The Intra-operative Phase

INTRAOPERATIVE – period of time from when the patient is

transferred to the operating table to when he or she is
admitted to the PACU.
 THE STERILE TEAM:
✓ The SURGEON THE NON STERILE
✓ First ASSIST TEAM:
✓ Registered Nurse ✓ The
First Assistant (RNFA) Anesthesiologist
✓ The SCRUB nurse ✓ Certified
→ RN Registered Nurse
→ LPN Anesthetist (CRNA)
→ Surgical Technician ✓ The Circulating
Nurse
 The Surgeon
→ The Head of the Surgical Team
→ A Physician specially trained and
qualified to perform the surgical
procedure.

→ May be a resident, intern,

physician’s assistant, or a
perioperative nurse
→ Assist in retracting, hemostasis,
suturing, etc..
→expanded role of perioperative nursing.
→under the direct supervision of the surgeon.
→Responsibilities: handling tissue, providing exposure at
the operative field, suturing and maintaining
hemostasis.
 RN, a licensed LPN or Surgical Technician

→Selects instruments, equipment and

Back Table
other supplies appropriate for the
and the surgery.
Mayo Table →Prepares the sterile field and sets-up
sterile tables.
→Selects instruments, equipment and
other supplies appropriate for the
Surgical Counts- surgery.
the counting of →Prepares the sterile field and sets-up
sponges, sharps
and instruments
sterile tables.
that are opened
and delivered to →Anticipates the surgeons needs.
the sterile field
for use during
Hands the instruments, sutures etc in
surgery. a appropriate & timely manner.
 -is a physician
specifically trained in
the art and science of
anesthesiology.
▪ is a qualified health care

CRNA
professional who administers
anesthetics.
▪ Administers anesthesia under
the direct supervision of the
anesthesiologist .

→ Assesses the patient before surgery

→ Selects and administers anesthesia
→ Intubates the patient if necessary
→ Manages any technical problems related to the administration
of anesthetic agent
→ Supervises the patient condition throughout the surgical
procedure
→ Monitors BP, pulse, respirations, ECG, blood O2 saturation
level.
Completes a preoperative assessment
Establish and implement the intraoperative plan of
care, evaluate the care, and provide for the
continuity of care postoperatively.
Assists the anesthesia care provider with
endotracheal intubation
Performing on going patient assessment.
Monitors sterile technique of all members of the
team and a safe OR environment
Assist the surgeon and scrub nurse by operating
non sterile equipment, providing additional
instrument and supplies.
Maintain accurate and complete documentation.
Tracking sponge, needle, and instrument counts.
Preparing and disposing of specimens.
 The Surgical Environment

Surgical Zones
Unrestricted
Street clothes are allowed
Semi restricted
Where attire consists of
scrub suits and caps
Restricted zone
Where attire consists of
scrub suits, caps, shoe
covers and masks are
worn.
Surgical Zones Entrance & Exit for Personnel
Unrestricted & Patients, Dressing Rooms,
PACU, offices, holding area,
Street clothes are
lounges, storage for supplies.
allowed
Semi restricted
Storage areas for
Where attire clean and sterile
consists of scrub supplies, sterilization
suits and caps processing,
Restricted zone preparation area for
Where attire equipment.
consists of scrub Where surgery is
suits, caps, shoe performed.
covers and masks Adjacent sub-sterile
areas where scrub
are worn. sinks are located.
✓ Exposure to blood and body fluids
✓ Hazards associated with laser beams
✓ Exposure to latex and adhesive
substance
✓ Exposure to radiation and toxic agents
✓ Unintentional leaving of an object in
the cavity during a surgical procedure
INTRA-OPERATIVE
NURSING
MANAGEMENT:
Goals & Nursing
Interventions:
I. To Reduce Anxiety

• Introduce self
• Address the patient
by name
• Verify details
• Encourage and answer questions
• Pay attention to physical comfort
II. To prevent infection

A Surgical incision creates an opportunity for

microorganisms to enter the body and for infection
to result.

SOURCES OF INFECTION:
ENDOGENOUS (source of infection arise from within
the body)
PATIENTS
EXOGENOUS (from outside the body)
PERSONNEL
ENVIRONMENT
EQUIPMENT
CONTROL OF SOURCES OF
INFECTION:
→ADHERENCE TO ASEPTIC PRACTICES:

Asepsis – refers to the absence of

pathogenic organisms.

