Nursing Management

Intraoperative Care

The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.

Martin Luther King, Jr.

Reviewed by Ronald R. Castaldo, CRNA, MBA, MS, CCRN, Staff Nurse Anesthetist, Anesthesia Services, New Castle, Delaware; Lisa Kiper, RN, MSN, Assistant Professor of Nursing, Morehead State University, Morehead, Kentucky; Angela M. Martinelli, RN, PhD, CNOR, Science Officer, Congressionally Directed Medical Research Programs, Fort Detrick, Maryland; and Cynthia Schoonover, RN, MS, CCRN, Associate Nursing Professor, Sinclair Community College, Dayton, Ohio and PACU Staff Nurse, Kettering Medical Center, Kettering, Ohio.

Historically, surgery took place in the traditional environment of the hospital operating room (OR). However, now the majority of surgical procedures are performed as ambulatory surgery (outpatient surgery). This chapter includes a discussion of the intraoperative care that is applicable to all surgical patients regardless of where the surgery if performed.

Physical Environment of Operating Room

Surgical Team

Registered Nurse

The perioperative nurse is a registered nurse (RN) who implements patient care during the perioperative period. Through close collaboration with the other members of the surgical team, you prepare the OR for patients before they arrive. You are usually the first member of the surgical team who meets the patient. You are the patient’s advocate throughout the intraoperative experience. This includes maintaining the patient’s safety, privacy, dignity, and confidentiality; communicating with the patient; and providing physical care. Assess the patient to determine any additional needs or tasks to complete before surgery. Provide physical and emotional comfort and patient and caregiver teaching regarding the upcoming surgery. In addition, work with the patient’s caregivers, keeping them informed and answering questions. This is particularly important in day-surgery areas where caregivers must assume greater responsibility for preoperative and postoperative care.

In the perioperative role, you assume functions that involve either sterile or unsterile activities (Table 19-1). When you serve in the role of scrub nurse, you follow the designated scrub procedure, are gowned and gloved in sterile attire, and remain in the sterile field (Fig. 19-2). When you serve in the role of circulating nurse, you remain in the unsterile field and so you are not gowned and gloved in sterile attire.

TABLE 19-1

INTRAOPERATIVE ACTIVITIES OF PERIOPERATIVE NURSE

Circulating, Nonsterile Activities

• Reviews anatomy, physiology, and surgical procedure

• Assists in preparing room, ensuring that supplies and equipment are available, in working order, and sterile (if required)

• Maintains aseptic technique in all required activities

• Monitors practices of aseptic technique in self and others

• Checks mechanical and electrical equipment and environmental factors

• Conducts a preprocedure verification process

• Assesses patient’s physical and emotional status

• Verifies and implements ordered SCIP measures

• Plans and coordinates intraoperative nursing care

• Checks chart and relates pertinent data to team members

• Participates in the application of monitoring devices and insertion of invasive lines and other devices

• Assists with and ensures patient safety in transferring and positioning patient

• Assists with induction of anesthesia

• Monitors draping procedure

• Participates in surgical time-out

• Documents intraoperative care

• Prepares, records, labels, and sends blood, pathology, and any anatomic specimens to proper locations

• Measures blood, urine output, and other fluid loss

• Verifies, dispenses, and records medications used, including local anesthetics

• Coordinates all intraoperative activities with team members and other health-related staff and departments

• Maintains accurate count of sponges, needles, instruments, and medical devices that could be retained in the patient

• Accompanies patient to PACU

• Provides hand-off report to PACU nurse with information relevant to care of patient

Scrubbed, Sterile Activities

• Reviews anatomy, physiology, and surgical procedure

• Assists in preparing the operating room

• Completes surgical hand and arm scrub, and gowns and gloves self and other members of surgical team

• Prepares instrument table and organizes sterile equipment for functional use

• Assists with draping procedure

• Participates in surgical time-out procedure

• Passes instruments to surgeon and assistants by anticipating their needs

• Maintains accurate count of sponges, needles, instruments, and medical devices that could be retained in the patient

• Monitors practices of aseptic technique in self and others

• Keeps track of irrigation solutions used for calculation of blood loss

• Accepts, verifies, and reports medications used by surgeon and/or ACP, including local anesthetics

ACP, Anesthesia care provider; PACU, postanesthesia care unit; SCIP, Surgical Care Improvement Project.

