4. Intraoperative Nursing Management
Learning Objectives
On completion of this lecture, the learner will be
able to :
1- Identify surgical team.
2- Describe the principles of surgical asepsis .
3- Identify adverse effect of surgery and anesthesia.
4- Identify surgical risk factor related to age group
and nursing interventions.
5- Compare various types of anesthesia.
6- Apply nursing process for optimizing patient
outcomes during the intraoperative period.
5. Intraoperative Nursing Care
Intraoperative phase
Begins when the patient is transferred into the
operating room and ends with his admission to the
post anesthesia recovery room (PARR) or post
anesthesia care unit (PACU).
7. Activity time, peer teaching
What do you know about surgical
team responsibilities ?
10 min
8. Surgical team (cont).
Surgeon- Responsible for :
- Determining the preoperative diagnosis,
- The choice and execution of the surgical procedure,
- The explanation of the risks and benefits.
- The postoperative management of the patient’s care.
9. Surgical team (cont).
Scrub nurse (RN or Scrub tech)- Responsible for:
- 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, and
supplies; sharps count.
10. Surgical team (cont).
Circulating Nurse - Responsible for:
Creating a safe environment,
Managing the activities outside the sterile field,
Providing nursing care to the patient.
Documenting intra-operative nursing care.
11. Circulating Nurse cont.
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.
12. Surgical team (cont).
Anesthesiologist / anesthetist- Responsible for:
- Anesthetizing the pt.
- Monitoring the pt’s physiologic status and
providing the best operative conditions for the
surgeons.
Other personnel- pathologist, radiologist, …..
13. The surgical environment
- The surgical environment is known for its
appearance and cool temperature.
- The surgical suite is behind double doors, and
access is limited to the authorized personnel.
14. The surgical environment
- To provide the best conditions for surgery, the
OR is suited in a location that is central to all
supporting services (pathology , radiology, and
laboratory).
- The OR has special air filtration devices to
screen out contamination items, dust, and
pollutant.
15. The surgical environment
The surgical area divided into three zones:
1- Unrestricted zone: where street clothes
are allowed.
2- Semirestricted zone: where attire
consists of scrub clothes and caps.
3- Restricted zone: where scrub clothes ,
masks are worn.
16.
17.
18.
19.
20. Health hazard associated with the
surgical environment
* physical
*psychological
*Biological
*Thermal
*electrical
22. 22
Preoperative Checklist
History and physical examination.
Name of procedure on surgical consent.
Signed surgical consent.
Laboratory results.
Client is wearing an identification bracelet.
Allergies have been identified.
NPO.
Skin preparation completed.
Vital signs assessed.
23. 23
Jewelry removed.
Dentures removed.
Client is wearing a hospital gown and hair cover.
Client has urinated.
Location of IV site, type of intravenous solution, rate of
infusion is identified.
The prescribed preoperative medication has been given.
27. Anesthesia
Anesthesia is a state of
narcosis ( sever central
nervous system depression
produced by
pharmacological agents).
28. Types of Anesthesia
Regional General
- Spinal or Epidural
at its trunk level (for whole leg)
- Peripheral nerve block
at the level of one of its roots (for specific part)
29. 29
Types of anesthesia cont.
1. General Anesthesia (inhaled or intravenously)
refers to drug – induced depression of the central
nervous system that produces analgesia, amnesia
and unconsciousness (affects whole body).
- General anesthesia consists of four stages, each
associated with specific clinical manifestation.
30. Stages of Anesthesia
*Stage 1: induction :Patient feel detachment
warmth, dizziness, though still conscious.
- The nurse avoid unnecessary noises
or motion.
*Stage 2: Excitement: as struggling, shouting,
singing , laughing or crying.
- the patient should be restrained
- anesthetic is administered smoothly.
31. Stages of Anesthesia cont.
*Stage 3:
Surgical Anesthesia: the patient is
unconscious and lies quietly on the table.
This stage may be maintained for hours .
32. Stages of Anesthesia cont.
*Stage 4 (overdose): Brain stem/Medullary depression:
this stage is reached when too much anesthesia has been
administered .
- Respiration become shallow.
- Pulse weak and thready.
- Pupils become widely dilated and no contract
in response to light.
- Cyanosis developed.
- Death rapidly follow.
If this stage develop, the anesthetic is discontinued
immediately.
33. Types of anesthesia cont.
2. Regional anesthesia: is a form of local
anesthesia that suspends sensation and motion in
body region or part; the client remains awake.
