical
procedure
5. Risk for compromised dignity associated with general
anesthesia or sedation
Thanks