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INTRAOPERATIVE PHASE
Intraoperative Phase
- Transferred to OR-ends with the transfer to
the recovery area.
• Transfer onto the operating table
• Phases of anesthesia
• Operative proceedure
• Transfer from operating table to stretcher
• Safe transport to post-operative area (PACU)
SURGICAL TEAM
• Surgeon
• Anesthesiologist
• Scrub Nurse
• Circulating Nurse
• OR techs
Surgical team
• Surgeon-responsible for determining the preoperative
diagnosis, the choice and execution of the surgical
procedure, the explanation of the risks and benefits,
obtaining inform consent and the postoperative
management of the patient’s care.
• Scrub nurse- (RN or Scrub tech
)- preparation of
supplies and equipment on the sterile field; maintenance
of pt.s safety and integrity: observation of the scrubbed
team for breaks in the sterile fields; provision of
appropriate sterile instrumentation, sutures, and
supplies; sharps count.
Surgical team
• Circulating Nurse - responsible for creating a safe
environment, managing the activities outside the
sterile field, providing nursing care to the patient.
Documenting intraoperative nursing care and
ensuring surgical specimens are identified and place
in the right media. In charge of the instrument and
sharps count and communicating relevant information
to individual outside of the OR, such as family
members.
Surgical team
• Anesthesiologist and anesthetist- anesthetizing
the pt. providing appropriate levels of pain
relief, monitoring the pt’s physiologic status and
providing the best operative conditions for the
surgeons.
• Other personnel- pathologist, radiologist,
perfusionist, EVS personnel.
Nursing Roles:
Staff education
Client/family teaching
Support and reassurance
Advocacy
Control of the environment
Provision of resources
Maintenance of asepsis
Monitoring of physiologic and psychological status
Elements of Aseptic Technique
*Sterile gowns and gloves.
*Sterile drapes used to create sterile field.
*Sterilization of items used in sterile field.
Surgical asepsis
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The absence of pathogenic microorganisms.
Ensure sterility
Alert for breaks
The practice of aseptic technique requires the
development of sterile conscience, an
individual’s personal honesty and integrity
with regard to adherence to the principles of
aseptic technique.
Preanesthetic Preparation
• Avoidance of foods and drink prevents
passive regurgitation of gastric contents
• Clients should typically continue medications
up to surgery
• Consent must be received
Sedation
• Reduction of stress, excitement, or irritability
and some suppression of CNS
• Typically used to relieve anxiety and
discomfort during a procedure
• Residual effects include amnesia and
letheragy
Types of Anesthesia
• Regional
Local
Nerve block
Epidural
Spinal
• General
Spinal Anesthesia
• Injected into cerebrospinal fluid (approx L 3-5) subarachnoid space
• Indications
surgical procedures below the diaphragm
-patients with cardiac or respiratory disease
• Advantages
-mental status monitoring
-shorter recovery
• Disadvantages
-necessary extra expertise
-possible patient pain
• Contraindications
-coagulopathy
-uncorrected hypovolemia
-
Spinal Anesthesia
• Involved medications
-lidocaine
-bupivacaine
-tetracaine
• Patient assessment
-continuous heart rate, rhythm, and pulse
oximetry monitoring
-level of anesthesia
-motor function and sensation return
monitoring
Spinal Anesthesia
• Complications
-hypotension
-bradycardia
-urine retention
-postural puncture headache
-back pain
Spinal Anesthesia (Subarachnoid Block)
• Anesthesia: tip of xiphoid to toes
• Risks:
– Loss of vasomotor tone
– “Spinal Headache”
– Infection, Rising anesthesia above diaphragm
• Nursing: KEEP FLAT, MONITOR VS & OFFER
FLUIDS WHEN APPROPRIATE
General Anesthesia
• Inhalation-Mask, Endotracheal tube (ETT) or
Laryngeal managed airway (LMA)
• Intravenous
• Combination
General Anesthesia: Inhalation Agents
• Inhalation most controllable method; lungs act as passageway
for entrance & exit of agent
• Gas Agents : Nitrous Oxide
– must be given with oxygen
– require assisted to mechanical ventilation
– frequently shiver
– taken in & excreted via lungs
– Examples: halothane, enthrane, florane…
Adjuncts to General Anesthesia
• Hypnotics (Versed, Valium)
– also used for conscious sedation
• Opioid Analgesics (morphine, Demerol)
– respiratory depression
• Neuromuscular Blocking Agents
– Causes muscle paralysis
– Examples: Pavulon, Succinycholine
– What vital function is affected?
Potential General Anesthesia
Complications
• Overdose (consider risk factors)
• Hypoventilation postoperatively
• Intubation related: sore throat,
hoarseness, broken teeth, vocal cord
trauma
• MALIGNANT HYPERTHERMIA
– Genetic predisposition
– Triggered by anesthetics such as Halothane
Potential Intraoperative Complications
 Nausea and vomiting
 Anaphylaxis
 Respiratory complications
 Inadequate ventilation, airway occlusion, intubation of the
esophagus, and hypoxia
 Hypothermia
 Malignant hyperthermia
 Disseminated Intravascular Coagulation
What are measures to prevent or treat these
complications?
Nursing Interventions
Communicating plan of care
Identifying nursing activities
Establishing priorities
Coordinate care with team members
Coordinate supplies and equipment
Control environment
Document plan of care
Intraoperative Nursing Care
Nurses are responsible for managing six areas
of risk:
• Risk of infection related to
invasive procedure and
exposure to pathogens.
