Perioperative Nursing: Intraoperative Nursing Care
INTRAOPERATIVE PHASE
Definition
The intraoperative phase extends from the time the patient is admitted to the operating room (OR) to the administration of anaesthesia, performance of the surgical procedure, and until the patient is transported to the recovery room or post-anaesthesia care unit (PACU).
PURPOSE OF INTRAOPERATIVE CARE
To maintain patient safety and comfort during the surgical procedure.
To maintain homeostasis throughout the procedure.
To maintain strict sterile techniques and minimize the risk of infection.
To ensure that the patient is secure on the operating table.
To prevent injury from surgical positioning.
SURGERY SITES
Common surgery sites include:
Radiology centres
Emergency rooms
Operating rooms in hospitals
Cardiac catheterisation laboratories
Ambulatory or outpatient surgical centres
Specialized units for endoscopy procedures
LAYOUT OF OPERATING THEATRE
Holding Bay:
Place for pre-operative patient admission procedures, final checks, monitoring, and for families to have their first direct contact with perioperative staff. The area helps calm patients, confirm documentation, and ensures patients are ready for their procedure.
Anaesthesia Bay
Operation Room
Post Anaesthesia Care Unit
SURGICAL TEAM MEMBERS
Team Member Roles:
Surgeon:
Performs the procedure/surgery.
Surgical (first) assistant:
Assists the surgeon; can be another surgeon or a Registered Nurse (RN) trained in OR.
Anaesthesiologist/Anaesthetist and nurse anaesthetist:
Deliver anaesthesia, place the patient in proper position on the operating table, and monitor the patient's condition during surgery.
Scrub nurse:
Scrubs for surgery and performs sterile technique procedures in OR; handles sterile surgical supplies and instruments, hands sterile instruments to the surgeon.
Circulating nurse:
Verifies consent; coordinates the team; ensures cleanliness and proper OR temperature and humidity; adjusts lighting; assesses the function of equipment and availability of supplies and materials; monitors that aseptic practices are maintained; documents patient care in the OR.
Surgical (second) assistant/technician:
Manages the OR tasks.
NON-STERILE TEAM MEMBERS
Anaesthetist and nurse anaesthetist
Circulating nurse
Radiography personnel
STERILE TEAM MEMBERS
Surgeon
First assistant
Scrub nurse
ACTIVITIES IN HOLDING BAY
Review the patient’s chart: Verify patient’s name, age, allergies, surgeon, written consents, surgical procedure, surgical site, investigation results, past medical and surgical history.
Answer patient’s questions; alleviate anxiety.
Introduce the patient to the anaesthetist and the nurse anaesthetist, who also verify patient information and explain the type of anaesthesia to be used.
Establish intravenous (IV) fluids; monitor vital signs and document.
Inform the patient what to expect in the OR as the patient enters the OR.
SURGICAL ENVIRONMENT
Health of the Staff
Essential criteria:
Fingernails must be short.
Wearing artificial fingernails is discouraged as they harbour microorganisms.
Any team member with infectious disease, upper respiratory tract infection (URTI), or infected skin lesions should not have direct patient care contact and should not work in the OR until the infectious process resolves.
Operating Room Attire
Headgear:
Must completely cover hair.
Shoes:
Comfortable and supportive, covered with disposable shoe covers, worn only once and removed upon leaving the restricted area.
Shoes dedicated to OR should be removed before leaving to avoid tracking blood and debris.
Jewellery and wristwatch:
Should be removed before entering semi-restricted and restricted zones.
Scrub suits:
Clean, fresh attire must be donned each time on arrival in OR.
Should not be worn outside the OR. Wet or soiled attire should be changed.
Knitted cuffs:
Prevent microorganism shedding from perineum, legs, and arms into immediate surroundings.
Mask:
Must be tight-fitting, covering nose and mouth completely; should not hang around neck; change if damp; replace between patients.
Sterility of Equipment and Surfaces
All surgical materials that may come in contact with surgical wound and exposed tissues must be sterilised before use.
Instruments are cleaned and sterilised; only sterile equipment, linens, drapes, and solutions are used.
Individual wrapping for sterile items is preferable.
Standard OR ventilation provides air exchange/hour; laminar air flow units = air exchange/hour.
Procedures for Sterility
Personnel must scrub hands and arms with soap and water and don long sleeve sterile gowns and gloves, don cap, and mask.
