1. Nursing Care of theNursing Care of the
Intraoperative PatientIntraoperative Patient
Sharon Haas, RN, MSN, CDN
Cardinal Stritch University
FA 2013

2. IntraoperativeIntraoperative
The nurses primary responsibility is toThe nurses primary responsibility is to
insure patient safetyinsure patient safety

3. Intraoperative CareIntraoperative Care
 Historically, took place in ORHistorically, took place in OR
 Current trend toCurrent trend to ↓↓ in-hospital surgeryin-hospital surgery
andand ↑↑ ambulatory proceduresambulatory procedures
 Healthier patientsHealthier patients
 Shorter proceduresShorter procedures
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

4. Intraoperative CareIntraoperative Care
 Specialties with highest numbers ofSpecialties with highest numbers of
surgical patientssurgical patients
 OphthalmologyOphthalmology
 GynecologyGynecology
 Plastic surgeryPlastic surgery
 OtorhinolaryngologyOtorhinolaryngology
 Orthopedic surgeryOrthopedic surgery
 General surgery (e.g., hernia repair)General surgery (e.g., hernia repair)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

5. Intraoperative CareIntraoperative Care
 Nursing care requires an understanding ofNursing care requires an understanding of
 AnesthesiaAnesthesia
 PharmacologyPharmacology
 SurgerySurgery
 Surgical interventionsSurgical interventions
 Allows you to monitor patient’s responseAllows you to monitor patient’s response
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

6. Intraoperative CareIntraoperative Care
 You must keep current onYou must keep current on
technologies.technologies.
 Maintain asepsis in the surgicalMaintain asepsis in the surgical
environment.environment.
 Continue to be a strong advocate forContinue to be a strong advocate for
the patient.the patient.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

7. Physical EnvironmentPhysical Environment
 Holding areaHolding area
 Waiting area inside or adjacent toWaiting area inside or adjacent to
surgical areasurgical area
 Final identification and assessmentFinal identification and assessment
 Friends/family allowedFriends/family allowed
 Surgical Care Improvement ProjectSurgical Care Improvement Project
(SCIP) measures to implement here(SCIP) measures to implement here
 Patient warmingPatient warming
 Prophylactic antibiotic administrationProphylactic antibiotic administration
 Application of sequential compressionApplication of sequential compression
devicesdevices
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

8. Surgical SuiteSurgical Suite
Unrestricted Areas Semi-Restricted Areas Restricted Areas
Personnel in street
clothes interact with
those in scrubs.
Holding area
Locker room
Information areas
Nursing station
Control desk
Peripheral support
areas and corridors
with only authorized
people
Must wear surgical
attire and cover all
head and facial hair
Operating rooms
Scrub sink areas
Clean core
Surgical attire, head
covers, and masks
required

10. Surgical TeamSurgical Team
 Perioperative NursePerioperative Nurse
 Prepares the room with the teamPrepares the room with the team
 Patient AdvocatePatient Advocate
 Circulating NurseCirculating Nurse
 Not scrubbed, gowned or glovedNot scrubbed, gowned or gloved
 Remains in unsterile fieldRemains in unsterile field
 DocumentsDocuments
 Scrub NurseScrub Nurse
 Scrubbed inScrubbed in
 Remains in sterile fieldRemains in sterile field

11. Nursing ManagementNursing Management
 Safety considerationsSafety considerations
 Smoke particlesSmoke particles
 Grounding padGrounding pad
 Universal protocolUniversal protocol
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

12. Circulating NurseCirculating Nurse
Responsible for all of the activities within theirResponsible for all of the activities within their
assigned ORassigned OR
 Set-up for the procedureSet-up for the procedure
 Checks equipmentChecks equipment
 Primary RN who communicates with the ptPrimary RN who communicates with the pt
 Positions patient on the OR tablePositions patient on the OR table
 Preps surgical sitePreps surgical site

