Intraoperative Nursing Notes

Intraoperative Phase

Notes on intraoperative nursing care, safety measures, and potential complications during surgery.

Objectives

  • Intraoperative Care
  • Safety Measures
  • Complications

Degree of Urgency for Surgery

  • Elective
  • Urgent
  • Emergency

Surgical Care Improvement Project (SCIP)

  • Core Measures:
    • Antibiotics: Proper administration and timing.
    • Foley catheters: Appropriate use and removal.
    • Hair removal: Proper technique to minimize infection risk.
    • Venous thromboembolism (VTE) prophylaxis: Measures to prevent blood clots.
    • Temperature management: Maintaining patient normothermia.
    • Cardiac surgery patients: Controlled post-operative blood glucose levels.

National Patient Safety Goals (NPSGs)

  • Pre-procedure verification process:
    • Verification of relevant documentation.
    • Required blood products, implants, devices, and special equipment must be available.
    • Results of diagnostic studies included.
    • Surgeon must mark the procedure site (with patient involvement).

Surgical Phases

  • Preoperative Phase
  • Intraoperative Phase
  • Postoperative Phase

Patient Flow in the OR Department

Pre-op → Intraoperative → PACU (Post Anesthesia Care Unit) → Post-Op d/c home

Pre-op Review

  • What is pre-op?
  • Who is in pre-op?
  • Why is there pre-op?
  • Informed consent: Legal and ethical issues.

Surgical Risk Factors

  • Advanced age
  • Obesity
  • Malnutrition
  • Dehydration
  • Cardiovascular disorders
  • Respiratory disorders
  • Renal and liver dysfunction
  • Alcoholism
  • Nicotine use
  • Adolescence
  • Medications
  • Diabetes mellitus

Intraoperative Considerations

  • Monitoring the patient:
    • Level of consciousness
    • Hemodynamic status
    • Muscle relaxation
    • Airway assessment
  • Room prepped
  • Complications:
    • Latex allergy
    • Malignant hyperthermia

Safety Considerations

  • Infections/Asepsis
  • Physical trauma
  • Physiological effects of surgery
  • Joint Commission’s National Patient Safety Goals
  • Surgical Time Out

Aseptic Principles

  • Only sterile items on a sterile field.
  • Only sterile persons touch sterile items.
  • “When in doubt, throw it out!”

Surgical Time Out

  • Identify the Patient
  • Identify the Procedure
  • Identify the Body Part

Positioning the Patient

  • Prevent occlusion of arteries and veins
  • Prevent injury
  • Secure extremities
  • Provide adequate padding and support

OR Team Roles

  • Circulating nurse
  • Scrub nurse
  • The surgical technician
  • Anesthesia
  • The surgeon
  • The patient!

The Circulating Nurse Role

  • Unsterile team member
  • Helps gather needed supplies and equipment
  • Counts and documents countable items with scrub nurse
  • Documents intra-op care
  • Patient Advocate/Safety/ Identifies Patient
  • Assists with transfer to OR table and positioning
  • Plans and coordinates intra-op care
  • Surgical “TIME OUT” (joint responsibility)

The Scrub Nurse Role

  • Sterile
  • Counts equipment
  • Passes instruments
  • Guardian of sterile field

The First Assistant Role

  • Another surgeon, PA, or registered nurse first assist

Anesthesia Care Provider

  • Anesthesiologist
  • Nurse Anesthetist (CRNA)
  • Anesthetist Assistant (AA)

The Surgeon

  • Performs the surgery or procedure

The Patient

  • The most important team member; both inside and outside the sterile field.

Types of Anesthesia

  • General
  • Monitored Anesthesia Care (MAC)
  • Moderate Sedation
  • Regional
  • Local

General Anesthesia

  • Administered:
    • Inhalation
    • Intravenous
  • Adjuncts to anesthesia
  • Dissociative anesthesia
  • Advantages:
    • Rapid onset
    • Used for long procedures

General Anesthesia - Phases

  • Preinduction
  • Induction
    • Pt is put to sleep
  • Maintenance
    • Surgery
  • Emergence
    • Reversal agents given
  • Monitor for complications

Disadvantages of General Anesthesia

  • Requires advanced airway
  • Medically complicated patients
  • Elderly patients

Monitored Anesthesia Care (MAC)

  • Similar to general anesthesia
  • Sedative, anxiolytic, analgesic
  • No inhalation gases

Moderate Sedation

  • Combination of opioids and benzodiazepines
  • Patient still conscious, decreased awareness
  • Crash Cart close by
  • (used to be called conscious sedation)

Local Anesthesia

  • Topical: Lidocaine
  • Can also come in nebulizer, injectable (Novocaine) or ophthalmic form
  • Minor procedures

Regional Anesthesia (AKA: Block)

  • Includes spinal blocks and epidurals
  • Implantable pumps

Epidural & Spinal Blocks (are also considered regional blocks)

  • Spinal blocks
    • Local anesthetic injected into the cerebrospinal fluid in the subarachnoid space
  • Epidural blocks
    • Local anesthetic injected into the epidural (extradural) space through a thoracic or lumbar approach.

Post Anesthesia Care Unit (PACU)

  • Review

Post Op Complications

  • Pulmonary
  • Cardiac
  • Renal/GU
  • GI
  • Hypovolemia/Shock
  • Hemorrhage
  • Hypothermia
  • Emergence delirium
  • Wound dehiscence/evisceration
  • Gerontological considerations

Assessments of Complications and Interventions

  • Pulmonary
  • Cardiac
  • Renal/GU
  • GI
  • Hypovolemia/Shock
  • Hemorrhage
  • Hypothermia
  • Emergence delirium
  • Wound dehiscence/evisceration

Retained Surgical Items

  • Retained lap sponge
  • Retracted ureteral stent