Ongoing assessment of the patient is essential because the patient’s condition may change quickly. You respond to these changes and revise the plan of care as needed. Examples of nursing activities that characterize each phase surrounding the surgical experience are presented in Table 19-2.

TABLE 19-2

NURSING ACTIVITIES DURING SURGICAL EXPERIENCE *

Before	During	After
Assessment and Planning	Implementation	Evaluation
Home, Clinic, Holding Area Initiates preoperative assessment Plans teaching appropriate to patient’s needs Involves caregiver Surgical Unit Completes preoperative assessment Coordinates patient teaching with staff Develops a plan of care that reflects patient’s level of function and ability Surgical Suite Conducts preprocedure verification Assesses patient’s level of consciousness, skin integrity, mobility, emotional status, and functional limitations Reviews chart Ensures all supplies and equipment needed are available, functioning, and sterile, if appropriate	Safety Maintenance Ensures integrity of sterile field Ensures that sponge, needle, instrument, and medical device counts are correct Positions patient to ensure correct alignment, exposure of surgical site, and prevention of injury Prevents chemical injury from prepping solutions, pharmaceuticals, etc. Ensures safe use of electrical equipment Safely administers medications Monitoring Physical Status Monitors and reports changes in patient’s vital signs Monitors blood loss and urine output Monitoring Psychologic Status Provides emotional support to patient Stands near or touches patient during procedures Ensures patient’s right to privacy is maintained Communicates patient’s emotional status to health care team	Postanesthesia, Discharge Area Determines patient’s response to surgical intervention Monitors ABCs, vital signs, level of consciousness Safely administers medications Clinical Unit Evaluates effectiveness of nursing care in OR using patient outcome criteria Determines patient’s level of satisfaction with care given during perioperative period Determines patient’s psychologic status Assists with discharge planning Home, Clinic Seeks patient’s perception of surgery in terms of effects of anesthetic agents, impact on body image, immobilization Determines caregiver’s perceptions of surgery

ABCs, Airway, breathing, circulation.

^*List of activities is not all-inclusive.

As patients move through the surgical experience, they are cared for by many team members. Opportunities for error are created whenever clinical information is shared among these members.⁷ The Joint Commission requires that all health care providers implement a standardized approach to hand-off communication. The perioperative RN ensures that a complete and accurate hand-off using a consistent format, such as SBAR (see Table 1-7), occurs every time the responsibility for patient care is transferred to another professional. Examples of such transfers include change of shift, surgeon to nurse, and OR nurse to postanesthesia nurse.

You also have the opportunity to become a certified operating room nurse (CNOR). Certification reflects expertise in surgical nursing. The credential is a personal commitment to higher standards that inspires credibility and confidence with patients and peers in the workplace.⁸

Licensed Practical/Vocational Nurse and Surgical Technologist

Depending on your state nurse practice act, the role of the circulating or scrub nurse may be filled by a licensed practical/vocational nurse or a surgical technologist. Surgical technologists may attend an associate degree program, a vocational training program, or a hospital or military training program. The Association of Surgical Technologists is an organization that sets standards for education, provides continuing education opportunities, and offers certification for surgical technologists.⁹

If the circulating nurse is not an RN, the licensed practical/vocational nurse or surgical technologist must have access to an RN at all times. You are responsible for supervising the licensed practical/vocational nurse or surgical technologist in the performance of all delegated nursing tasks.¹⁰

