Intraoperative Phase - Perioperative Nursing

The intraoperative phase runs from the moment the patient enters the operating room, through anesthesia and the procedure, until transfer to the recovery room or postanesthesia care unit (PACU). Throughout it the nurse is the patient's chief advocate. The patient is anesthetized and cannot protect himself, so someone has to guard his safety and physiologic status the whole time. That is the job.

Goals

Promote asepsis, maintain homeostasis, deliver anesthesia safely, and maintain hemostasis.

The Surgical Team

The surgeon leads the team and is ultimately responsible for performing the surgery effectively and safely, but depends on the team for the patient's emotional well-being and physiologic monitoring. The anesthesiologist or anesthetist induces anesthesia smoothly to prevent pain, maintains adequate relaxation for the duration of the case, and continually monitors oxygen exchange, systemic circulation, neurologic status, and vital signs, advising the surgeon of impending complications. The scrub nurse or surgical technician prepares the sterile setup, maintains surgical asepsis while draping and handling instruments, and passes instruments, sutures, and supplies. The circulating nurse responds to requests from the surgeon and anesthesia provider, obtains and delivers supplies to the sterile field, and carries out the nursing care plan.

Nursing Functions

Circulating Nurse

The circulating nurse manages the operating room and protects the patient by monitoring the surgical team and the room conditions. Responsibilities: assure cleanliness in the OR; guarantee proper room temperature, humidity, and lighting; confirm equipment is functioning safely; ensure supplies and materials are available; monitor aseptic technique while coordinating personnel movement; and monitor the patient throughout the procedure to ensure safety and well-being.

Scrub Nurse

The scrub nurse assists the surgeon by anticipating needed instruments and setting up the sterile field. Responsibilities: scrub for surgery; set up sterile tables; prepare sutures and special equipment; assist the surgeon and assistant by anticipating instruments, sponges, drains, and equipment; track how long the patient is under anesthesia and how long the wound is open; and account for needles, sponges, and instruments as the incision is closed.

Classification of Physical Status for Anesthesia Before Surgery

The anesthesiologist visits the patient before surgery to provide information, answer questions, and allay fears. The anesthetic agent is discussed, and the patient discloses previous anesthetic reactions and any current medications that may affect the choice of agent. General condition is assessed because it affects anesthesia management, so the anesthesiologist evaluates the cardiovascular system and lungs and asks about preexisting pulmonary infection and how much the patient smokes.

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 .

Anesthesia

Anesthesia controls pain during surgery using medicines and close monitoring to keep the patient comfortable, and it can help control breathing, blood pressure, blood flow, and heart rate and rhythm when needed. Anesthetics fall into two classes: those that suspend sensation in the whole body (general anesthesia) and those that suspend sensation in a region (local, regional, epidural, or spinal anesthesia).

General Anesthesia

General anesthesia causes total loss of consciousness and sensation, usually achieved by inhalation or IV administration, and affects the brain and the entire body. Volatile liquid anesthetics produce anesthesia when their vapors are inhaled: halothane (Fluothane), methoxyflurane (Penthrane), enflurane (Ethrane), and isoflurane (Forane). Gas anesthetics are inhaled and are always combined with oxygen: nitrous oxide and cyclopropane.

General anesthesia has four stages, each with a distinct set of signs.

Stage I (onset, induction, beginning anesthesia) runs from administration to loss of consciousness. The patient may have ringing, roaring, or buzzing in the ears and, though still conscious, feels unable to move the extremities easily; low voices and minor sounds seem distressingly loud and unreal.

Stage II (excitement, delirium) runs from loss of consciousness to loss of the lid reflex. It is marked by struggling, shouting, talking, singing, laughing, or crying, which can be avoided if the anesthetic is given smoothly and quickly. Pupils dilate but constrict to light. Pulse is rapid and respirations are irregular.

Stage III (surgical anesthesia) runs from loss of the lid reflex to loss of most reflexes. The patient is unconscious and lies quietly, respirations are regular, and the pulse rate is normal.

Stage IV (overdosage, medullary, stage of danger) is reached when too much anesthesia has been given. It brings respiratory or cardiac depression or arrest: respirations become shallow, the pulse is weak and thready, and the pupils are widely dilated and no longer constrict to light. Cyanosis follows and death comes rapidly unless action is immediate. Stop the anesthetic at once and provide respiratory and circulatory support.

Local Anesthesia

Local anesthetics can be topical, isolated to the surface, usually as gels, creams, or sprays. They may be applied to the skin before injecting a deeper local anesthetic to avoid the pain of the needle or the drug itself (penicillin, for example, hurts on injection).

Regional Anesthesia

Regional anesthesia blocks pain to a larger part of the body by injecting anesthetic around major nerves or the spinal cord; medications may be added to help the patient relax or sleep. Major types include peripheral nerve blocks (anesthetic near a specific nerve or group of nerves, blocking pain in the area that nerve supplies, used most often for the hands, arms, feet, legs, or face) and epidural and spinal anesthesia (anesthetic near the spinal cord and its connecting nerves, blocking pain from an entire region such as the belly, hips, or legs). The patient under spinal or local anesthesia is awake and aware. Regional anesthesia carries more risk than local, including seizures and heart attacks, because of greater central nervous system involvement, and sometimes it fails to provide enough pain relief or paralysis, requiring a switch to general anesthesia.

Spinal Anesthesia

Spinal anesthesia is a conduction nerve block created by introducing a local anesthetic into the subarachnoid space at the lumbar level, usually between L4 and L5. Use sterile technique for the spinal puncture and inject medication through the needle. The spread of the agent and the level of anesthesia depend on the amount of fluid injected, the speed of injection, the patient's position after injection, and the specific gravity of the agent.

After anesthesia, monitor vital signs and record the time when motion and sensation return to the legs and toes. Side effects include numbness or reduced feeling in part of the body (local anesthesia), nausea and vomiting, and a mild drop in body temperature.

The anesthesiologist chooses the type of anesthesia based on the procedure and the patient's current health.

Positioning

Know which position a given surgical procedure requires. Position the patient as comfortably as possible whether awake or asleep, expose the operative area adequately, and avoid obstructing vascular supply with an awkward position or undue pressure. Do not interfere with respiration through pressure of the arms on the chest or constriction of the neck or chest by a gown. Protect the nerves from undue pressure, since improper positioning of the arms, hands, legs, or feet can cause serious injury or paralysis, and pad shoulder braces well to prevent nerve injury. Observe patient safety at all times, and use gentle restraint before induction if the patient is agitated.

Nursing Responsibilities

Safety is the highest priority. Place the feet simultaneously to prevent hip dislocation. Always apply the knee strap. Keep the arms abducted no more than 90 degrees. Prepare and apply the cautery pad; cautery is used to stop bleeding.