Aseptic Technique – refers to the

practices by which contamination with
microorganisms in the surgical environment is
prevented.
Surgical Conscience – is an inner
commitment to adhere to aseptic
practice, to report any break in the
aseptic practice, and to correct
any violation, whether or not
anyone else is present or observes
the violation.
ASEPTIC PRACTICES:
1. SURGICAL ATTIRE –
Appropriate surgical attire in
the OR includes caps/hats,
scrub outfits or commonly
referred to as “scrubs”, and
shoe covers (optional).
2. GOWNING & GLOVING
3. SCRUBBING
4. PATIENT SKIN PREPARATION

PURPOSE: To lower the bacteria on the

skin prior to surgery

Assess rashes, moles, warts or other

conditions prior to hair removal
5. STERILIZATION OF INSTRUMENTS & EQUIPMENTS

6. CREATION & MAINTENANCE OF A STERILE FIELD

CREATION OF A STERILE FIELD : DRAPING

DRAPES – serves as a barrier to prevent the

passage of microorganisms between sterile
and non-sterile areas.

STERILE DRAPES – used to create a sterile

surface around the incision site that may be
used for sterile supplies and equipment.
7. MAINTAINING A STERILE FIELD
→Scrubbed person function within the sterile
field.
→Items used within the sterile field should be
sterile.
→Items introduced to a sterile field should be
opened, dispensed, and transferred by
methods that maintain sterility and integrity.
→A sterile field should be maintained and
monitored continuously.
→All the personnel moving within or around a
sterile field should do so in a manner that will
maintain the sterile field.
8. CONTROL OF THE ENVIRONMENT SOURCES OF
INFECTION

TRAFFIC PATTERNS
✓ OR divided in 3 areas
✓ Numbers of personnel & movement is kept to a minimum.
✓ contaminated, soiled, or dirty items should NOT be
transported through the same corridors as clean and
sterile items.

OPERATING ROOM ENVIRONMENT

✓ The OR is considered a clean environment.
✓ Room temperature - 20°C - 23°C
• (higher humidity=mold growth; lower humidity= excessive dust
=bacteria)

SANITATION – adherence to specified practices

III. To Prevent Intraoperative Positioning
Injury.

BENEFITS OF PROPER POSITIONING

✓ The surgeon will have optimal access to the
surgical site
✓ The patient will not suffer injury

Complications of improper positioning:

1. Post-operative musculoskeletal pain
2. Joint dislocation
3. Peripheral nerve damage
4. Skin breakdown including necrosis
5. Cardiovascular & Respiratory compromise
Positioning Devices

Typical table attachments:

✓ Headrest
✓ Anesthesia screen
✓ Padded arm boards
✓ Shoulder braces
✓ Kidney brace
✓ Table strap
✓ Leg stirrups
✓ Table extensions
✓ Table attachment holders
Positioning accessories:
Blankets (for patient’s warmth)
Draw sheet (serve as a lift sheet)
Donut (used as head rest;to protect the ears and
nerves of the head and face)
Pillows (to elevate body part)
Sandbags (used for immobilization)
Tape (to secure an extremity in a flexed position.
Laminectomy Frame or body rolls made from
sheets (to support the body off the chest while in
a prone position.
BASIC SURGICAL POSITIONS:

1. Dorsal Recumbent / Supine – most common

• Abdominal surgeries ;anterior approach, head, neck and
most extremity surgery.
2, Trendelenburg
• lower abdomen and pelvis
3. Reverse Trendelenburg
• Head and neck procedures
4. Lithothomy
• perineum, pelvic organs, and genitalia.
5. Sims’ or Lateral
• Access to the thorax, kidney, retroperitoneal space, and hip
6. Sitting (Semi-sitting; Semi- Fowler’s)
• Cranial procedures
7. Prone
• spine, back, rectum, and posterior aspects of the extremities.
8. Jackknife or Kraske’s
• Proctologic procedures, rectal surgeries
COMMON TYPES OF POSITIONING
IV. To Protect Patient From Injury

▪Verify information, check the chart for

completeness
→Correct informed consent with patient’s signature
→Complete records for history and physical
examination
→Results of diagnostic studies
→Allergies

▪Safe transferring practices

▪Patients undergoing surgery are at risk for

injury related to unintentionally retained
foreign body.
 How to reduce the potential for a retained foreign body?

Surgical Counts – refers to the counting of sponges ,sharps, and

instruments that are opened and delivered to the field for use
during surgery.

Purpose: To reconcile what was delivered to the sterile field before

an incision is made and during the surgery with what remains at
the end of surgery.

➢ Usually performed by the scrub person and circulating nurse;

counts must be done together and aloud. They must share the
responsibility equally. And items being counted must be visible.

