1. Intraoperative Nursing
CH 18

2. Objectives
Describe the intradisciplinary approach to patient care during surgery
Describe the roles of each member of the surgical team
Describe the principles of surgical asepsis
List the adverse effects of anesthesia and surgery
List the surgical risk factors & nursing interventions to reduce them
Compare types of anesthesia
Describe the role of the nurse in patient safety during surgery

3. Surgical Team
Surgeon
First assistant (Physician or RNFA who assists surgeon in performing hemostasis, tissue retraction, and wound closure).
Anesthesiologist
Certified Registered Nurse Anesthetist (CRNA)
Perioperative/operating room nurses:
Scrub nurse (an LP/VN, RN, or surgical technologist who prepares and maintains integrity, safety, and efficiency of the sterile field throughout the operation).
Circulating nurse (an RN) who is in charge of the environment and personnel in the surgical room. She/he may have to give meds, go get extra equipment, etc. She/he documents entry and exit of the patient, start and stop of procedure, and any other documentation required)

4. Surgical Team Surgical specialties
Cardiothoracic/cardiovas cular surgery
General surgery
Neurological surgery/neurosurgery
Obstetrics and gynecological surgery
Ophthalmology

5. Surgical Team Surgical specialties Oral and maxillofacial surgery
Orthopaedic surgery
Otolaryngology
Plastic and reconstructive surgery
Urological/genitourinary surgery

6. Intraoperative Nursing Care Outcomes
Nurses are responsible for managing six areas
of risk:
Risk of infection related to invasive procedure and exposure to pathogens.
Risk for injury related to positioning during surgery.
Risk of injury related to foreign objects inadvertently left in the wound.
Risk for injury related to chemical, physical, and electrical hazards.
Risk for impaired tissue integrity.
Risk for alteration in fluid and electrolyte balance related to abnormal blood loss and NPO status.

7. Nursing Sensitive Outcomes
AORN has established the Perioperative Nursing Data Set (PNDS)
Specific terminology used to describe interventions provided by perioperative nurses
Valid, reliable, and useful for clinical practice

8. PNDS
The Perioperative Nursing Data Set (PNDS) is the first of its kind: a standardized nursing vocabulary that addresses the perioperative patient experience from pre-admission until discharge. As a nursing language, PNDS is validated, reliable, and useful for clinical practice.
Recognized by the American Nurses Association, the PNDS can serve many purposes:
Providing a framework to standardize documentation
Providing a universal language for perioperative nursing practice and education
Assisting in the measurement and evaluation of patient care outcomes
Providing a foundation for perioperative nursing research and evaluation of patient outcomes 
Informing decisions about the relationship of staffing to patient outcomes 
Providing data about the contributions of nurses to patient outcomes in the perioperative arena

9. When the surgical patient is a child
Age-specific care means tailoring interventions to the developmental stage
Physical care of children is different. Institutions providing pediatric surgery have personnel trained in pediatric airway management, medication weight/dosage calculation, cardiovascular physiology, pain management, psychosocial differences
Preop teaching should include tour of hospital
Children are encouraged to bring stuffed animal/doll. Nurses demonstrate procedures on doll
Parents stay with children as much as possible, even walking them to OR
Pain management should begin in preop, w/ pain assessment discussion (faces scale)

10. When the surgical patient is elderly
Multiple comorbid conditions may limit functional capacity
The most common complications are cardiovascular, alterations in diabetes status, decreased pulmonary volumes
Higher % of DVT/ pulmonary embolism. Interventions need to be aggressive for thrombosis prophylaxis
Early ambulation, leg compression devices, leg exercises
Pulmonary disease accounts for 40% of elderly postop complications and 20% of deaths
Interventions to decrease complications: antibiotics, bronchodilators, postural drainage, chest physiotherapy.

11. The surgical environment
Lights, temperature and humidity are controlled
Traffic control’s goal is to minimize the influx of microorganisms
Sterile supplies are separated from “contaminated” supplies
Restricted vs. unrestricted areas

12. Surgical environment
Humidity: Staph Aureus thrives in humidity above 65% and below 35%. Most OR’s maintain 50%
Laminar airflow systems filter circulating airflow in parallel-flowing planes
Positive pressure airflows at doorways and corridors prevent “unclean” air from entering surgical suite
Ventilation parameters have been established, usually 15 air changes of filtered air/hr., 3 of these fresh air.
Best temperature for adult surgical patients is degrees

13. Standard precautions Handwashing (duh!)
Surgical scrubs only in restricted areas, all personnel
PPE—gloves, protective facewear, eyewear, gowns, caps, gloves, shoe covers, boots—during procedures
Gloves don’t take the place of handwashing
Masks should be changed b/t patients
Specimens must be handled with gloves, labeled, and go in biohazard bags
Prion diseases can be caused by instruments infected with these highly resistant protein-containing infectious agents. Thus instruments used in high-risk tissue—brain, spinal cord, eye, is mostly disposable

14. Basic Guidelines for Surgical Asepsis
All materials in contact with the wound and within the sterile field must be sterile.
Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above the elbow to the cuff.
Only the top of a draped table is considered sterile. During draping, the drape is held well above the area and is placed from front to back.
Items are dispensed by methods to preserve sterility.
Movements of the surgical team are from sterile to sterile and from unsterile to sterile only.