Personnel who are scrubbed and gowned can only touch sterilised objects while non-scrubbed personnel refrain from touching anything that is sterile.
Skin areas must be meticulously cleansed and antiseptic agents applied; remainder covered with sterile drapes.
Cleanliness of the Room
Zones of the Surgical Area:
Unrestricted zone → Street clothes and scrub suit
Semi-restricted zone → Scrub suit, OR shoes, and headgear
Restricted zone → Scrub suit, shoe covers, headgear, and mask
Cleanliness in OR is absolutely necessary as postoperative wound infections have been traced to the OR.
Each surgical case is treated as potentially contaminated.
Cleaning Routines
Must be practiced clearly and adhered to at:
Beginning of each day
Between operations
Completion of the day’s operations
Types of Cleaning in OR:
Preliminary cleaning: Initial cleaning and disinfecting before each patient enters OR.
End of procedure/cleaning between cases: Cleaning and disinfecting done after each case to prevent the spread of germs.
Terminal cleaning: Performed at the end of the day.
Procedure for Cleaning and Disinfecting
Cleaning should be done from top to bottom, from the periphery to the center (since the center is where most patient care happens).
Cleanliness of all fixtures, equipment, furniture, and scrub sinks is mandatory.
Damp-dusting with antiseptic germicidal solution; the floor damp-mopped or wet-vacuumed.
Maintenance of Cleanliness
All used surgical drapes and gowns must be bagged and removed.
All trash/disposable items must be bagged.
All surgical instruments must be rinsed and washed with gloved hands before being sent for sterilisation.
ASEPSIS AND STERILITY
Definitions
Asepsis: Absence of microorganisms that cause disease; not the same as sterile.
Contaminated: Soiled or infected by microorganisms.
Sterile: Free from living microorganisms, including all spores.
Unsterile: Inanimate objects that have not been subjected to a sterilisation process.
Aseptic Technique
Asepsis = “Without dirt” and implies the absense of pathogenic microoganism that cause infection
A method whereby microbial contamination is inhibited
Practiced to prevent the transfer of microorganisms onto items that need to remain sterile.
Aims to minimize contamination from pathogens.
Sterile Technique
A set of specific practices to make equipment and areas free from all microorganisms and maintain sterility.
Involves strategies to reduce exposure to microorganisms.
Foundation of modern surgery; all surgical team members must wear sterile attire within a sterile field to establish a bacterial barrier.
Principles of Sterile Technique in OR
Only sterile items are used within the sterile field.
Sterile personnel are gowned and gloved.
The table is sterile only at table level.
Sterile personnel touch only sterile items/areas; unsterile personnel touch only unsterile items/areas.
Unsterile personnel avoid reaching over the sterile field; sterile personnel avoid leaning over unsterile areas.
Edges of anything enclosing sterile contents are considered unsterile.
Sterile field is created as close as possible to the time of use.
Sterile areas are continuously kept in view.
Sterile personnel keep well within sterile area.
Sterile personnel keep contact with sterile areas to a minimum.
Unsterile personnel avoid sterile areas.
Any destruction of the integrity of microbial barriers results in contamination.
Microorganisms are kept to an irreducible minimum.
SURGICAL SAFETY CHECKLIST
WHO Patient Safety Checklist
Before induction of anaesthesia:
Confirm patient’s identity, site, procedure, and consent.
Mark the site.
Verify anaesthesia machine and medication checks.
Ensure pulse oximeter is on and functioning.
Identify known allergies or risks.
Before skin incision:
Confirm team members introduce themselves.
Reaffirm patient’s name, procedure, and incision site.
Ensure antibiotic prophylaxis is given within the last 60 minutes.
Discuss anticipated critical events.
Before patient leaves the operating room:
Verbally confirm the name of the procedure and completion of counts.
Label specimens correctly.
POSITIONING OF PATIENT ON OPERATING TABLE
Goals of Proper Positioning:
Maintain the patient's airway and avoid constriction or pressure on the chest cavity.
Maintain circulation.
Prevent nerve damage.
Provide adequate exposure of the operative site.
Ensure comfort and safety for the patient.
Factors Influencing Patient Positioning:
Surgical procedure being performed.
Physical condition of the patient.
Positioning must avoid discomfort or permanent injury:
Awkward positions.
Hyperextending joints.
Compressing arteries.
Pressing on nerves.
Sustained positions for long periods.
Considerations During Positioning:
Ensure patient is in the most comfortable position possible, whether asleep or awake.