34. 34
Spinal Anesthesia is local anesthesia injected into the
subarachniod space at lumbar level between L4 and L5
to block nerves and suspend sensation and motion to
the lower extremities, perineum, and lower abdomen.
Types of anesthesia
52. Single Port Access Surgery
Advantages
Cosmetic: one incision! Basically scarless
Less pain
Quicker recovery
Disadvantages
Takes longer
Higher cost
Restricted degree of movement (tough on surgeon)
54. The Evolution of Robotic
Surgery
World’s first surgical robot, 1983
1st robotic cholecystectomy using PUMA, 1987
da Vinci Surgical Robot clears FDA, 1999-2000
1st robotic-assisted heart bypass in USA, 1999
Remote robotic chole USA to France, 2001
Robotic-assisted kidney transplant, 2009
da Vinci Single-Site Platform FDA-approved,
2011
56. Robotic Surgery
Benefits
More precise/range of motion
3D vision/magnified
Less bleeding
More comfortable for surgeon
Can be done remotely
Disadvantages
Cost?
Long set-up/procedure time
Higher learning curve
57. Robotic Surgery
Commonly used for
Urology (prostatectomy)
Cardiac (heart surgery)
Gynecology (hysterectomy)
Was previously thought to be
less useful in general
surgery…UNTIL NOW!
60. Single-Site Robotic Surgery
Compared to robotic multi-port surgery…
Advantages
Cosmetic (scarless!)
Less pain, quicker recovery
Disadvantages
Non-wristed instruments (not for long…)
61. Post- Anathesia Care unit (PACU)
LOCATION
Should be located close to the operating suite.
Immediate access to x-ray, blood bank, clinical labs.
An open ward is optimal for patient observation, with
at least one isolation room.
Piped in oxygen, air and vacuum suction.
Required good ventilation.
62. PACU equipment
Automated BP , pulse ox., ECG, and
intravenous supports should be located at each
bed.
Capability for arterial and CVP. Monitoring.
Supply of emergency equipment, crash chart,
Defibrillation.
63. Admission history
Preoperative history.
Intraoperative factors.
- procedure
- type of anesthesia.
- EBL (estimated blood loss).
- UO ( urinary output).
• Assessment and report of current status.
• Postoperative instructions.
64. 64
INITIAL POSTOPERATIVE ASSESSMENTS
Level of consciousness.
Vital signs.(every 15 minutes for 1 hour,
every 30 minutes for 2 hours and then,
every 4 hours for 24 hours)
Effectiveness of respirations.
Presence or need for supplemental oxygen.
Location of drains and drainage
characteristics.
Location, type, and rate of intravenous fluid.
Level of pain and need for analgesia.
Presence of a urinary catheter and urine
volume.
65. 65
Nursing Management During
Recovery From Surgery
Preventing respiratory complications.
Relieving pain.
Encouraging activity. (2 hr. po)
Promoting wound healing.
Maintaining normal body temperature.
Managing GI function.
Nutrition.
Monitor urinary function.
67. 1- Nausea and Vomiting
Nausea and vomiting, may affect patients
during the intraoperative period. If gagging
occurs.
68. Nursing role
The patient is turned to the side, the head of the
table is lowered, and a basin is provided to collect
the vomitus.
Suction is used .
In some cases, the anesthesiologist administers
antiemetic preoperatively or Intraoperatively to
counteract possible aspiration.
Pneumonia and pulmonary edema can
subsequently develop, leading to extreme hypoxia.
69. 2- Anaphylaxis
Anaphylaxis can occur to any anesthetic
agent and in all types of anaesthesia.
The severity of the reaction may vary but
features may include:
- Rash - Urticaria - Bronchospasm
- Hypotension and Vomiting.
70. Nursing role
- Looked for in the pre-operative assessment and previous
general anesthetic charts.
- Nurses must be aware of the type and method of
anesthesia used as well as the specific agents.
- Referred for further investigation to try to determine the
exact cause.
- The nurse should be alert to the possibility and observe
the patient for changes in vital signs and symptoms of
anaphylaxis when these products are used.
71. 3- Hypoxia and other respiratory
complications
Inadequate ventilation, occlusion of the airway,
and hypoxia are significant potential problems of
general anesthesia.
Many factors can contribute to inadequate
ventilation.
Respiratory depression caused by anesthetic agents,
aspiration of respiratory tract secretions or vomitus
or relaxation of the tongue,
and the patient’s position on the operating table can
compromise the exchange of gases.