13. Nursing ManagementNursing Management
 Positioning of patientPositioning of patient
 Accessibility of operative siteAccessibility of operative site
 Administration and monitoring ofAdministration and monitoring of
anesthetic agentsanesthetic agents
 Maintenance of airwayMaintenance of airway
 Correct skeletal alignmentCorrect skeletal alignment
 Prevent pressure on nerves, skin, bonyPrevent pressure on nerves, skin, bony
prominences, or eyes.prominences, or eyes.
 Provide for adequate thoracic excursion.Provide for adequate thoracic excursion.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

14. Nursing ManagementNursing Management
 Positioning of patientPositioning of patient
 Prevent occlusion of arteries and veins.Prevent occlusion of arteries and veins.
 Provide modesty in exposure.Provide modesty in exposure.
 Recognize and respect needs such asRecognize and respect needs such as
pain or deformities.pain or deformities.
 Prevent injuryPrevent injury
 Patient will not feel pain impulses because ofPatient will not feel pain impulses because of
anesthesia.anesthesia.
 Secure extremities.Secure extremities.
 Provide adequate padding and support.Provide adequate padding and support.Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.

15. OR PositioningOR Positioning

16. ScrubScrub NurseNurse
Sets up the sterile field and sterile instruments to be usedSets up the sterile field and sterile instruments to be used
in the procedurein the procedure
Provides surgeon with instrumentsProvides surgeon with instruments
MUST understand anatomy and physiology of the bodyMUST understand anatomy and physiology of the body
Maintain accurate sponge and needle count throughoutMaintain accurate sponge and needle count throughout
procedureprocedure
Accounts for all instrumentsAccounts for all instruments
Accounts for all irrigation fluid usedAccounts for all irrigation fluid used

18. AnesthesiaAnesthesia
Anesthesia is an artificially induced state of partialAnesthesia is an artificially induced state of partial
or total loss of sensation, occurring with oror total loss of sensation, occurring with or
without loss of consciousnesswithout loss of consciousness

20. Elsevier items and derived items © 2006 by Elsevier Inc.
General AnesthesiaGeneral Anesthesia
 Reversible loss of consciousnessReversible loss of consciousness
 Central nervous system is depressed, resulting in analgesia,Central nervous system is depressed, resulting in analgesia,
amnesia, and unconsciousness, with loss of muscle tone andamnesia, and unconsciousness, with loss of muscle tone and
reflexes.reflexes.
 Technique of choice for surgeries with significant duration orTechnique of choice for surgeries with significant duration or
that require relaxation/uncomfortable position/control ofthat require relaxation/uncomfortable position/control of
respirationrespiration
 Loss of sensation with loss of consciousnessLoss of sensation with loss of consciousness
 May be induced by IV or inhalationMay be induced by IV or inhalation

21. Elsevier items and derived items © 2006 by Elsevier Inc.
Stages of GeneralStages of General
AnesthesiaAnesthesia
 Stage 1: analgesiaStage 1: analgesia
 Stage 2: excitementStage 2: excitement
 Stage 3: operativeStage 3: operative
 Stage 4: dangerStage 4: danger

22. Types of AnesthesiaTypes of Anesthesia
 InhalationInhalation: intake and excretion of anesthetic gas or: intake and excretion of anesthetic gas or
vapor to the lungs through a maskvapor to the lungs through a mask
 Intravenous injectionIntravenous injection: barbiturates, ketamine, and: barbiturates, ketamine, and
propofol through the bloodpropofol through the blood
 Adjuncts to general anesthetic agentsAdjuncts to general anesthetic agents: hypnotics, opioid: hypnotics, opioid
analgesics, neuromuscular blocking agentsanalgesics, neuromuscular blocking agents

