Intraoperative Nursing

Intraoperative Nursing

By: Bryan Mae H. Degorio, BSN, RN [email protected]

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 Team 2. 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 airway b. ensure that the person has an adequate oxygen and carbon dioxide exchange

c. infuse blood, medications and fluids as necessary d. alert the surgeon immediately for signs of complication 4. 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 technique d. contacts the x-ray and pathologic departments if requested by the surgeon e. do skin preparation f. document the specific activity throughout the operation

g. verify consent and coordinate with the team Aseptic Technique •

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. 3. 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 caps c. 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 Attire a. masks b. headgear - should cover completely the hair, neckline and beard c. gown d. gloves

Sedation and Anesthesia: 4 Levels 3. 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: 2. Halothane 3. Methoxyflurane 4. Enflurane 5. Isoflurane 6. Sevoflurane 7. Desflurane Gases 1. Nitrous oxide

4. Anesthesia - is the state of narcosis, analgesia and relaxation and reflex loss - the client is not arousable even to painful stimuli

Stages of Anesthesia Stage

Start-Point

End-Point

Physical Reaction

I Onset

Anesthetic administratio n

Loss of consciousness

Drowsy or dizzy, possible visual or auditory hallucination

II Loss of Loss of eyelid Excitem consciousness reflexes ent

Increase in autonomic activity and irregular breathing, client may struggle

Nsg. Intervention s Close operating room doors, keep room quiet, stand by to assist the client Remain quiet at client’s side assist anesthesia as needed

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 Administration 2. 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 Anesthesia a. 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

2.

-Types of Regional Anesthesia 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 fiber 2. 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 NS 7. 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 abdomen Complications and Discomforts of Spinal Anesthesia 3. Hypotension -due to paralysis of the vasomotor nerves shortly after the induction of anesthesia.

- Nsg interventions a. Administer O2 b. Vasoactive drug c. 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, antiemetic b. 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 binder b. fluids and analgesic c. 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 CNS c. transient response to anesthetics d. position during surgery

-Interventions: a. supportive care for transient forms b. antibiotic and steroid therapy c. rehbilitation for permanent paralysis