72. Nurse role
Brain damage from hypoxia may occur within minutes,
assessment of the patient’s oxygenation status is a
primary function of the anesthesiologist or anesthetist
and the circulating nurse.
Peripheral perfusion is checked frequently,
and pulse oximetry values are monitored continuously.
73. 4- Hypothermia
During anesthesia, the patient’s temperature may fall.
Glucose metabolism is reduced, and as a result metabolic
acidosis may develop. This condition is called hypothermia
and is indicated by a:
Core body temperature below normal (36.6°C [98.0°F] or
lower).
In the OR, infusion of cold fluids, inhalation of cold gases,
Open body wounds or cavities,
Decreased muscle activity,
Advanced age, or the pharmaceutical agents used (eg,
vasodilators,, general anesthetics).
74. Hypothermia Prevention
The goal is safe return to normal body temperature.
Environmental temperature in the OR can
temporarily be set at 25° to 26.6°C (78° to 80°F).
Intravenous and irrigating fluids are warmed to
37°C (98.6°F).
75. Hypothermia Prevention cont.
Wet gowns and drapes are removed promptly and
replaced with dry materials because wet linens
promote heat loss.
Monitoring of core temperature, urinary output,
ECG, blood pressure,
76. 5- Malignant Hyperthermia
Malignant hyperthermia is a muscle disorder chemically
induced by anesthetic agents with the mortality rate exceeding
50%, identifying patients at risk for malignant hyperthermia
is imperative.
Susceptible people include :
Those with strong and bulky muscles,
A history of muscle cramps or muscle weakness
Temperature elevation
77. Clinical Manifestations
Tachycardia (heart rate above 150 beats/min) is often the
earliest sign.
Sympathetic nervous stimulation leads to ventricular
dysrhythmia,
Hypotension, decreased cardiac output, oliguria, and, later,
cardiac arrest.
With the abnormal transport of calcium, rigidity or tetanus-like
movements occur, often in the jaw.
The rise in temperature is actually a late sign that develops
rapidly; body temperature can increase 1° to 2°C (2° to 4°F)
every 5 minutes.
78. Medical Management
Although malignant hyperthermia usually presents
about 10 to 20 minutes after induction of
anesthesia, it can also occur in the first 24 hours
after surgery. As soon as the diagnosis is made,
Anesthesia and surgery are halted and the patient
is hyperventilated with 100% oxygen.
A skeletal muscle relaxant is administered
immediately
Continued monitoring of all parameters is
necessary to evaluate the patient’s status.
79. Nurse role
The nurse must identify patients at risk,
recognize the signs and symptoms,
have the appropriate medication and
equipment available,
Be knowledgeable about the protocol to
follow.
This information may be lifesaving.
80. 6- DISSEMINATED INTRAVASCULAR
COAGULOPATHY (DIC)
Disseminated intravascular coagulopathy is a life-
threatening condition characterized by;
- Thrombus formation
- The exact cause is unknown, but predisposing factors
include many conditions that may occur with emergency
surgery, such as:
* Massive trauma,
* Head injury,
* liver or kidney involvement, or shock.
81. Pathophysiology
In DIC, the normal hemostatic mechanisms are altered so
that a massive amount of tiny clots forms in the
microcirculation. Initially, the coagulation time is normal.
* The clinical manifestations of DIC are reflected in the
organs, which are affected either by excessive clot
formation (with resultant ischemia to all or part of the
organ) or by bleeding.
82. Pathophysiology cont.
The bleeding is characterized by low platelet and
fibrinogen levels; Prolonged PT, PTT, and thrombin
time.
The mortality rate can exceed 80% of patients who
develop DIC.
Identification of patients who are at risk for DIC and
recognition of the early clinical manifestations of this
syndrome can result in earlier medical intervention,
which may improve the prognosis.
83. Clinical Manifestations
Patients with DIC may bleed from mucous
membranes, venipuncture sites, and the
gastrointestinal and urinary tracts.
The bleeding can range from minimal occult internal
bleeding to profuse hemorrhage.
Patients may also develop organ dysfunction, such as
renal failure.
84. Medical Management
The most important management issue is treating the underlying cause
of the DIC.
A second goal is to correct the secondary effects of tissue ischemia by: *
improving oxygenation, * replacing fluids, correcting electrolyte
imbalances, administering vasopressor medications.
Cryoprecipitate is given to replace fibrinogen and factors V and VII.
A controversial method to interrupt the thrombosis process is the use of
heparin infusion.