General rule: counts are performed and documented prior to the

beginning of the surgery, during surgery when items are added to
the field, before closure of a body cavity or deep incision, before
closure of a cavity within a cavity (cesarean section), and at skin
closure.
 Factors that can contribute to an error in the
count process:

✓ Over time, counting becomes a routine

task, which contributes to the potential for
error.
✓ Excessive talking during counts
✓ Sponges placed in the cavities for packing
during the case
✓ Circulating nurse out of the room when
sponges are added to the field.
✓ Signing for counts that were not
performed.
▪Prevent injury related to use of
electrosurgery

Purpose:
Cutting tissue or
Coagulating bleeding points

• Prevent burns; shock

V. To maintain the patients dignity

Maintain patients physical

and emotional comfort
Provide physical privacy
(prompt and complete
draping of exposed areas)
Make sure the patient is
treated as a person
Maintain confidentiality
VI. To monitor and manage complications:

It is the responsibility of the surgeon and the

anesthesiologist or anesthetist to monitor and manage
complications.

However, intraoperative nurses play an important role.

Being alert to and reporting changes in vital

signs, symptoms of nausea and vomiting,
anaphylaxis and other potential intra-op
complications
Assist in managing complications
Maintain asepsis
✓ Exposure to blood and body fluids
✓ Hazards associated with laser beams
✓ Exposure to latex and adhesive
substance
✓ Exposure to radiation and toxic agents
✓ Unintentional leaving of an object in
the cavity during a surgical procedure
→ REGIONAL ANESTHESIA

→ an anesthetic agent is injected around nerves so that

the area supplied by these nerves is anesthetized.

→ Patient - awake and aware

→ Administration techniques includes:

→ Spinal
→ Epidural and Caudal
→ Intravenous Block
→ Nerve Block
→ Local Infiltration
→ Topical
 SPINAL ANESTHESIA
Spinal anesthesia is obtained when the
anesthetic agent is injected into the CSF in the
subarachnoid space.

Injection is made through a lumbar interspace

between L2 & L3 or below (usually between L4 &
L5)

• produces anesthesia of the lower extremities,

perineum, and lower abdomen.

• Frequently used agents for spinal: Bupivacaine

(Sensorcaine), Tetracaine (Pontocaine)
SPINAL
1. NURSING INTERVENTION

2. Proper positioning
→ Sitting
→ Lateral Decubitus Position
3. Provide support during administration of anesthesia
→ Remain with the patient
→ Help the patient feel secure
4. Institute measures to prevent falling
5. Strict attention to asepsis
6. Suction or emesis basin should be readily available
7. Headache may be an after-effect of spinal anesthesia (24-48 H
post spinal anesthesia).
Factors related to the incidence of
headache (spinal headache):
→ size of the spinal needle used
→ leakage of fluid from the subarachnoid
space through the puncture site
→ Patient’s hydration status

Interventions:
→ Maintain a quite environment
→ Keep the patient lying flat / bed rest
→ Keep the patient well hydrated (oral
or IVF)
→ Oral Caffeine
EPIDURAL and CAUDAL ANESTHESIA
Injection of the anesthetic agent into the
epidural space that surrounds the Dura mater of
the spinal cord.

Catheter can be left in place for continuous

infusion – useful for pain management in the
post-operative period.

Advantage: absence of H/A that occasionally

results from SAB
Disadvantage: greater technical challenge of
introducing the anesthetic
 CAUDAL-the anesthetic is injected into the
epidural space through the caudal canal in the
sacrum.
Epidural & Caudal are commonly used for:
✓ Surgery of the lower limbs
✓ Anorectal, vaginal
✓ Perineal
✓ often used in Obstetric surgery, Epidural is
administered as an anesthetic during labor.
Complications:
▪ Dural puncture – post Dural headache
▪ Inadvertent subarachnoid injection – total
spinal anesthesia
▪ Inadvertent intravascular injection - extreme
hypotension & cardiac arrest
CAUDAL
 Nerve block
The anesthetic agent is injected into and around a nerve
or nerve group that supplies sensation to a small area of
the body.
→ Commonly used for sustained relief in patient with
chronic pain.
Major Nerve Block: involves multiple nerves or a plexus
Example: Brachial Plexus
Orbital Block
Cervical Block
Minor Nerve Block: involves a single nerve
Example: Radial & Ulnar nerve blocks

Nursing Intervention:
→assist during nerve block
Local Anesthesia
Involves injection of the anesthetic agent into
subcutaneous tissue at, or close to, the
anticipated site.
Given to temporarily stop the sensation of pain
in a particular area of the body.
Useful for minor, superficial procedures.
Nursing Responsibility:
Be alert to the possibility of toxic REACTION
Initials S/S: restlessness, lightheadedness,
visual & auditory disturbance, dizziness,
tremors, convulsions.

