Intra-operative care
Definition
The intraoperative
phase extends from the time the client is admitted to the
operating room, to the time of anesthesia administration, performance of the
surgical procedure and until the client is transported to the recovery room or
postanesthesia care unit (PACU).
Throughout the
surgical experience the nurse functions as the patient’s chief advocate. The
nurse’s care and concern extend from the time the patient is prepared for and
instructed about the forthcoming surgical procedure to the immediate
preoperative period and into the operative phase and recovery from anesthesia.
The patient needs the security of knowing that someone is providing protection
during the procedure and while he is anesthetized because surgery is usually a
stressful experience.
Contents
1. Goals
1.
Promote the principle of asepsis
asepsis.
2.
Homeostasis
3.
Safe administration of anesthesia
4.
Hemostasis
2. The Surgical
Team
The
intraoperative phase begins when the patient is received in the surgical area
and lasts until the patient is transferred to the recovery area. Although the
surgeon has the most important role in this phase, there are key members of the
surgical team.
1.
Surgeon – leader of the surgical
team. He or she is ultimately responsible for performing the surgery
effectively and safely; however, he is dependent upon other members of the team
for the patient’s emotional well being and physiologic monitoring.
2.
Anesthesiologist or anesthetist –
provides smooth induction of the patient’s anesthesia in order to prevent pain.
This member is also responsible for maintaining satisfactory degrees of
relaxation of the patient for the duration of the surgical procedure. Aside
from that, the anesthesiologist continually monitors the physiologic status of the
patient for the duration of the surgical procedure and the physiologic status
of the patient to include oxygen exchange, systemic circulation, neurologic
status, and vital signs. He or she then informs and advises the surgeon of
impending complications.
3.
Scrub Nurse or Assistant – a nurse
or surgical technician who prepares the surgical set-up, maintains surgical
asepsis while draping and handling instruments, and assists the surgeon by
passing instruments, sutures, and supplies.
4.
Circulating Nurse – respond to
request from the surgeon, anesthesiologist or anesthetist, obtain supplies,
deliver supplies to the sterile field, and carry out the nursing care plan.
3. Nursing
Functions
Circulating Nurse
The circulating
nurse manages the operating room and protects the safety and health needs
of the patient by monitoring activities of members of the surgical team and
checking the conditions in the operating room. Responsibilities of a
circulation nurse are the following:
1.
Assures cleanliness in the OR.
2.
Guarantees the proper room temperature,
humidity and lighting in OR.
3.
Make certain that equipments are safely
functioning.
4.
Ensure that supplies and materials are
available for use during surgical procedures.
5.
Monitors aseptic technique while
coordinating the movement of related personnel.
6.
Monitors the patient throughout the
operative procedure to ensure the person’s safety and well being.
Scrub Nurse
The scrub
nurse assists the surgeon during the whole procedure by anticipating the
required instruments and setting up the sterile table. The responsibilities of
the scrub nurse are:
1.
Scrubbing for surgery.
2.
Setting up sterile tables.
3.
Preparing sutures and special
equipments.
4.
Assists the surgeon and assistant during
the surgical procedure by anticipating the required instruments, sponges,
drains and other equipment.
5.
Keeps track of the time the patient is
under anesthesia and the time the wound is open.
6.
Checks equipments and materials such as
needles, sponges and instruments as the surgical incision is closed.
Classification of Physical
Status for Anesthesia Before Surgery
The
anesthesiologist should visit the patient before the surgery to provide
information, answer questions and allay fears that may exist in the patient’s
mind.
The choice of
anesthetic agent will be discussed and the patient has an opportunity to
disclose and the patient has opportunity to disclose previous reactions and
information about any medication currently being taken that may affect the
choice of an agent. Aside from that, the patient’s general condition must also
be assessed because it may affect the management of anesthesia. Thus, the
anesthesiologist assesses the patient’s cardiovascular system and lungs.
Inquiry about
preexisting pulmonary infection sand the extent to which the patient smokes
must also be determined. The classification of a client’s physical status for
anesthesia before surgery is summarized below.
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Classification of
Physical Status for Anesthesia Before Surgery
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Classification
|
Description
|
Example
|
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Good
|
No
organic disease; no systemic disturbance
|
Uncomplicated
hernias, fracture
|
|
Fair
|
Mild to
moderate systemic disturbance
|
Mild
cardiac (I and II) disease, mild diabetes
|
|
Poor
|
Severe
systemic disturbance
|
Poorly
controlled diabetes, pulmonary complications, moderate cardiac (III) disease
|
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Serious
|
Systemic
disease threatening life
|
Severe
renal disease, severe cardiac disease (IV), decompensation
|
|
Moribund
|
Little
chance of survival but submitting to operation in desperation
|
Massive
pulmonary embolus, ruptured abdominal aneurysm with profound shock
|
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Emergency
|
Any of
the above when surgery is performed in an emergency situation
|
An
uncomplicated hernia that is now strangulated and associated with nausea and
vomiting.
|
Source: Brunner and Suddarth’s
Medical-Surgical Nursing by Smeltzer and Bare
4.Anesthesia
Anesthesia
controls pain during surgery or other medical procedures. It includes using
medicines, and sometimes close monitoring, to keep you comfortable. It can also
help control breathing, blood pressure, blood flow, and heart rate and rhythm,
when needed. Anesthetics are divided into two classes:
1.
Those that suspend sensation in the
whole body – General anesthesia
2.
Those that suspend sensation in certain
parts of the body – local, regional, epidural or spinal anesthesia
General Anesthesia
This type of anesthesia
promotes total loss of consciousness and sensation. General anesthesia is
commonly achieved when the anesthetic is inhaled or administered intravenously.