• Risk for injury related to
positioning during surgery.
• Risk of injury related to
foreign objects
inadvertently left in the
wound.
• Risk for injury related to
chemical, physical, and
electrical hazards.
• Risk for impaired tissue
integrity.
• Risk for alteration in fluid
and electrolyte balance
related to abnormal blood
loss and NPO status.
Nursing Process Intraop Phase
• Intervention
– Safety
– Advocacy
– Verification
– Counting-instruments, sponges, needles
Altered Skin Integrity
• How many sutures?
• Staples or sutures or
glue???
POSTOPERATIVE PHASE
• Postoperative
- Begins with transfer to PACU and ends with the
discharge of the patients from the surgical facility or
the hospital.
• Nursing Interventions
Communicating pertinent information about surgery to
the PACU staff.
Postoperative evaluation in clinic or home.
Nursing assessment in the Recovery Room
• Vital signs- presence of artificial airway, o2
sat,BP,pulse, temperature.
• Ability to follow command, pupillary response
• Urinary output
• Skin integrity
• Pain
• Condition of surgical wound
• Presence of IV lines
• Position of patient
Immediate Post-anesthesia Care
• Airway
• Breathing
• Circulation
How often should vital
signs be assessed?
Postop SKIN Assessment
“Altered Skin Integrity”
• Day 3 or so to Day 14 (or 21 or more)
– Proliferation: fibrin strands form scaffold
• Collagen with blood = granulation tissue
• Protect from damage or stress
– No lifting, heavy exercise, driving etc.
• At risk for dehiscence or evisceration
• Day 15 (or weeks, months, years)
– Scar is organized, less red, stronger
– Max strength = 70 – 80%
Postoperative RESPIRATORY
Assessment
• Impaired gas exchange or impaired airway
clearance
• Risks: pneumonia, atelectasis
• Assessment:
– Open airway
– Pulse oximetry (what is normal?)
– Check opioid use (why?)
– Monitor quality & quantity of respirations
Postoperative RESPIRATORY Assessment
• Interventions:
– Turn (also relates to
cardiovascular risk – any
ideas?)
– Deep breathe & cough
– Incentive spirometry
– In-bed exercises (see
text)
– AMBULATION!!
Postop SKIN Assessment
“Altered Skin Integrity”
• Wound healing
– How is the face healing time-line different from
the foot?
• OR to Day 2 (may 3-5)
– Inflammation vs. infection
• redness, pain, swelling, warmth
• skin held together by blood clots & tiny new blood
vessels
– Avoid pressure/ be sure to splint
Postop CARDIOVASCULAR
Assessment: Potential for hypoxemia
• Think (hypovolemic) shock (hemorrhage)
– Assessment:
• Prevention of venous stasis
– Who is at risk?
– What should be done?
Avoiding Venous Stasis
• Avoidance of positions
leading to venous stasis
• In Bed Exercises
• Antiembolism stockings
• Sequential Compression
Device
• When all is said & done,
AMBULATION is the
best!
Postop NEUROLOGIC Assessment
• Assess cerebral function
– Think elderly
• Assess motor/sensory function
Postop F & E Assessment
• Fluid Status
– Intake
– Output
• Why would a postop client need an IV??
Postop URINARY Assessment
• Anuria (define)
• Urinary Retention
– Or Urinary retention with overflow
• Differentiate
• Intervention:
– Fluids
– AMBULATION
– Careful monitoring
Postop GI Assessment
• Nausea & vomiting
• Assessment of peristalsis/paralytic ileus
• Interventions:
– N/G tube, GI rest (NPO), AMBULATION
• Postop Diets
– Why are clear liquids usually the first diet?
– What does “advance as tolerated” mean?
– What are nursing responsibilities??
Postoperative Diets
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1. Clear Liquid
2. Full Liquid
3. Soft
4. Regular
Postop Diets
– Why are clear liquids usually
the first diet?
– What does “advance as
tolerated” mean?
– What are nursing
responsibilities??
Postop SKIN Assessment
“Altered Skin Integrity”
•
•
•
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R edness
E dema
E cchymosis
D rainage
A pproximation
Is a scar as strong
as the original
skin?
The Ultimate in “Altered Skin
Integrity”
• Risk factors:
-Dehiscence
-Evisceration
• Prevention:
-Wound Splinting
-Abdominal binder
-Diet
Nursing Diagnosis
• Ineffective airway clearance- increased
secretions 2 to anesthesia, ineffective cough,
pain
• Ineffective breathing pattern- anesthetic and
drug effects, incisional pain
• Acute pain
• Urinary retention
• Risk for infection
Postoperative Goals
• Re-establishment of physiologic equilibrium
• Alleviation of pain
• Prevention of complications
Postoperative Management
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Maintain a patent airway
Stabilize vital signs
Ensure patient safety
Provide pain
Recognize & manage complications
When caring for post-surgical patient, think of
the “4 W’s”
• Wind: prevent respiratory
complications
• Wound: prevent infection
• Water: monitor I & O
• Walk: prevent thrombophlebitis
Complications
• Respiratory- atelectasis, pulm. Embolus
• Cardiovascular- venous thrombosis
• Gastrointestinal-Hiccoughs, N/V,abd.
Distention, paralytic ileus, stress ulcer.
• GU- urinary retention
• Hemorrhage-slipping of a ligature(suture)
• Wound infection• Wound dehiscence and evisceration-
Postoperative Pain Control
• What is the definition of Pain?
• As nurses, what do we need to remember
about the pain experience?
• What is the key reason to control
postoperative pain?