Surgeon and Assistant

The surgeon is the physician who performs the surgical procedure. The surgeon is primarily responsible for the following:

• Preoperative medical history and physical assessment, including need for surgical intervention, choice of surgical procedure, management of preoperative testing, and discussion of the risks of and alternatives to surgical intervention

• Patient safety and management in the OR

• Postoperative management of the patient

The surgeon’s assistant can be a physician who functions in an assisting role during the surgical procedure. The assistant usually holds retractors to expose surgical areas and assists with hemostasis and suturing. In some instances, especially in educational settings, the assistant may perform some portions of the surgery under the surgeon’s direct supervision. In many institutions the surgeon’s assistant is a registered nurse first assistant or a physician’s assistant (PA) who functions under the physician’s direct supervision.

Registered Nurse First Assistant

The registered nurse first assistant (RNFA) works in collaboration with the surgeon to produce an optimal surgical outcome for the patient. The Association of periOperative Registered Nurses (AORN) position statement on RNFAs states that the perioperative nurse must have formal education for this role and works collaboratively with the surgeon, patient, and surgical team by handling tissue, using instruments, providing exposure to the surgical site, assisting with hemostasis, and suturing.6,11 RNFA education programs are designed to provide RNs with the education necessary to assume this expanded role.¹² The RNFA can also obtain certification.

Anesthesia Care Provider

The anesthesia care provider (ACP) is a person who administers anesthesia and can be an anesthesiologist, nurse anesthetist, or anesthesiologist assistant (AA). Anesthesiology is a discipline within the practice of medicine that specializes in the following.

• Medically managing patients who are unconscious or insensible to pain and emotional stress during surgical and other medical procedures

• Protecting functions and vital organs under the stress of anesthetic, surgical, or other medical procedures

• Managing pain

• Managing cardiopulmonary resuscitation

• Managing problems in pulmonary care

• Managing critically ill patients in special care units

ACPs who are anesthesiologists are responsible for administering anesthetic agents to relieve pain and manage vital life functions (e.g., breathing, blood pressure [BP]) during surgery. After surgery they provide care during recovery.¹³

A nurse anesthetist is an RN who has graduated from an accredited nurse anesthesia program (minimally a master’s degree program) and successfully completed a national certification examination to become a certified registered nurse anesthetist (CRNA). The CRNA scope of practice includes the following:¹⁴

• Performing and documenting a preanesthetic assessment and evaluation

• Developing and implementing a plan for delivering anesthesia

• Selecting and initiating the planned anesthetic technique

• Selecting, obtaining, and administering the anesthesia, adjuvant drugs, and fluids

• Selecting, applying, and inserting appropriate noninvasive and invasive monitoring devices

• Managing a patient’s airway and pulmonary status

• Managing emergence and recovery from anesthesia

• Releasing or discharging patients from a PACU

• Ordering, initiating, or modifying pain relief therapy

• Responding to emergency situations by providing airway management, and administering emergency fluids and drugs

• Assuming additional responsibilities within the expertise of the individual

An anesthesiologist assistant (AA) is a specialty PA who functions under the direction of an anesthesiologist in many states. The AA has graduated from an accredited program (minimally a master’s degree program) and successfully completed a national certification examination. AAs participate in the provision of all types of anesthesia, including administering drugs, obtaining vascular access, applying and interpreting monitors, establishing and maintaining airways, and assisting with preoperative assessments.

Nursing Management Patient before Surgery

The preoperative assessment of the surgical patient establishes baseline data for intraoperative and postoperative care. Preoperative care of the patient is discussed in Chapter 18. Some additional information is discussed in this chapter.

Psychosocial Assessment

Knowing about the activities that occur when a patient is moved into the surgical suite allows you to provide explanations and reassurances, especially to the anxious patient. You can usually answer general questions regarding surgery or anesthesia, such as “When will I go to sleep?” “Who will be in the room?” “When will my surgeon arrive?” “How much of my body will be exposed?” “Will I be cold?” “When will I wake up?” Specific questions relating to details of the surgical procedure and anesthesia may be referred to the surgeon or the ACP.