Ensure adequate exposure of the operative area.
Ensure vascular supply is not obstructed by positioning.
Allow for proper respiration; avoid compression of the chest and neck.
Protect nerves from undue pressure; ensure padding is applied, particularly in certain positions such as Trendelenburg.
Safety precautions must be noted for thin, elderly, obese, and paediatric patients.
Restraints may be necessary, pad the area to be restrained to prevent skin trauma.
RESPONSIBILITIES OF OPERATING ROOM NURSING STAFF
Responsibilities of a Circulating Nurse:
Prepares OR with necessary equipment and supplies; ensures equipment is functional.
Arranges sterile and unsterile supplies; opens sterile supplies for scrub nurse.
Visits the patient, identifies them, explains roles, and answers questions.
Performs patient assessment and confirms correct patient.
Maintains continuous observation during surgery to anticipate needs of the surgical team.
Observes sterile field for breaches and reports as necessary.
Assists in safe patient transfer to the OR table and positions them per procedure and surgeon’s preference.
Verifies completeness of patient records and required consent.
Maintains strict adherence to sterile field protocols.
Document operative records and nurse’s notes.
Counts instruments and sponges before closure of incision.
Accompanies patient to PACU and provides report.
Responsibilities of a Scrub Nurse:
Performs surgical hand scrub.
Don sterile gown and gloves aseptically.
Arranges sterile supplies and instruments.
Counts instruments/sponges with circulating nurse.
Gowns and gloves surgeon upon entry.
Assists with surgical draping.
Maintains order of sterile field and corrects breaches in aseptic technique.
Hands necessary instruments and supplies to the surgeon during the procedure.
Maintains count of sponges, needles and instruments so none will be misplaced or lost in the wound.
Maintains strict adherence to principles of asepsis.
Identifies surgical specimens correctly.
Monitors patient safety throughout the procedure.
POTENTIAL INTRAOPERATIVE COMPLICATIONS
Common Intraoperative Complications:
Nausea and Vomiting:
Possible in patients with a full stomach.
Management: Position patient to the side, provide basin for vomitus, suction to remove saliva and gastric contents, may administer oral antacids preoperatively.
Hypoxia and Respiratory Complications:
Causes include respiratory depression, airway occlusion, aspiration, positioning.
Risk of brain damage within minutes; requires monitoring of pulse oximeter and peripheral perfusion.
Hypothermia (< 36.6°C):
Causes include low OR temperature, infusion of cold fluids, and open wounds, inhalation of cold gases, less muscle activity, use of pharmaceutical agents [vasodilators, phenothoazines]
Must be warmed gradually [it allows the body’s systems to prepare for increased physical demand, which helps prevent injuries like muscle strains and reduces stress on the CVS system]; manage via maintained environmental temperature of 25°C - 26.6°C and warmed IV fluids.
Administer oxygen, adequate hydration
Close monitoring of core temperature, urinary output, ECG, BP, ABG and serum electrolytes.
Malignant Hyperthermia:
Caused by inherited muscle disorders, exposure to certain anaesthetic agents [Halothane, isoflurane (Inhalant anaesthetic)] [Succinylcholine (muscle relaxant)] ; rare but with a high mortality rate
Large amounts of calcium suddenly flood into the muscle cells, causing continuous muscle contraction and severe rigidity. This uncontrolled activity uses enormous amounts of energy and produces extreme heat
Risk factors include muscular build, history of muscle cramps/ weakness, rheumatoid arthirtis.
Signs and Symptoms: Tachycardia, tachypnea, muscle stiffness, significant temperature increases, metabolic/ respiratory acidosis, cardiac dysrhythmuas, tetany like movement in the jaw, elevated BP, changes in CO2, myoglobinuria.
Management
Halting anaesthesia and hyperventilate with 100% O2 at 10/L min [ Hyperventilating the patient with 100% oxygen helps by quickly blowing off the excess CO₂, which reduces respiratory acidosis and stabilizes the blood pH. It also provides a high concentration of oxygen to meet the body’s increased metabolic needs and helps prevent complications such as arrhythmias or cardiac arrest.]
Administer Dantrolene sodium 2-3 mg/kg IV bolus repeat every 5-10 mins.
