intraoperative nursing

Intraoperative Nursing

By:Bryan Mae H. Degorio, BSN, RN

dbryanmae@yahoo.com

Intraoperative Phase- is the time when the person is

transferred to the operating room-anesthesia is administered and the person undergoes the scheduled

surgical procedure.-the emphasis is on the asepsis,

homeostasis and safe administration of anesthesia

The Surgical Team1. Surgeon

-is the head of the surgical team and makes the major decision

- Surgeons have medical degrees, specialized surgical training of up to seven years, and in most cases have passed national board certification exams.

2. Scrub Nurse-participates directly during the

procedure, setting up the operating room and making certain that the environment for surgery is sterile.

-during the surgery, she maintains an accurate count of sponges, sharps ad instruments on the sterile field and

count the same materials together with the circulating nurse.

3. Anesthesiologist/ Nurse Anesthetist- anesthesiologists are physicians

with at least four years of advanced training in anesthesia.

- anesthetists are qualified health care professionals who administer anesthesia.

- their functions include:a. maintain the person airwayb. ensure that the person has an

adequate oxygen and carbon dioxide exchange

c. infuse blood, medications and fluids as necessaryd. alert the surgeon immediately for signs of

complication4. Circulating Nurse

- act as the manager of the operating room

- the functions include:a. check that all equipments are working properly before the

surgery

b. prepares and autoclave instrument for surgery c. alert team members of any break in the sterile techniqued. contacts the x-ray and

pathologic departments if requested by the

surgeone. do skin preparationf. document the specific activity throughout the

operation

g. verify consent and coordinate with the team

Aseptic Technique

1. Sterilize all supplies used for sterile procedures. When in doubt, consider an object unsterile.

2. When putting on sterile gloves, do not touch the outside of bare hands. When wearing sterile gloves, only touch sterile articles. If a glove is punctured, remove the damaged glove, wash hands, and put on a new glove as promptly as patient safety permits.

3. The outer wrappings and edges of packs that contain sterile items are not sterile. They should be opened or handled by the person who is not wearing sterile gloves. Open sterile packages with the edges of the wrapper directed away from your body to avoid touching your uniform or reaching over a sterile field. Touch only the outside of a sterile wrapper. Once a sterile pack has been opened, use it; if it is not used, rewrap and resterilize it.

4. Avoid sneezing, coughing or talking directly over a sterile field or object.

5. Do not reach across or above a sterile field or wound.

6. Avoid spilling solutions on a sterile setup. 7. A sterile field should be away from drafts,

fans, and windows. 8. Store sterile packages in dry areas.

Frequently wash hands using correct technique.

9. Be constantly aware of need for clean surroundings.  

10. Hold sterile objects and gloved hands above waist level or level to the sterile field. Since it can not be sterilized, any object that touches it is considered contaminated. Have a special receptacle or waxed paper or plastic bag to receive contaminated materials.

Surgical Environment:- a surgical suite is designed to

promote safe therapeutic environment for the patient.

1. Traffic control- The in and out of the operating room

is kept to minimum-3 zones:

a. unrestricted area-provide entrance to and exit

from the operating room-people may wear street clothes.-it includes the holding area, lounges, dressing room and offices.

b. semirestricted area-provide access to the restricted zone and peripheral

support areas within the surgical suite

- scrub attire is required with capsc. restricted area

-includes the individual OR’s, scrub areas, sub sterile room, and clean core areas.-in this area, scrub attire, hair covering and masks must be

worn

2. Operating Room Attirea. masksb. headgear

- should cover completely the hair, neckline and beard

c. gownd. gloves

Sedation and Anesthesia:4 Levels

1. Minimal sedation-is a drug induced state during

which the patient can respond normally to verbal command

-cognitive functioning and coordination maybe impaired but ventilatory and cardiovascular functioning is not impaired

2. Moderate sedation-is a form of anesthesia that maybe produced intravenously.-there is a depressed level of consciousness that does not

impaired the patient’s ability to maintain a patent airway and to respond appropriately to physical stimulation

and verbal command

-midazolam and diazepam are the frequently used for

intravenous sedation- the nurse must monitor the client

for dysrhythmias, respiratory and central nervous system depression

- the nurse must be trained to detect dysrhythmia, administering

oxygen and performing rescuscitation.

