Intraoperative Nursing Care

Intraoperative Care of Nursing Patient

Objectives

• Describe the role of the surgical team

• Explain the importance of sterile technique and infection prevention protocols

• Describe protocols for ensuring patient safety

• Differentiate between general, regional, and local anesthesia

• Recognize signs of anesthesia complications and communicate those to anesthesia

Intraoperative Phase

• Definition: The intraoperative phase is the period where the patient is transferred to the operating room during the procedure and then transported to the PACU (Post Anesthesia Care Unit) area.

Role of the Intraoperative Nurse

• Proactive Care: The intraoperative nurse must care for patients who cannot voice concerns due to anesthesia, hence must anticipate needs and provide safe care.

• Patient Documentation: Review the patient’s electronic health record to ensure all documentation, pre-operative procedures, and orders are complete.

  • Check that the surgical informed consent is signed, dated, and includes a witness's signature.

  • Verify scheduled procedure matches the consent form.

  • Confirm the surgical site is marked (the same one as on the surgical consent).

  • Double-check patient allergies listed in the chart.

  • Obtain accurate recent weight for anesthesia dosing.

• Medical Preparations:

  • Verify all labs have been drawn and resulted.

  • Ensure recent vital signs were taken (within 1-2 hours before surgery).

  • Review special needs or concerns of the patient and family and communicate them to the O team if needed.

  • Confirm all personal belongings and jewelry have been removed; patient in OR gown.

  • Place anti-embolism stockings if ordered.

  • Ensure all ID bracelets are on the patient:

  • ID band

  • Blood bands

  • Allergy bands

  • Restricted extremity bands

  • Medication bands

  • Check dentures, glasses, contacts, hearing aids—remove just before transfer to OR to assist communication.

• Final Checks:

  • Remove any hair pins or accessories to prevent fires or burns.

  • Remove fingernail polish to ensure pulse oximeter reads accurately.

  • Assist patient to empty bladder before medications are given to avoid complications.

Surgical Team Roles

• Anesthesia: CRNA (Certified Registered Nurse Anesthetist) or anesthesiologist manages airway and anesthesia.

• Circulating Nurse: Non-sterile member who gets necessary supplies, assists in surgical counts, monitors patient, updates surgical records, helps position patients, aids anesthesia, and takes verbal orders from the surgeon.

• Scrub Nurse/Surgical Tech: Sterile member, scrubs in with the surgeon, assists with the procedure, sets up and breaks down the case, ensures sterility, and counts supplies to prevent retained objects.

• Surgical First Assistant: Assists surgeon during the procedure, including suturing and manipulation of body parts.

• Surgeon: Performing the operation.

Safety Systems in the Operating Room (O)

• High Stakes Environment: Due to complexity, multiple surgeons may work on a single patient, hence safety systems are crucial.

• Preoperative Checklist: Recommended by the Joint Commission, WHO, and AON to ensure safe patient preparation for surgery.

• Surgical Timeout:

  • A non-negotiable break allowing the surgical team to verify correct patient, procedure, and surgical site.

  • Confirm allergies and medications before incision.

  • Identify risks, including fire, and confirm all needed equipment is present.

  • All team members must be present to voice concerns before proceeding.

• Surgical Count:

  • Ensures no surgical objects (sponges, needles) are retained in the patient.

  • Items counted before and after the procedure.

• Team Approach and Accountability: No single member carries more weight; everyone must be able to speak up about potential issues freely.

Sterile Technique

• Definition: Set of deliberate practices creating and maintaining a microorganism-free environment during invasive procedures to prevent infection.

• Difference with Aseptic Technique:

  • Sterile technique goes further, as it is crucial during surgical incisions where microorganisms must be eliminated entirely.

  • Aseptic technique reduces microorganism spread during non-invasive procedures.

• Creating a Sterile Field:

  • Open supply packages safely (away from self first).

  • Establish a 1-inch margin of sterility around the sterile field.

  • Only sterile items may touch the field; discard anything that may become contaminated.

Anesthesia Overview

• Definition: A medically controlled state reducing or eliminating sensation, pain, and awareness during procedures.

Types of Anesthesia

1. General Anesthesia:

   • Drug-induced state of unconsciousness; loss of awareness, sensation, and protective reflexes.

   • Used for major surgeries requiring complete immobility.

   • Requires airway support.

   • Key features: amnesia, analgesia, muscle relaxation.

2. Regional Anesthesia:

   • Blocks sensation to larger body regions by injecting anesthetic near major nerves or spinal cord.

   • Common forms include:

     • Spinal Anesthesia (orthopedic surgeries, knee replacements)

     • Epidural Anesthesia (C-sections, childbirth)

     • Peripheral Nerve Blocks (hand and arm procedures)

   • Patients may be awake or sedated.

3. Local Anesthesia:

   • Numbs specific areas of the body through direct injection or application.

   • Used for minor procedures like sutures, biopsies; patient is fully awake.

   • Minimal systemic effects.

4. Monitored Anesthetic Care (MAC):

   • Combination of sedation and analgesics while the patient maintains airway and reflexes.

   • Patient is relaxed but not fully unconscious; continuous monitoring by an anesthesia provider.

   • Commonly used in endoscopy and minor surgeries.

5. Conscious Sedation:

   • Reduced awareness; patient is relaxed and able to respond but maintains airway.

   • Used for procedures requiring comfort without deep anesthesia.

   • Knowledge of reversal agents required (e.g., naloxone for opioids).

Stages of Anesthesia

1. Stage One:

   • Analgesia begins; patient is drowsy but conscious; airway reflexes intact.

   • Maintain a calm environment.

2. Stage Two:

   • Excitement stage where consciousness is lost.

   • Irregular respirations and secretions increase; may be agitation and involuntary movements.

   • The goal is to pass through this quickly to avoid self-harm.

3. Stage Three:

   • Surgical anesthesia; regular respirations achieved; airway management established.

   • Monitor and assist with intubation as needed.

4. Stage Four:

   • Medullary depression; severe CNS depression may lead to respiratory failure or cardiovascular collapse; requires immediate resuscitation.

   • Not a desirable stage to reach; objective to remain within stage three.

Patient Positioning

• Importance of planning for positioning as the patient cannot communicate discomfort post-anesthesia.

• Assess range of motion before surgery and accommodate any pre-existing limitations.

• Maintain patient warmth using blankets or bear hugger devices.

• Monitor pressure points to prevent skin injury, especially during long procedures.

• Trendelenburg Position: Head down, feet up; safety straps and padding needed to prevent falls.

Transfer to PACU

• Verify surgical count and accuracy of operative records before transferring.

• Assist with patient emergence from anesthesia and extubation.

• Ensure all necessary equipment for transfer (e.g., oxygen tanks, monitors) is available.

• Upon arrival at PACU, assess airway first, then respiratory status, and lastly circulation (ABCs).

• Report: communicate pertinent information about the patient’s demographics, operative procedure, incision conditions, and dressings.

Conclusion

• The intraoperative phase is critical in ensuring patient safety and effective care in the operating room. The roles of the surgical team, adherence to sterile technique, and safety protocols are paramount to positive surgical outcomes. Questions may be brought to Q&A.