15. Basic Guidelines for Surgical Asepsis
Movement around the sterile field must not cause contamination of the field. At least a 1-foot distance from the sterile field must be maintained.
Whenever a sterile barrier is breached, the area is considered contaminated.
Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered unsterile.
Sterile fields are prepared as close as possible to time of use.

16. Surgical Asepsis The absence of pathogenic microorganisms.
Sterilization kills all microorganisms and spores
Disinfection kills only the microorganisms
Sanitization removes organic debris for disinfection
Microorganisms cannot penetrate DRY cotton fabric, nonwoven or plastic wrappers
Microorganisms are transmitted by direct contact, droplet, fluids or capillary (wicking) action
If something is wet, it is considered contaminated. The patient drapes, the covers of the surgical tables, all have water-resistant backing to prevent wicking action from the nonsterile to the sterile surfaces.

17. Sterilization methods
High pressure or temperature steam sterilization per autoclave
Dry heat requires higher temperatures
Gas sterilization with ethylene oxide per gas sterilizer
Cold chemical sterilization
Though many items are available for purchase in one-time-use sterilized packs, some must be done in-house. Most units have a “flash” sterilizer that can be used by staff. AORN has set forth guidelines for their use. But most in-house sterilization is done in Central Processing, where equipment is strictly monitored for safety and effectiveness.

19. Cold sterilization

20. Surgical garb
Surgery personnel wear scrubs obtained in surgery dressing room. Shoes are not to be worn anywhere except at work
Surgical gown, gloves, hat, shoe covers, face splash guard required new for each case

21. Surgical scrub
Hands—sterile personnel begin by doing a 3 minute surgical scrub with a brush and appropriate soap. This is repeated between cases
The patient’s incision site is scrubbed by the circulating nurse prior to draping. This reduces the # of microorganisms on the skin prior to incision. Scrub technique goes from the center out, sometimes a circular motion is used.
Shave preps are no longer routine.

22. Non-Sterile Members of the Surgical Team
Anesthesia provider.
Circulating nurse (an RN responsible for management of personnel, equipment, supplies, environment, and communication throughout a surgical procedure).
The nonsterile team is responsible for patient positioning.
All limbs must be in anatomical position.
Limbs must be supported at the joints during movement and positioning
See page 437 for various positions used and positioning guidelines

23. Goals of patient positioning
Prevent occlusion of arteries and veins
Provide modesty in exposure
Recognize and respect needs such as pain or deformities
Prevent injury
Patient will not feel pain impulses due to anesthesia
Secure extremities
Provide adequate padding and support

24. Laparotomy Position, Trendelenburg Position, Lithotomy
Position, and Sidelying Position for Kidney Surgery

25. Other duties of the Nonsterile Team
Preparing surgical site
Scrubbing or cleaning around the surgical site with antimicrobial agents
Circular motion from clean to dirty area
Hair may be removed with clippers
A Foley may be inserted after a spinal block (OB)

26. Sterile members of the team
Surgeon
Assistant(s)
Scrub nurse
The sterile team does a surgical scrub, enters the OR room, and the scrub nurse hands them towels, gown, then gloves.
The nonsterile team carefully ties the gowns of the sterile team

27. Sterile Field
The area surrounding the client and the surgical site that is free from all microorganisms. It is defined by surgical drapes.
The sterile field is above the waist, and in front of the body. Everything behind you and below the waist is considered not sterile. Never turn your back on the sterile field.
Think about how you would add a pair of gloves to the sterile field. An instrument? How about if the scrub nurse needs a syringe and a vial of local anesthetic?

28. Sterile Conscience
The practice of aseptic technique requires the development of sterile conscience, an individual’s personal honesty and integrity with regard to adherence to the principles of aseptic technique.

29. General surgical principles
The skin is cut with a knife (scalpel)
The knife is discarded, as the skin is contaminated. The surgeon puts it in a basin the scrub nurse holds. She places it on the edge of her table out of the way.
Subsequent layers are separated with scissors and hemostats.
How many layers are there to get through to enter the abdominal cavity?

30. Wound Closure
Closure is accomplished with suture, layer by layer. Some layers may be stapled. Sometimes mesh is put into a layer for stability.

31. Used to strengthen deep tissues. Sewn in for permanent support.
Surgical mesh
Used to strengthen deep
tissues. Sewn in for
permanent support.