Other drugs are procainamide [treat arrythmias]
Sodium bicarbonate [acts as a buffer to correct metabolic acidosis]
Insulin [treat hyperkalemia]
Calcium chloride [stabilize the heart during hyperkalemia]
Mannitol [protect the kidneys from rhabdomyolysis and increase urine output]
Administer cold IV NS
Put patient on plastic sheet and apply ice bags and ice water
Correct electrolyte imbalances (blood sampling of electrolytes, pH, blood gases)
Monitor CVP, CVP line may need to be inserted
Monitor urine output, urine sample for Hb and myoglobin to assess kidney function and detect potential muscle damage.
Nursing Diagnoses for Intraoperative Phase
Risk of perioperative injury related to positioning, chemicals, and electrical equipment.
Expected Outcome: Patient free from injury.
Risk of impaired skin integrity related to chemicals, positioning, and immobility.
Expected Outcome: Skin integrity maintained.
Risk of deficient fluid volume related to NPO status and blood loss.
Expected Outcome: Maintains blood pressure, pulse, and urine output within normal limits.
Risk of infection related to incision and invasive procedures.
Expected Outcome: Free from symptoms of infection.
MANAGEMENT OF ANXIETY RELATED TO THE ENVIRONMENT IN OR
Interventions and Rationale:
Introduce self warmly and address the patient by name: to build trust and rapport and also confirms correct patient.
Encourage patient to articulate concerns: to allow inaccurate information to be corrected and to provide reassurance regarding their safety and the procedures they will undergo.
Verify details, provide explanations: to provide a sense of professionalism and friendliness that helps patient feel secure.
Use basic communication skills,when discussing what to expect such as eye contact: to foster comfort and to demonstrate that the nurse is interested to help
Inform patients about personnel present and procedure expectations: to help patient prepare for the experience and gain a sense of control
MAINTENANCE OF PATIENT SAFETY (DOCUMENTATION)
Important Checks:
Check patient’s name with identification band: correct patient.
Verifying patient surgical consent with patient signature: ensure correct patient for correct surgery
Complete record of health history and physical examination: ensure any abnormalities noted to the surgical team
Review of diagnostic studies: help the healthcare team understand the patient’s overall health status and identify any hidden problems that could increase surgical risks
Check that preoperative checklist was done: to ensure patient can proceed with surgery
Maintenance of patient safety (a circulating nurse must)
Obtain necessary equpment specific for the surgery: prevent delat in case of emergencies
Assess the need for non-routine medications, blood components, instrumnets and supplies: prevent delay incase of emergencies
Assess readiness of the room [room temperatyre, humidity, unnecessary traffic]: to create an optimal environment for the surgical procedure and minimize potential risks to the patient.
Set up and maintain suction in working order, invasive line access, and monitoring equipment: to ensure immediate availability during the procedure and facilitate timely responses to any complications.
Position the grounding pads properly onto patient: to prevent electrical burns and ensure effective functioning of the electrosurgical equipment.
Remove excess povidone iodine or other surgical germicide from patient’s skin after completion of surgery: to prevent staining and irritation of the skin.
Drape exposed areas promptly and completely after the sterile field has been created: decrease risk of hyperthermia
Risk for perioperative injury
Check that patient is positioned in anatomic position and padding equpment are not compressing any body structures: prevent body injury or discomfort
Assess peripheral pulse frequently: To ensure no obstruction to circulation
Perform sponge, shaprs and instrument count according to hospital protocols by scrub nurse: to ensure no items left in body upon closure
Risk of deficient fluid volulme related to blood and fluid loss
Expected outcome: patient will maintain BP, pulse and urine output within normal limits
Check dressings and incisions for colour and amount of drainage: detect fluid loss
Maintain IV fluids at a ordered rate: To replace fluid loss and avoid fluid overload
Monitor intake and output: to detect imbalances
Inform Dr if urine output <30ml/hr: enable detection of early signs of kidney injury and facilitate early interventions
Risk of perioperative positioning injury
Expected outcome: Patient will be free from injury related to perioperative positioning
Identify surgical site and determine appropriate position: to minimise stress or injury to other parts of the body
Obtain needed positioning aid and padding materials: to prevent nerve damage, pressure ulcers and strain during prolonged surgery
Ensure a safe transfer of patient from the trolley to the OR table: prevent falls, shearing and joint injuries during movement
Secure patient using restraining straps to the OR table without compromising circulation: prevents accidental falls ot movement during surgery while maintaining proper blood flow and avoiding vascular injury
Ensure proper function of OR table: prevents accidental movement or collapse and supports correct surgical positioning throughout the procedure.