It affects the brain as well as the entire body. Types of general anesthesia
administration:
Volatile liquid
anesthetics – this type of anesthetic produces anesthesia when their
vapors are inhaled. Included in this group are the following:
1.
Halothane (Fluothane)
2.
Methoxyflurane (Penthrane)
3.
Enflurane (Ethrane)
4.
Isoflurane (Forane)
Gas
Anesthetics – anesthetics administered by inhalation and are ALWAYS
combined with oxygen. Included in this group are the following:
1.
Nitrous Oxide
2.
Cyclopropane
Stages
General
anesthesia consists of four stages, each of which presents a definite group of
signs and symptoms.
Stage
I: Onset or Induction or Beginning anesthesia.
This stage
extends from the administration of anesthesia to the time of loss of
consciousness. The patient may have a ringing, roaring or buzzing in the ears
and though still conscious, is aware of being unable to move the extremities
easily. Low voices or minor sounds appear distressingly loud and unreal during
this stage.
Stage
II: Excitement or Delirium.
Stage II extends
from the time of loss of consciousness to the time of loss of lid reflex. This
stage is characterized by struggling, shouting, talking, singing, laughing or
even crying. However, these things may be avoided if the anesthetic is
administered smoothly and quickly. The pupils become dilated but contract if
exposed to light. Pulse rate is rapid and respirations are irregular.
Stage
III: Surgical Anesthesia.
This stage
extends from the loss of lid reflex to the loss of most reflexes. It is reached
by continued administration of the vapor or gas. The patient now is unconscious
and is lying quietly on the table. Respirations are regular and the pulse rate
is normal.
Stage
IV: Overdosage or Medullary or Stage of Danger.
This stage is
reached when too much anesthesia has been administered. It is characterized by
respiratory or cardiac depression or arrest. Respirations become shallow, the
pulse is weak and thread and the pupils are widely dilated and no longer
contract when exposed to light. Cyanosis develops afterwards and death follows
rapidly unless prompt action is taken. To prevent death, immediate
discontinuation of anesthetic should be done and respiratory and circulatory
support is necessary.
Local Anesthesia
Local
anesthetics can be topical, or isolated just to the surface. These are
usually in the form of gels, creams or sprays. They may be applied to the skin
before the injection of a local anesthetic that works to numb the area more
deeply, in order to avoid the pain of the needle or the drug itself
(penicillin, for example, causes pain upon injection).
Regional anesthesia
Regional anesthesia
blocks pain to a larger part of the body. Anesthetic is injected around major
nerves or the spinal cord. Medications may be administered to help the patient
relax or sleep. Major types of regional anesthesia include:
1.
Peripheral nerve blocks. A nerve block
is a shot of anesthetic near a specific nerve or group of nerves. It blocks
pain in the part of the body supplied by the nerve. Nerve blocks are most often
used for procedures on the hands, arms, feet, legs, or face.
2.
Epidural and spinal anesthesia. This is
a shot of anesthetic near the spinal cord and the nerves that connect to it. It
blocks pain from an entire region of the body, such as the belly, hips, or
legs.
With regional
anesthesia, an anesthetic agent is injected around the nerved so that the area
supplied by these nerves is anesthetized. The effect depends on the type of
nerve involved. The patient under a spinal or local anesthesia is awake and
aware of his or her surroundings.
Regional
anesthesia carries more risks than local anesthesia, such as seizures and heart
attacks, because of the increased involvement of the central nervous system.
Sometimes regional anesthesia fails to provide enough pain relief or paralysis,
and switching to general anesthesia is necessary.
Spinal Anesthesia
This is a type
of conduction nerve block that occurs by introducing a local anesthetic into
the subarachnoid space at the lumbar level which is usually between L4 and L5.
Sterile technique is used as the spinal puncture is made and medication is
injected through the needle. The spread of the anesthetic agent and the level
of anesthesia depend on:
1.
the amount of fluid injected
2.
the speed with which it is injected
3.
positioning of the patient after
injection
4.
specific gravity of the agent
5.
Nursing
Assessment
The following
are nursing assessment after anesthesia:
1.
Monitoring vital signs.
2.
Observe patient and record the time when
motion and sensation of the legs and the toes return.
Side
Effects
1.
Some numbness or reduced feeling in part
of your body (local anesthesia)
2.
Nausea and vomiting.
3.
A mild drop in body temperature.
How do anesthesiologists determine the type of
anesthesia to be used?
The type of
anesthesia the anesthesiologist chooses depends on many factors. These include
the procedure the client is having and his or her current health.
Positioning
The nurse should
have an idea which patient position is required for a certain surgical
procedure to be performed. There are lots of factors to consider in positioning
the patient which includes the following:
1.
Patient should be in a comfortable
position as possible whether he or she is awake or asleep.
2.
The operative area must be adequately
exposed.
3.
The vascular supply should not be
obstructed by an awkward position or undue pressure on a part.
4.
There should be no interference with the
patient’s respiration as a result of pressure of the arms on the chest or
constriction of the neck or chest caused by a gown.
5.
The nerves of the client must be
protected from undue pressure. Serious injury or paralysis may result from
improper positioning of the arms, hands, legs or feet.
6.
Shoulder braces must be well padded to
prevent irreparable nerve injury.
7.
Patient safety must be observed at all
times.
8.
In case of excitement, the patient needs
gentle restraint before induction.
Nursing
Responsibilities
Here are the
nursing responsibilities during intraoperative phase:
1.
Safety is the highest priority.
2.
Simultaneous placement of feet. This is
to prevent dislocation of hip.
3.
Always apply knee strap.
4.
Arms should not be more than 90°
5.
Prepare and apply cautery pad. Cautery
is used to stop bleedin
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