Intraoperative Nursing

Introduction

 Today’s class:
– The OR environment
– Safety in the OR
– Nursing measures
– Medications & effect on patients
Intraoperative Phase

 Major nursing goal: help the patient

make it through surgery without injury
 A team effort
Surgical Team
MEMBERS OF THE SURGICAL
TEAM:
 Patient
 Holding Area Nurse
 Circulating nurse
 Scrub role
 Surgeon
 Registered nurse first assistant
 Anesthesiologist, anesthetist
Patient
Holding Area Nurses

 Patient waits here until OR

 Greet patient
 Review medical record/pre-op check-
list
 Verify consent forms are signed
 Document risk assessment
 Assesses physical/emotional status
 Gives emotional support
 Answers questions
 Provides extra education PRN
Marking Patient prior to surgery
Circulating Nurse

 RN
 Manager of that OR suite
 Sets up the room – supplies, blood
products, etc.
 Gathers and inspects all equipment
 Prepares the OR bed
 Meets, greets, identifies patient
 Transfers Pt to OR bed, positions
 Monitors aseptic technique and watches
for breaks
 Greets patient, assists with positioning
 Coordinates xray, lab
 Assists anesthesiologist as he/she
induces patient
 Assists with documentation including:
– Count of all sponges, sharps, and
instruments
 Notifies PACU of arrival time and any
special needs
Scrub Role

 RN,LPN, OR technician, Certified

Surgical Technologist (CST)
 Sets up sterile field
 Drapes patient
 Hands sterile instruments, sponges,
sutures, etc., to surgeon
 Aids in gowning and gloving
 Assists with sponge, needle, and
instrument counts
 Observes team for breaks in aseptic
technique
 This role also done by:
– Operating room technicians (ORT’s)
– Certified Surgical technologists (CST’s)
Surgeon and Surgical Assistants

 Surgeon
– Heads the surgical
team
– Makes major
decisions
– Performs surgery
 Surgical assistants
– intern, resident, med student, another MD,
PA, CRNFA, or surgical technologist
– Help expose operative site
» Hold retractors
» Suction wound
» Cut tissue
» Suture
» Dress wounds
RN First Assistant

 Assist surgeon
Anesthesia Providers

 Anesthesiologist:
– MD who specializes in giving anesthetic
agents
 Certified Registered Nurse Anesthetist
CRNA:
– RN who has graduated from accredited
nurse anesthesia program
– Supervised by anesthesiologist, surgeon,
dentist, or podiatrist
 Duties:
– Administers anesthesia
– Evaluates patient pre-operatively
– Keeps patient alive during surgery!
– Alerts surgeon to any problems
– Monitors VS, I & O, cardiopulmonary
function
OR Nursing Staff
PHYSICAL ENVIRONMENT

 Pre-op Holding
Area
– Pt waits in here until
surgery
– IV started,
assessment
– In some hospitals,
family can stay with
pt until time to go to
OR
 Operating Room
– Environmentally controlled
– Temperature 68 - 75 degrees
– Restrict # of people
– Wear special clothes, booties, cap, etc.
– Room cleaned inbetween cases with
detergent germicide
Operating Room
Minimally Invasive and Robotic
Surgery
Health Hazards Associated with
the Surgical Environment
 Exposure to blood/body fluids
 Lazer risk
 Exposure to latex, radiation, toxic
agents
 Potential for Infection
Prevention of Infection

 Surgical environment
– Unrestricted zone
– Semirestricted zone
– Restricted zone
 Surgical asepsis
 Environmental controls
Surgical Asepsis
Surgical Scrub, Gowning, and
Gloving
Nursing Management in the
Operating Room
 Provide emotional care
– Greet patient at door; help patient to feel
safe and secure
– If awake during surgery -> support,
explain and reassure patient
– During initial stage of anesthesia, stand at
bedside, touch shoulder, hold hand, etc.
Provide Safety

 surgical asepsis
 send correct speciman
 correct sponge count
Assist with Surgical Positions
Prevent Perioperative
Positioning Injury
Interventions include:
 Proper body position
 Pad bed with foam or silicone gel pads
 Properly place grounding pad
 Prevent obstruction of:
– circulation,
– respiration, and
– nerve conduction
 Good access to surgical site
Prevent infection of wound

 Assess patient for risk

 Do skin prep
 Maintain sterile technique
 Use of Plastic adhesive drapes
 Skin closures, sutures and staples,
nonabsorbable sutures
Common Skin Closures
 Insertion of drains
 Application of dressing
Prevent Hypoventilation

 Continuous monitoring (every 5

minutes) of:
– Breathing
– Circulation
– Cardiac rhythms
– Blood pressure and heart rate
 Continuous presence of an anesthesia
provider
 Prevent client heat loss
– apply warming blanket after surgery
 Transfer patient from the operating
room table to a stretcher
ADMINISTRATION OF
ANESTHETICS
Anesthetics

 Agents that depress the central nervous

system (CNS)
– Depress consciousness
– Lose ability to respond to sensory
stimulation (including pain)
– Muscle relaxation
Classifications

 General anesthesia
 Local anesthesia
GENERAL ANESTHESIA

 Administering a combination of several

different drugs to achieve the following
goals:
– Analgesia (loss of pain perception)
– Unconsciousness
– Amnesia
– Block the body’s reflexes
 Ideal result:
– Best effects with the fewest adverse effects.
Four Stages of General
Anesthesia
 Stage 1—analgesia stage
– No pain but still awake
 Stage 2—excitement stage
– Excitement, often combative
– Many signs of sympathetic stimulation
(tachycardia, ↑ RR, BP changes)
 Stage 3—surgical anesthesia stage
– Skeletal muscles relax, RR becomes
regular, progressive loss of eye reflexes,
pupils dilate
– Can do surgery in this stage
 Stage 4—medullary paralysis
– Danger! CNS depression; patient can die
Also 3 phases:

 Induction – from beginning of

anesthesia to Stage 3
 Maintenance – stage 3  completion
 Recovery – DC of anesthesia until
patient has awakened and
communicated
Administration of General
Anesthesia
 Inhalation
 IV injection
 Balanced anesthesia
– Combination of IV drugs and inhalation
agents used to obtain specific effects
 One Example:
– thiopental for induction,
– nitrous oxide for amnesia,
– morphine for analgesia, and
– pancuronium for muscle relaxation
 Adjuncts to general anesthetic agents:
– hypnotics, opioid analgesics,
neuromuscular blocking agents
Handout
Inhalation Agents

 Volatile liquids or gases that are:

– Vaporized in oxygen
– Inhaled to induce anesthesia
 Advantages:
– Easy to administer
– Can rapidly excrete by ventilation
 Disadvantage:
– May irritate lungs, cause coughing
Inhalation Agents - volatile
liquids
Inhaled Gases (“carrier” gases)

 Nitrous Oxide - “laughing gas”

– most widely used
– used to deliver inhalation agent to patient’s
lungs
– Helps to increase effectiveness of volatile
liquids so less is needed
Intravenous Anesthetics
Sedative-hypnotics

 Barbiturates
 Benzodiazepines
Barbiturates

 Two most frequently used barbiturates

used:
– thiopental (Pentothal)
– methohexital (Brevital)
 How barbiturates work:
– Increase cell’s affinity for GABA, a
neurotrnsmitter that brings us peace and
tranquility
GABA quiets cell firing.

GABA

Neuron
Benzodiazepines

 Most commonly used:

– Midazolam (Versed)
– diazepam (Valium)
 cause amnesia
 decrease anxiety
Neuromuscular Blocking Agents
(NMBA)
 Block transmission of nerve impulses - create
muscle relaxation
 Used to maintain controlled ventilation
during surgery
 Succinylcholine
– Paralyzes quickly, is gone quickly (four - eight
minutes)
– For ET intubation
– Causes complete respiratory paralysis
– Does not cause sedation, does not relieve pain!
Antiemetics

 Prevent and treat nausea and vomiting

(most common side effect of anesthesia)
 Examples:
– droperidol (Inapsine)
– metoclopramide (Reglan)
GENERAL MECHANISM OF
ACTION OF INHALED & IV
ANESTHETICS
 Easily cross blood-brain barrier
 Concentrate in nerve cell membranes
 Overall effect: orderly and systematic
reduction of sensory & motor CNS
functions
 Therapeutic doses: minimal depression
of vital functions
 Overdose: death due to circulatory &
respiratory failure
Side Effects & Adverse Effects

 Not as many as in the past

 Dose dependant
 Vary with each drug
Most common side effects

 Myocardial depression
 Respiratory depression
Complications from General
Anesthesia
 Malignant hyperthermia
 Overdose
 Unrecognized hypoventilation
 Complications of specific anesthetic
agents
 Complications of intubation
Malignant Hyperthermia

 Cause:
– inherited defect of skeletal muscle;
stimulated by muscle relaxants or
anesthetic agent.
– Calcium (inside the cells) increases causing
increased metabolic rate
 Signs and symptoms:
– Tachycardia (150)
– increased temperature (105)
– muscle rigidity
– end stage is cardiac arrhythmias, vascular
collapse, death
 Mortality rate: 50%
 Treatment
– First - STOP the anesthetic agents and give
100% oxygen
– Give Dantrolene IV (to block release of
calcium)
– Cool the body slowly - ice packs, chilled IV
or irrigation fluids, cold sponge bath
– Foley
 – IV drugs - Na Bicarb
– Monitor and treat arrhythmias (Lidocaine)
 May occur 10-20 minutes after
induction, or up to 48 hours after OR.
May recur up to 3 days after the first
episode.
 Important to get good history prior to
OR
Local Anesthesia

 Briefly disrupts sensory nerve impulse

transmission from a specific body area
or region
 Delivered topically and by local
infiltration
 Patient remains conscious and able to
follow instructions
Regional Anesthesia

 Type of local anesthesia

 Blocks multiple peripheral nerves in a
specific body region
– Field block
– Nerve block
– Spinal block
– Epidural block
Nerve Block Sites
Spinal and Epidural Anesthesia
Complications of Local or
Regional Anesthesia
 Anaphylaxis
 Incorrect delivery technique
 Systemic absorption
 Overdose
 Local complications
Treatment of Complications

 Establish open airway.

 Give oxygen.
 Notify the surgeon.
 Fast-acting barbiturate is usual
treatment.
 Epinephrine for unexplained
bradycardia.
Gerontologic Considerations

 Elderly patients at increased risk for

complications of surgery, anesthesia
due to:
– Multiple health issues
– Aging heart, lungs
– Decreased homeostatic mechanisms
– Changes in responses to drugs due to
aging changes (decreased renal function)
– Changes in body composition of fat, water
Nursing Interventions for the
Patient in the Intraoperative
Period
 Reduce anxiety
 Reduce latex exposure
 Prevent intraoperative positioning
injuries
 Protect patient from injury
 Serve as patient advocate
 Monitor, manage potential
complications
 Protect the Patient from Injury

 Patient identification
 Correct informed consent
 Verification of records of health history,
exam
 Results of diagnostic tests
 Allergies (include latex allergy)
 Monitor, modify physical environment
 Safety measures (grounding of
equipment, restraints, not leaving a
sedated patient)
 Verification, accessibility of blood