Performing a cultural and spiritual assessment can help you understand the patient’s response to the surgical experience (see Tables 2-7 and Table 10-5 for additional information). For example, members of the Jehovah’s Witness community may refuse blood transfusions.¹⁵ For Muslims, the left hand is considered unclean, so you should use the right hand to give forms, drugs, and treatments.¹⁶ Some Native American patients may request that surgically removed body tissue be preserved so that it may be buried. Some tattoos and body piercings may also have cultural meaning.¹⁷ Some patients may have a prayer cloth or other traditional or sacred item with them. Consider spiritual needs and beliefs in the individualized plan of care. For patients who do not speak English, a qualified interpreter must be used (see Table 2-10).

Physical Assessment

Perform a thorough physical assessment during the preoperative preparation of the patient (see Chapter 18).

Chart Review

Required chart data vary with agency policy, patient condition, and specific surgical procedures. Because ambulatory surgery facilities tend to have a healthier population, fewer tests may be required. Examples of data that are obtained during the preoperative assessment can be found in Tables 18-2 and 18-4. This information contributes to an understanding of past and present history, cardiopulmonary status, and potential for infection and other complications.

Admitting the Patient

Hospital policy designates the protocol to be followed when admitting the patient to the holding area and OR. A general routine includes initial greeting, extension of human contact and warmth, and proper identification. A preprocedure verification process is conducted before the start of surgery. In some institutions this takes place in the holding area; in others it takes place in the OR itself.

Complementary and alternative therapies such as therapeutic touch, aromatherapy, music therapy, guided imagery, and even movies may be used for surgical patients. (See the Complementary & Alternative Therapies box above on music and Chapter 6.) These therapies may decrease anxiety, promote relaxation, reduce pain, and accelerate the healing process.^6,18 In some facilities these therapies are initiated before the patient’s admission to the OR. In others, such as ambulatory settings, they may be started after the patient’s arrival in the holding area.

The admitting procedure is continued with reassessment of the patient and with time allowed for last-minute questions. Complete the chart review for the previously mentioned data and note any abnormalities or changes. Question the patient concerning valuables, prostheses, and last intake of food and fluid. Validate that the correct preoperative medications were given (if ordered). Provide a pillow or position adjustment if the patient is uncomfortable. Most hospitals require the patient’s hair to be covered just before transfer to the OR suite to reduce potential shedding. Specific SCIP measures may include a prophylactic antibiotic started within 30 to 60 minutes before the surgical incision, and application of a warming blanket and SCDs.

Nursing Management Patient During Surgery

Room Preparation

Before transferring the patient into the OR, prepare the room to ensure privacy, prevention of infection, and safety. Individualization of this preparation is essential to achieve the expected patient outcomes. For example, when an obese patient is admitted to the OR, there are several special considerations (see Chapter 41). Ask such questions as, What equipment is needed to safely transfer the patient to and from the OR table? Will extra staff be required for safe transfer and positioning? Is special equipment needed (e.g., extra-long instrumentation)? What special precautions, if any, must be taken to ensure maintenance of the patient’s airway? The unique needs of each patient must be addressed for a safe surgical experience.

Surgical attire (pants and shirts, masks, protective eyewear, and caps or hoods) is worn by all people entering the OR (Fig. 19-3). All electrical and mechanical equipment is checked for proper functioning. Aseptic technique is practiced as each surgical item is opened and placed on the instrument table.¹⁹ Sponges, needles, instruments, and small medical devices (e.g., surgical clip cartridges, universal adapters) are counted according to strict processes to ensure accurate retrieval at the end of the procedure. Any retained surgical supplies, devices, or instruments are sentinel events that can result in negative outcomes for the patient.^20,21