23. Elsevier items and derived items © 2006 by Elsevier Inc.
Balanced AnesthesiaBalanced Anesthesia
 Combination of intravenous drugs and inhalation agentsCombination of intravenous drugs and inhalation agents
used to obtain specific effectsused to obtain specific effects
 Combination used to provide hypnosis, amnesia,Combination used to provide hypnosis, amnesia,
analgesia, muscle relaxation, and reduced reflexes withanalgesia, muscle relaxation, and reduced reflexes with
minimal disturbance of physiologic functionminimal disturbance of physiologic function

24. Cascade to MalignantCascade to Malignant
HyperthermiaHyperthermia
 MH susceptible person – mutation resulting in abnormal proteins in
muscle cells
 Exposure to anesthetic agent
 Abnormal release of Carelease of Ca++++
inside muscle cellinside muscle cell
 Sustained muscle contraction & the abnormal increase in energy
utilization and heat production
 Muscle cells eventually run out of energy and die
 Large amounts of K+ are released into the bloodstream, 
heart rhythm abnormalities.
 Muscle pigment myoglobin is also released and may be toxic to the
kidney
 Left untreated, these changes can cause cardiac arrest, kidney
failure, blood coagulation problems, internal hemorrhage, brain
injury, liver failure, and may be fatal.

25. Malignant Hyperthermia
 The general signs of the MH crisis include
tachycardia, increased body metabolism, muscle
rigidity and/or fever that may exceed 110°F (43°C).
 Severe complications include: cardiac arrest, brain
damage, internal bleeding or failure of other body
systems. Thus, death, primarily due to a secondary
cardiovascular collapse, can result.

26. Elsevier items and derived items © 2006 by Elsevier Inc.
Complications from General AnesthesiaComplications from General Anesthesia
 Malignant hyperthermia: TX: DantroleneMalignant hyperthermia: TX: Dantrolene
 OverdoseOverdose
 Unrecognized hypoventilationUnrecognized hypoventilation
 Complications of specific anesthetic agentsComplications of specific anesthetic agents
 Complications of intubationComplications of intubation

27. WHAT DRUGS TRIGGER
MH?
 Volatile gaseous inhalation anesthetics:
 Sevoflurane
 Desflurane
 Isoflurane
 Halothane
 Enflurane
 methoxyflurane
 Depolarizing muscle relaxant:
 Succinylcholine (Anectine)

28. Elsevier items and derived items © 2006 by Elsevier Inc.
Local or Regional AnesthesiaLocal or Regional Anesthesia
 Sensory nerve impulse transmission from a specific bodySensory nerve impulse transmission from a specific body
area or region is briefly disrupted.area or region is briefly disrupted.
 Motor function may be affected.Motor function may be affected.
 Client remains conscious and able to follow instructions.Client remains conscious and able to follow instructions.
 Gag and cough reflexes remain intact.Gag and cough reflexes remain intact.
 Sedatives, opioid analgesics, or hypnotics are often usedSedatives, opioid analgesics, or hypnotics are often used
as supplements to reduce anxiety.as supplements to reduce anxiety.

29. Elsevier items and derived items © 2006 by Elsevier Inc.
Local AnesthesiaLocal Anesthesia
 Topical anesthesiaTopical anesthesia
 Local infiltrationLocal infiltration
 Regional anesthesiaRegional anesthesia
 Field blockField block
 Nerve block (brachial plexus,Nerve block (brachial plexus,
retrobulbar)retrobulbar)
 Spinal anesthesiaSpinal anesthesia
 Epidural anesthesiaEpidural anesthesia

30. Advantages/DisadvantagesAdvantages/Disadvantages
ofof
Local or Regional AnesthesiaLocal or Regional Anesthesia
 Little systemic absorptionLittle systemic absorption
 Rapid recoveryRapid recovery
 Little residual “hangover”Little residual “hangover”
 Possible discomfort, hypotension, andPossible discomfort, hypotension, and
seizuresseizures
 Technical difficultiesTechnical difficulties