This may be followed by: unconsciousness, apnea

& cardiac arrest.
 TOPICAL ANESTHESIA
The anesthetic is applied directly to
a mucous membrane or an open wound.

Used for nasal surgery, cystoscopy, and

procedures of the respiratory tract

Commonly used topical anesthetics are:

• pontocaine (Tetracaine) in the eye;
• cocaine is used in nasal passages;
• lidocaine (Xylocaine) in the throat, nose,
esophagus, and genitourinary tract.
 General Anesthesia
- is a drug induced loss of consciousness during
which patients cannot be aroused, even by
painful stimulation
- Patient loses all sensations and reflexes.
Effective GA includes:
AMNESIA
ANALGESIA
SKELETAL MUSCLE RELAXATION

Administered during major procedures requiring extensive

tissue manipulation or anytime analgesia, muscle relaxation,
immobility, and control of the autonomic nervous system
 Anesthetic Agents used in general anesthesia are
either INHALED or ADMINISTERED BY INTRAVENOUS:
Or they maybe used in combination.

Inhalation Anesthetic Delivery Methods:

Laryngeal mask airway (LMA) / General
Anesthesia by Mask (GAM)

2. Nasal endotracheal catheter / General

Anesthesia Naso Tracheal (GANT)

3. Oral endotracheal intubation / General

Anesthesia Endo Tracheal (GETA)

INHALATION AGENTS:
Nitrous Oxide, Isoflurane & Sevoflurane
 GA ADMINISTERED BY IV

Intravenous agents are introduced directly to the

circulatory system, usually through a peripheral vein.

→ INDUCTION AGENTS
Barbiturate: Thiopental Sodium
Non Barbiturate: Propofol
Dissociative: Ketamine HCl
→ NARCOTICS
Meperidine, Morphine, Fentanyl
→ BENZODIAZEPINES
Diazepam, Midazolam
→ NEUROVASCULAR BLOCKERS (Muscle Relaxant)
Succinylcholine
 POTENTIAL INTRA-OPERATIVE
COMPLICATIONS
1. ASPIRATION – entry of gastric, oropharyngeal, or
other substance into the lungs.

→Remove as much aspirate as possible

→ Lower the head of the OR bed with right lateral tilt
for postural drainage
→ Perform Suctioning of the oropharynx and the
tracheobronchial tree
→Oxygenation
→May require endo-tracheal intubation
 2. LARYNGOSPASM & BRONCHOSPASM

LARYNGOSPASM- closure of the vocal cords as

an involuntary reflex action.
BRONCHOSPASM – contraction of smooth
muscle in the walls of the bronchi.

→Oxygenation
→Tracheal intubation
→Neuromuscular blockers
→Bronchodilators
 3. PULMONARY EMBOLISM

– is an obstruction of the pulmonary artery

or one of its branches by an embolus
(blood clot)

*major cause of death

→Prophylactic anti-coagulants or anti-

platelets for high risk patients
→Routine measures to prevent venous stasis
→Bed rest
 4. CARDIAC ARREST

– cessation of circulatory action

→ CPR
→DEFIBRILLATION
→IV drugs generally use to improve
circulation (ex. Antidysryhthmics,
Anticholinergics)
 5. HYPOVOLEMIA
decreased circulating blood volume
from loss of blood and plasma
deficit of extracellular fluid volume ?
→Fluid volume replacement
→Position patient: elevate the legs
→Keep patient warm
→Provide oxygen
 6. HEMORRHAGE

– abnormal internal or external loss of

blood from an arterial, venous or
capillary source.

→Estimate blood loss – weigh sponges

→Administration of blood volume
expanders (ex. Dextran)
→Blood loss replacement
 8. SHOCK
– state of inadequate blood perfusion to parts
of the body.

HYPOVOLEMIC SHOCK – fluid loss greater than

compensatory absorption of interstitial fluid
into the circulation.
HEMORRHAGIC SHOCK – shock results from
hemorrhage or inadequate blood volume
replacement.
NEUROGENIC SHOCK- Loss of vasomotor tone
in peripheral blood vessels leads to sudden
vasodilation and pooling of blood.

→ best treatment is prevention

CARING FOR THE PATIENT DURING SURDERY

Intraoperative care is patient care during an operation and

ancillary to that operation. Activities such as
Monitoring the patient's vital signs, blood oxygenation levels,
fluid therapy, medication transfusion, anesthesia, radiography,
and retrieving samples for laboratory tests, are examples of
intraoperative care, measuring I&O,
like urine output, blood loss, irrigants, like saline etc,

Intraoperative Care | Encyclopedia.com

https://www.encyclopedia.com › medicine › intraoperative-
care-0