85. NURSING DIAGNOSES
Based on the assessment data, major nursing
diagnoses for the patient with DIC may include the
following:
Risk for deficient fluid volume related to bleeding.
Risk for impaired skin integrity related to ischemia or
bleeding.
Potential for excess fluid volume related to excessive
blood/factor component replacement
Ineffective tissue perfusion related to microthrombi
Anxiety and fear of the unknown and possible death
88. Alcohol Based Hand Rub Versus Traditional Surgical Scrub Among Nursing
Students: Randomized Controlled Trial
By
Basma Magdy Korany, 2020
Students evaluation of sterilium met WHO
criteria for acceptability and
tolerability.There was more compliance and
preference to sterilium. Recommendation:
Applying ABHR as alternative to TIHS will
increase staff compliance and decrease hand
skin complication resulting from harsh
effect of PI.
89. A Formal Testing Model for Operating Room Control System Using
Internet of Things
Moez Krichen1 etal, 2021
A network of sensors and electronic components for measuring
temperature and humidity inside operating rooms.
A cloud layer based, which is used for storing and analyzing the data
sent by the sensors through the Raspberry card. •
A web application, which is used by the hospital managers to detect
variations in temperature and humidity in the operating rooms.
• An Android application developed with Android Studio that allows
to monitor variations in temperature and humidity in operating rooms.
•
A robot equipped with humidity and temperature sensors, controlled
by a mobile device via Bluetooth, which sends the collected values to
the Cloud
• A learning module that generates decision rules for controlling the
heating and cooling engines of the operating rooms.
90. Related Questions
True and false question.
A sterile field is an area free of microorganisms
that is able to receive sterile and nonsterile items.
T F.
91. Related Questions
MCQs:
A- In reviewing the chart of a patient to undergo general
anesthesia, which of the following is the greatest risk
factor? The patient who:
1- Expresses anxiety about the upcoming procedure.
2- Ate a snack within the last three hours.
3- Smoke and states his last cigarette was 24 hours ago.
4- Has a history of hypertension controlled by diet and
exercise.
92. Related Questions
b- The nurse is caring for a patient who is perioperative.
Which of the following is the priority nursing
intervention utilized to prevent infection in this client?
1- Preparation of the skin overlying the surgical site.
2- Maintenance of hemodynamic status.
3- Maintenance of client’s temperature.
4- Determination of estimated blood loss.
93. Related Questions
C- The nurse is caring for a patient in the immediate
postoperative period. Which of the following would
indicate that the client is becoming hypovolemic?
1- A diastolic blood pressure of 100 mm Hg.
2- The client complains of sever pain.
3- The client complains of anxiety.
4- Blood loss of 500 ml.
94. Related Questions
D- The nurse is caring for a client postoperatively
who has become hypothermic. The nurse’s best
action would be to:
1- position the client in a left lateral position.
2- administer an analgesic.
3- remove clothing saturated with blood.
4- monitor the intake and output.
95. Related Question
E- The nurse is obtaining a nursing history from a
client suspected to be at risk for malignant
hyperthermia, which of the following should the
nurse assess first to elicit the most accurate risk
assessment?
1- Previous history of complications associated with
surgery.
2- medication usage without explanation.
3- History of unexplained fever.
4- Drug allergies.
96. Related Question
F- Which of the following should the perioperative
nurse monitor when evaluating the presence of
ineffective thermoregulation in a client?
1- Cardiac rhythm.
2- Blood pressure.
3- Oxygen saturation level.
4- Temperature.
97. Related Question
G- Which of the following is the priority nursing
intervention that the nurse should perform for a
client in the immediate postoperative period?
1- establish a patent air way.
2- Maintain adequate blood pressure.
3- Establish level of consciousness.
4- assess level of pain.
98. Related Question
H- a client admitted to the post anesthesia care unit after
abdominal surgery, the nurse observe that the patient
suffering from wound dehiscence. The priority nursing
interventions would be to:
a. Increase the I.V. fluid rate.
b. Apply oxygen via nasal cannula at 8 L/min.
c. Cover the incision with a sterile dressing.
d. Contact the surgical team.
100. Reference
Brunner , Medical-Surgical Nursing .
Chapter 19.
• Krichen, M., Mechti, S., Alroobaea, R.,
Said, E., Singh, P., Khalaf, O. I., & Masud,
M. (2021). A formal testing model for
operating room control system using
internet of things. Computers, Materials &
Continua, 66(3), 2997-3011.
