Intraoperative Nursing Care
You may have heard the term perioperative nursing—this encompasses the preoperative, intraoperative, and postoperative phases of the patient’s surgical experience. This video will focus on intraoperative nursing care.
Nursing responsibilities during the intraoperative phase include continuing the assessment of the patient’s physiologic and psychologic status, promoting safety and privacy, preventing wound infection, and promoting healing.
The surgical team must work together to deliver safe and effective care to the patient in the intraoperative phase. The team is divided into categories based on responsibilities, and consists of the primary surgeon and assistants, the scrub tech/nurse, circulating nurse, and anesthesiologist. The surgeon, assistant, and scrub tech work in the sterile field, while the circulating nurse, anesthesiologist, and other personnel function outside the sterile field.
The circulating nurse is an RN with several responsibilities, including.
- Coordinating patient care before, during, and after the surgical procedure
- Providing emotional support to the patient and assisting the anesthesiologist during the initiation of anesthesia
- Ensuring patient safety, positioning and monitoring the patient, and enforcing policies and procedures throughout the surgery – including a “time out”
- Maintaining sterile technique while providing supplies and equipment for the sterile team
- Documenting all nursing care during the intraoperative period and making sure that surgical specimens are labeled correctly and placed in the appropriate media
- Recognizing and resolving environmental hazards that involve the patient or surgical team, including protecting the patient from electrical hazards
- Ensuring with the scrub tech that all sponge, instrument, and sharps counts are completed and documented
- And communicating relevant information to family members and other healthcare workers outside the OR
The surgical environment is designed to provide a safe therapeutic environment for the patient. Traffic in and out of the operating suite is kept to a minimum to decrease potential contamination from air turbulence and bacterial shedding. Floors, walls, and ceilings are made of materials that are easy to clean with antimicrobial agents. The temperature in the OR is kept between 68 and 75 degrees to reduce the risk of infection. The relative humidity is kept between 40 to 60%, which diminishes bacterial growth and restricts static electricity.
Aseptic technique involves following practices that prevent contamination from pathogens and must be followed by all members of the OR team to reduce the risk of surgical site infections. The Association of periOperative Registered Nurses (AORN) has “Perioperative Standards and Recommended Practices” for asepsis that include the following:
- Scrubbed persons should function within a sterile field.
- Sterile drapes should be used to establish a sterile field.
- Items used within a sterile field should be sterile.
- All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity.
- A sterile field should be maintained and monitored constantly.
- All personnel moving within or around a sterile field should do so in a manner that maintains the sterile field. (Sterile persons remain close to the sterile field and never turn their backs to it.)
- Policies and procedures for maintaining a sterile field should be developed, reviewed periodically, and readily available in the practice setting.
Individuals working in the OR are a major source of microbial contamination to the environment due to the large quantities of bacteria in the respiratory tract and on the skin, hair, and clothes. Surgical attire is required to reduce the patient’s risk of surgical site infection (SSI) from microorganisms and also to protect personnel from exposure to hazardous substances and infectious microorganisms.
Everyone in the OR will need to wear a surgical cap, mask, and shoe/boot covers. Dressing in OR attire progresses from head to toe—surgical hat first (to prevent the shedding of microbes from the head/hair to the scrubs), then surgical scrub suit, face mask and safety eyewear, and shoe/boot covers. Non-sterile team members should wear a long-sleeve scrub jacket. Those in the sterile field will also perform a surgical scrub of hands and arms before entering the OR to put on a sterile gown and gloves. Double gloving is recommended and has many benefits including preventing SSI and protecting the hands of healthcare providers.
Patient Skin Preparation
Patient skin preparation involves the patient showering thoroughly with an antiseptic wash prior to surgery. The intraoperative circulating nurse will be involved in hair removal from the surgical site (when necessary) and cleaning the incision site with skin antiseptic, using the manufacturer’s recommendation for contact and drying time. Skin preparation begins with mechanical scrubbing at the incision site, moving out in a circular fashion, away from the site. The sponge is considered contaminated when it reaches the outer edge and is then discarded. A new sponge is used each time the area is scrubbed.
Once the patient is prepped and draped in the OR, the circulating nurse usually initiates the “time-out” that takes place between the entire surgical team. The time-out is a verbal agreement that includes, at a minimum, the following: correct patient identity, correct site, and correct procedure to be performed. If implants or radiologic exams are involved, these should be verified at this time also. Document the completion of the time-out, indicating that everything has been verified and agreed upon.
The circulating RN plays a role in assisting the anesthesiologist with anesthesia. Anesthesia may be limited loss of feeling or total loss of feeling, with or without loss of consciousness. There are three main types of anesthesia: local, regional, and general. General anesthesia produces unconsciousness, regional anesthesia creates a loss of sensation in a particular area, and local anesthetic agents may be used alone or in conjunction with other anesthesia. The OR nurse needs to know the various types of anesthetics used in surgery, methods of administration, and the potential side effects and complications, in order to assist the anesthesia team.
