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Intraoperative Phase


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.

Goals

  1. Promote the principle of asepsis asepsis.
  2. Homeostasis
  3. Safe administration of anesthesia
  4. Hemostasis

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.

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
Classification Description Example
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
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
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

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.

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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:

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  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

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 bleeding.

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