3. Deep sedation-is a drug induced state that client cannot be easily aroused but can respond purposely after repeated stimulation.-usually achieved when anesthetic agent is inhaled or adm.

intravenously-the commonly use are the volatile liquids and gas anesthetics

Volatile liquids:1. Halothane2. Methoxyflurane3. Enflurane4. Isoflurane5. Sevoflurane6. DesfluraneGases1. Nitrous oxide

4. Anesthesia- is the state of narcosis, analgesia

and relaxation and reflex loss- the client is not arousable even to painful stimuli

Stage Start-Point End-Point Physical Reaction

Nsg. Interventions

I Onset Anesthetic administration

Loss of consciousness

Drowsy or dizzy, possible visual or auditory hallucination

Close operating room doors, keep room quiet, stand by to assist the client

II Excitement

Loss of consciousness

Loss of eyelid reflexes

Increase in autonomic activity and irregular breathing, client may struggle

Remain quiet at client’s side assist anesthesia as needed

Stages of Anesthesia

III surgical anesthesia

Loss of eyelid reflexes

Loss of most reflexes and depression of vital signs

Client is unconscious, muscles are relaxed, no blink or gaga reflex

Begin preparation when the client is breathing well with stable vital signs

IV Danger Functions excessively depressed

Respiratory and circulatory failure

Client is not breathing, heartbeat may or may not be present

If arrest occurs, respond immediately to assist in establishing airways and other procedures

Methods of Anesthesia Administration1. General Anesthesia

-blocks the pain stimulus at the cerebral cortex and induced depression of the CNS that is reversed by either a

metabolic change and elimination from the body and by pharmacologic agent.

-it is best indicated for surgery in the upper turso, head, neck, back and for prolong surgical procedure.

-Administration of General Anesthesiaa. Intravenous anesthesia

-when administered intravenously, the client experience unconscious 30 seconds after the administration.b. Inhalation anesthesia

-a mixture of volatile liquids or gas and oxygen is used.

-there is ease in administration and elimination.-these are usually use to maintain the stage 3 of the anesthesia

following induction which can be administered through a mask or endotracheal tube

2. Regional Anesthesia-Regional anesthesia means numbing only the portion of the body

which will be operated on. Usually an injection of local anesthetic is given in the area of nerves that provide feeling to that part of the

-Types of Regional Anesthesia1. Spinal Anesthesia

-A spinal anesthetic is often used for lower abdominal, pelvic, rectal, or lower extremity surgery. This type of anesthetic involves injecting a single dose of the anesthetic agent directly into the fluid (SUBARACHNOID SPACE) surrounding the spinal cord in the lower back, causing numbness in the lower body

-autonomic fiber is affected first and are the last to recover, (1) touch, (2) pain, (3) motor, (4) pressure, (5)

proprioceptive fiber2. Epidural Anesthesia

-This anesthetic is similar to a spinal anesthetic and also is commonly used

for surgery of the lower limbs and during labor and childbirth. This type of anesthesia involves continually infusing medication through a thin catheter that has been placed into the epidural space of the spinal column in the lower back, causing numbness in the lower body. 

-if the level of block is too high it may lead to depression or paralysis

3. Caudal Block-is produced by injection of local anesthetic into caudal or sacral

canal -commonly use for obstetric clients

4. Topical Anesthesia-anesthetic agent maybe applied

directly on the area to be desensitized. - it can be a solution, ointment, a gel a cream or a powder.

- this short acting anesthetic agent can block the peripheral nerve endings

5. Local Infiltration Anesthesia-involves the injection of anesthetic agent into the skin or

subcutaneous tissue of the area to be anesthetized.

- aspirate before injecting

6. Field Block Anesthesia-involves the injection of anesthetic agent to the area proximal to

the planned incision site.- this block forms the barrier between

the incision and the NS7. Peripheral Nerve Block

- a nerve block anesthetizes individual nerve or nerve plexus rather than all the local nerves.

- Nerve block can be obtained in a finger, entire upper arm or

chest or abdomenComplications and Discomforts of Spinal

Anesthesia 1. Hypotension

-due to paralysis of the vasomotor nerves shortly after the induction of anesthesia.

- Nsg interventionsa. Administer O2b. Vasoactive drugc. Trendelenburg position

2. Nausea and Vomiting- occurs mainly from abdominal

surgery because of the traction place in various structure within the abdomen

- Interventions:a. ephedrene, antiemeticb. oxygen and fluid

3. Headache- cerebrospinal fluid that is lost

through dural hole or leakage of fluid due to use of large spinal needle or poor hydration

- Nursing Interventions:a. Apply tight abdominal binderb. fluids and analgesicc. inject client blood to plug the hole

(10cc)d. flat on bed after the surgery

4. Respiratory Paralysis-occurs when the drug reaches upper thoracic and cervical spinal

level

-Intervention:a. artificial respiration

5. Neurological Complication- maybe due to:

a. unsterile needle, syringes or anesthetic agent

b. per-existing disease of CNSc. transient response to

anestheticsd. position during surgery

-Interventions:a. supportive care for transient formsb. antibiotic and steroid therapyc. rehbilitation for permanent

paralysis