Types of Anesthesia
Let’s look at a brief overview of the types of anesthesia. Local anesthetics block the conduction of pain impulses, affecting motor and sensory nerves. The nurse should be aware of signs of toxicity, including tachypnea, tachycardia or bradycardia, tinnitus, drowsiness, metallic taste, numbness around the mouth, paresthesias, tremors, seizures, and coma.
Regional anesthesia uses local anesthetics to cause a temporary loss of sensation in a particular portion of the body. Types of regional anesthesia include a spinal, epidural, nerve block, and Bier block.
Spinal anesthesia is usually used for surgery on the lower abdomen, groin area, perineum, or lower extremities. The anesthetic agent is injected into the cerebrospinal fluid (CSF) in the subarachnoid space. Risks include hypotension, inadvertent high level of anesthesia that causes respiratory arrest and complete paralysis, neurologic complications, spinal headache, and infection.
Epidural anesthesia can be used for abdominal, genitourinary, and lower extremity procedures. It involves injecting the anesthetic agent into the epidural space, which is outside the CSF. Compared to a spinal, an epidural requires higher doses of anesthetic, has a slower onset, and is not dependent on the patient’s position for the level of anesthesia. The provider is able to titrate the dose throughout the procedure. Risks include hypotension, headache, respiratory depression, and neurologic complications, but are not as common as with spinal anesthesia. Other risks include infection and a higher potential for failure than with a spinal.
Another regional anesthesia is the nerve block, in which the local anesthetic is injected around a peripheral nerve. A Bier block is an intravenous regional anesthetic, injected into the veins of an arm or leg while using a tourniquet to prevent the anesthetic from entering the systemic circulation. This technique must be limited to two hours or less, or tissue damage can occur from the use of the tourniquet.
Let’s look at the levels of sedation.
- Minimal sedation uses sedatives and anxiolytics that allow the patient to remain responsive and breathe independently.
- Moderate sedation and analgesia (also known as ‘conscious sedation’), is a drug-induced depression of consciousness in which the patient is able to respond purposefully to verbal commands and touch, maintain adequate spontaneous ventilation, and won’t remember anything from the procedure.
- Deep sedation and analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. Independent breathing may be impaired.
Phases of General Anesthesia
General anesthesia is the depression of the central nervous system by administration of drugs or inhalation agents. Patients are not arousable, even by painful stimuli, and respiratory and cardiovascular functions are often impaired. There are three phases of general anesthesia, including induction, maintenance, and emergence. The intraoperative nurse is involved in the induction of and emergence from general anesthesia of the patient.
Induction begins with the administration of the anesthetic agents. Endotracheal intubation is performed during this phase, while the nurse is at the patient’s bedside to provide support and to assist the anesthesiologist. The nurse may be asked to provide cricoid pressure before intubation, which prevents aspiration and regurgitation of stomach contents by obstructing the esophagus.
Once the patient is ready for positioning, skin prep, or incision, the patient is now in the maintenance phase of anesthesia, during which the anesthesiologist maintains the appropriate levels of anesthesia for the length of the procedure.
When the anesthesiologist begins to waken the patient, the emergence period has begun. The patient is extubated and the nurse needs to be available to assist the provider as needed with patient safety and comfort, since the patient may experience vomiting, shivering, or restlessness.
The intraoperative nurse also needs to be aware of the thermoregulatory response of the patient during surgery. General anesthetics, muscle relaxants, and opioids can all cause a decrease in body temperature. In the OR, the patient also loses core body heat due to the cool environment; infusion of IV fluids; cool skin prep solutions; cold, dry anesthetic gases; and escape through the surgical incision. The intraoperative nurse needs to take measures to keep the patient warm—covering exposed areas as much as possible with warmed blankets and using warmed IV solutions will help prevent hypothermia.
Occurring less often than hypothermia, is intraoperative hyperthermia, or an increase in body temperature of 3.6 degrees F per hour. It may be caused by sepsis, infection, or less commonly, malignant hyperthermia, in which the patient’s temperature may rise 1.8 to 3.6 degrees F every 5 minutes and may exceed 109.4 degrees F. It is a potentially fatal complication of general anesthesia, when there is a genetic defect in the muscle cell membrane, making the patient more susceptible. Along with the rising temperature, symptoms include muscle rigidity, respiratory and metabolic acidosis, and a fast heart rate.
Treatment includes immediately ceasing the causative agent, hyperventilating with 100% oxygen, cooling with ice packs or cooling blankets, restoring acid-base balance, treating hyperkalemia, and giving IV dantrolene (the antidote). Cooling measures should be stopped when the patient’s temperature reaches 100.4 degrees F.
Patient’s Psychosocial Needs
Caring for the patient in the intraoperative environment involves many technical activities; however, the nurse is also responsible for meeting the patient’s psychosocial needs. The operative phase is often short, and the patient may be sedated or unconscious most of the time. However, the intraoperative nurse has a significant impact on the patient’s response to the surgical experience. Surgery is a stressful experience for anyone, and providing explanations of procedures and events helps promote a sense of security and effective coping for the patient.
Thank you for watching this video tutorial about intraoperative nursing!