33. Patient safety Laser Surgical fire Latex Cardiac arrest DNR orders
Health Hazards
Patient safety
Laser
Surgical fire
Latex
Cardiac arrest
DNR orders

34. Anesthesia & Analgesia
Essential to healthcare delivery today.
Anesthesia – absence of normal sensation
Analgesia – pain relief without anesthesia

35. Anesthesia and Sedation
Types of anesthesia
Local
Regional
Spinal
Epidural
Nerve blocks
General

36. Preanesthetic Preparation
Avoidance of foods and drink prevents passive regurgitation of gastric contents
Preop administration of antacid and/or anticholinergics
Clients should typically continue medications up to surgery
Consent must be received

37. Sedation
Reduction of stress, excitement, or irritability and some suppression of CNS
Typically used to relieve anxiety and discomfort during a procedure
Different levels of sedation accomplish different goals
Minimalanxiolysis
Moderate procedural sedation conscious sedation
Deep not easily aroused, may need help maintaining a patent airway at this level.
Residual effects include amnesia and lethargy

38. Local anesthesia
Numbing of a small region using a “caine” derivative drug
Table 18-3—be familiar with the names and some general characteristics of regional and local anesthetic agents
Usually short acting, the medication blocks afferent nerve impulses in the injected tissue
The patient remains awake and alert

39. Conscious sedation (Moderate)
IV sedation for procedures like nerve blocks, colonoscopies, endoscopies, dental procedures
The patient is drowsy, but awake. They have a certain amount of amnesia when the medication wears off, depending on medication used
Meds used include benzodiazepines like Valium, Ativan, Versed. Also used are the opiates, Morphine, Demerol, Sublimaze. A typical combination is Versed and Propofol.
Must be administered by anesthesia personnel with resuscitation equipment available
The goal is that the patient remains “conscious”, can respond to verbal commands.
The nurse helps assess adequate respiratory effort, monitors VS

40. A region of the body is rendered insensible to pain.
Regional Anesthesia
A region of the body is rendered insensible to pain.
Femoral nerve block for ACL
reconstruction
Epidural block for C/Section

41. Types of Regional Anesthesia
Local
Nerve blocks
Spinal & Epidural blocks

42. Regional analgesia/anesthesia involving the spinal cord
Spinal cord ends at L1-L2
Spinal nerves exit the cord at regular intervals; each nerve supplies a specific dermatome
The meninges are 3 layers of CT coverings, beneath and above which are potential spaces

44. Structures Covering the Spinal Cord
Vertebrae
Epidural space filled with fat
Dura mater
Outer covering
Subdural space filled with interstitial fluid
Arachnoid = middle layer, spider web of collagen fibers
Subarachnoid space = CSF
Pia mater
thin layer covers blood vessels
Epidural block= anesthetic injected in epidural space, causes mostly sensory blockade
Spinal block=anesthetic injected in subarachnoid space, causes motor and sensory blockade

45. Spinal anesthesia Local anesthetic injected into CSF
Blocks both afferent and efferent impulses
Usually hyperbaric, moderately long-acting local anesthetic solution like bupivacaine is used
Limited to procedures below the upper abdomen
Risks: bleeding, hypotension, reaction to the medication, spinal H/A, injury, paralysis (rare)
Spinal H/A is always a risk when the dura is punctured. If too much fluid leaks out, an air bubble in the CSF rises to the brain when sitting/standing, causing severe H/A. The cure is fluid replacement and blood patch

46. Position for Epidural Block
Epidurals are most commonly used in OB
They provide a sensory block and very little motor block, so patients can push with contractions
Some motor blockade may occur, so ambulation usually contraindicated, and urination can be difficult.
Epidurals do not enter the spinal cord, so spinal H/A is (usually) avoided
Since labor may last a long time, they are frequently administered by drip or intermittent push
The biggest complication is hypotension, which affects fetal well-being. Other complications can include infection, bleeding, cord injury/paralysis

47. General Anesthesia
Involves unconsciousness and complete insensibility to pain
There are four stages of General Anesthesia:
Induction
Maintenance
Emergence
Recovery

48. Induction & Airway Management
Shortest stage of anesthesia but critical
Immediately after induction, the airway must be secured using a cuffed Endotracheal tube (ET)
The patient’s respirations are stopped due to paralysis of the diaphragm from the skeletal muscle relaxants used (Anectine)
PPV is established through the ET tube
Elimination of somatic, autonomic, and endocrine responses
(i.e., cough, vomiting, and sympathetic nervous system [SNS] response)

49. Cricoid pressure
Preparation for intubation may include giving cricoid pressure to facilitate tube placement by anesthesia personnel

51. Maintenance
General Anesthesia is maintained with a combination of IV and inhaled drugs
Inhaled drugs include halothane, ethrane, isoflourane, desflourane, nitrous oxide—some are highly flammable
IV drugs include ketamine, thiopental (pentathol—a barbiturate) opiods like fentanyl, propofol (diprivan, a nonbarbiturate hypnotic)
IV neuromuscular blocking agents facilitate intubation, surgical incisions. Mechanical ventilation used to maintain respirations until these wear off.