31. Elsevier items and derived items © 2006 by Elsevier Inc.
Complications of Local or RegionalComplications of Local or Regional
AnesthesiaAnesthesia
 AnaphylaxisAnaphylaxis
 Incorrect delivery techniqueIncorrect delivery technique
 Systemic absorptionSystemic absorption
 OverdoseOverdose
 Assess for central nervous system stimulationAssess for central nervous system stimulation
 Central nervous system and cardiac depressionCentral nervous system and cardiac depression
 RestlessnessRestlessness
 ExcitementExcitement

32. Elsevier items and derived items © 2006 by Elsevier Inc.
Complications of Local or RegionalComplications of Local or Regional
AnesthesiaAnesthesia (Continued)(Continued)
 Incoherent speechIncoherent speech
 HeadacheHeadache
 Blurred visionBlurred vision
 Metallic tasteMetallic taste
 Nausea and vomitingNausea and vomiting
 Tremors or seizuresTremors or seizures
 TachycardiaTachycardia
 TachypneaTachypnea
 HypertensionHypertension

33. Elsevier items and derived items © 2006 by Elsevier Inc.
Treatment of ComplicationsTreatment of Complications
 Establish an open airway.Establish an open airway.
 Give oxygen.Give oxygen.
 Notify the surgeon.Notify the surgeon.
 Fast-acting barbiturate is usual treatment.Fast-acting barbiturate is usual treatment.
 If toxic reaction is untreated, unconsciousness,If toxic reaction is untreated, unconsciousness,
hypotension, apnea, cardiac arrest, and deathhypotension, apnea, cardiac arrest, and death
may result.may result.

34. Monitored Anesthesia Care (MAC)Monitored Anesthesia Care (MAC)
Conscious SedationConscious Sedation
 IV delivery of sedative, hypnotic, and opioid drugs reduces theIV delivery of sedative, hypnotic, and opioid drugs reduces the
level of consciousness but allows the client to maintain alevel of consciousness but allows the client to maintain a
patent airway and to respond to verbal commands.patent airway and to respond to verbal commands.
 Diazepam, midazolam, meperidine, fentanyl, alfentanil, andDiazepam, midazolam, meperidine, fentanyl, alfentanil, and
morphine sulfate are the most commonly used drugs.morphine sulfate are the most commonly used drugs.
 Nursing assessment of airway, level of consciousness, oxygenNursing assessment of airway, level of consciousness, oxygen
saturation, electrocardiographic status, and vital signs are monitoredsaturation, electrocardiographic status, and vital signs are monitored
every 15 to 30 minutes.every 15 to 30 minutes.

35. Elsevier items and derived items © 2006 by Elsevier Inc.
Impaired Skin Integrity and ImpairedImpaired Skin Integrity and Impaired
Tissue IntegrityTissue Integrity
Interventions include:Interventions include:
 Plastic adhesive drapePlastic adhesive drape
 Skin closures, sutures and staples, non-Skin closures, sutures and staples, non-
absorbable suturesabsorbable sutures
 Insertion of drainsInsertion of drains
 Application of dressingApplication of dressing
 Transfer of client from the operating roomTransfer of client from the operating room
table to a stretchertable to a stretcher

36. Elsevier items and derived items © 2006 by Elsevier Inc.
Potential for HypoventilationPotential for Hypoventilation
 Continuous monitoring of:Continuous monitoring of:
 BreathingBreathing
 CirculationCirculation
 Cardiac rhythmsCardiac rhythms
 Blood pressure and heart rateBlood pressure and heart rate
 Continuous presence of an anesthesiaContinuous presence of an anesthesia
providerprovider

37. Nursing ManagementNursing Management
 After surgeryAfter surgery
 ACP and perioperative team memberACP and perioperative team member
take patient to PACU and give report.take patient to PACU and give report.
 Perioperative nursing data set (PNDS)Perioperative nursing data set (PNDS)
reflects standards of nursing care in anyreflects standards of nursing care in any
perioperative setting.perioperative setting.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate
of Elsevier Inc.