52. Emergence Client’s awareness returns as drug wears off
Emergence must be carefully controlled and monitored
The ET tube is removed when the patient is responsive
When they start to gag
When the tube is pulled, they may still drift back to a non-reflexive state for awhile and anesthesia personnel will place an oral airway, which the PACU nurses can remove when patient is more responsive
Emergence

53. Recovery
Recovery may be an extended process with memory and other aspects affected for a long period
Many anesthetics are absorbed into body fat and released slowly into the system, and excreted by the kidneys

54. More stages of anesthesia
Stage I—beginning anesthesia
Stage II—excitement
Stage III—surgical anesthesia
Stage IV—medullary depression
These are stages of depth of CNS depression. With today’s combinations of anesthetic drugs, some of these stages are skipped and there is a more controlled progression to the desirable level of anesthesia

55. General anesthesia
Procedure: IV induction and intubation, then anesthesia maintained by inhalation anesthetics
IV induction agents
Induce pleasant sleep
Rapid onset
Inhalation agents
Enter body through alveoli
Rapid excretion by ventilation
Meds involved in “balanced anesthesia”: Preoperatively a hypnotic like Ambien, and Versed in the room for amnesic effect. Pentothol (thiopental) and Anectine (succinylcholine) for placement of ET tube (short acting barbiturate and muscle relaxant, respectively). Anticholinergic (Atropine) for decreasing secretions. Fluothane, Ethrane, Penthrane for inhalation. These gases are flammable.

56. General anesthesia Side effects:
Respiratory depression
Hypotension
Dysrhythmias
Hepatic dysfunction
Nursing interventions as patient emerges from anesthesia
Monitor ABC’s (particularly A)
Monitor LOC VS
Urine output

57. Complications from General Anesthesia
ASPIRATION
LARYNGOSPASM & BRONCHOSPASM
RESPIRATORY OBSTRUCTION
HYPOXIA/HYPERCARBIA
PNEUMOTHORAX
AIR EMBOLISM
INTERCOSTAL MUSCLE SPASM (RIGID CHEST)
CONVULSIONS
INJURIES
HYPOVOLEMIA (DEHYDRATION)
HYPERVOLEMIA (EDEMA)
ARTERIAL HYPOTENSION
CIRCULATORY SHOCK

58. MALIGNANT HYPERTHERMIA
A rare, life threatening condition caused by anesthetics, causing a drastic, uncontrolled increase in skeletal muscle oxidative metabolism which overwhelms the body’s capacity for gas exchange and temperature maintenancecirculatory collapse.
Inherited, autosomal dominant disease
occurs more frequently in children
Manifested by increased muscle rigidity, heart rate and temperature, falling BP, P, metabolic acidosis
Occurs in first 20 minutes or can be 24 hrs.
Treatment is stop anesthesia, administer Dantrolene and bicarb, PPV100% O2. There is usually a treatment protocol or a malignant hyperthermia cart

59. Intraoperative Complications
Retained objects
Can you say “lawsuit?”
Hypothermia
Consequences
Managing patient’s temperature
Intraoperative fluid management
Safety in positioning and transporting
Wrong site surgery (eek! Is your malpractice insurance paid up?)

60. Complications N/V and aspiration Allergic reactions/anaphylaxis
Suction, turn head to side
Anesthesia may administer antiemetics
Allergic reactions/anaphylaxis
Antigen-antibody reaction
In response to exposure to a foreign substance
Can be many things—latex, anesthetic agents
Sx—acute onset, immediate respiratory and cardiac compromise hypotension, cardiac arrest, bronchospasm.
Tx—epinephrine, IV corticosteroids, symptomatic support

61. Perioperative Nurse Role
Comprehensive knowledge
Anesthesia
Post anesthesia care
Circulating or scrub roles
RNFA
Skills competency
Aseptic technique

62. Perioperative Nurse Role
Individualized nursing care plans
Advanced knowledge of anatomy and physiology
Legal and ethical issues
Participatory team member
Stay current via discussions and publications

63. Nursing Goals for the Patient in the Intraoperative Period
Reducing anxiety
Preventing positioning injuries
Maintaining patient safety
Patient identification
Correct informed consent
Verification of records of health history and exam
Results of diagnostic tests
Allergies (include latex allergy)
Monitoring and modifying the physical environment
Safety measures such as grounding of equipment, restraints, and not leaving a sedated patient
Maintaining the patient's dignity
Avoiding complications