Nursing Management
Intraoperative Care
Anita Jo Shoup and David M. Horner*
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.
1. Differentiate the purposes of the various areas of the perioperative/surgery department and the proper attire for each area.
2. Differentiate the roles and responsibilities of the interdisciplinary surgical team members.
3. Prioritize needs of patients undergoing surgery.
4. Analyze the role of the perioperative nurse in the management of the patient undergoing surgery.
5. Apply basic principles of aseptic technique used in the operating room.
6. Evaluate the importance of safety in the operating room relative to patients, equipment, and anesthesia.
7. Differentiate the common types of and delivery systems for anesthesia.
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
Department Layout
The surgical suite is a controlled environment designed to minimize the spread of pathogens and allow a smooth flow of patients, staff, and equipment needed to provide safe patient care. The suite is divided into three distinct areas: unrestricted, semirestricted, and restricted areas. The unrestricted area is where people in street clothes can interact with those in surgical attire. These areas typically include the points of entry for patients (e.g., holding area), staff (e.g., locker rooms), and information (e.g., nursing station or control desk). The semirestricted area includes the surrounding support areas and corridors. Only authorized staff are allowed access to the semirestricted areas. All staff in the semirestricted area must wear surgical attire and cover all head and facial hair. In the restricted area masks are required to supplement surgical attire.1 The restricted area can include the OR, scrub sink area, and clean core.
eTABLE 19-1
In addition, the physical layout is designed to reduce cross-contamination. The flow of clean and sterile supplies and equipment should be separated from contaminated supplies, equipment, and waste by space, time, and traffic patterns. Staff move supplies from clean areas, such as the clean core, through the OR for surgery, and on to the surrounding areas, such as the instrument decontamination area.2
Holding Area
The holding area, frequently called the preoperative holding area, is a special waiting area inside of or adjacent to the surgical suite. The size can range from a centralized area to accommodate numerous patients to a small designated area immediately outside the actual room scheduled for the surgical procedure. The holding area is where you identify and assess the patient before transferring him or her to the OR.
The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations focused on improving surgical care by significantly reducing the number of complications from surgery3 (refer to www.jointcommission.org/assets/1/6/Surgical%20Care%20Improvement%20Project.pdf). Several SCIP measures may be implemented in the holding area, such as drug administration, patient warming, and application of sequential compression devices (SCDs). Many minor procedures (e.g., inserting IV catheters and arterial lines) can also be performed here.
The National Patient Safety Goals (NPSGs) require a preprocedure process, including the verification of relevant documentation (e.g., history and physical examination, signed consent form, nursing and preanesthesia assessment). In addition, any required blood products, implants, devices, and special equipment need to be available. Further, any diagnostic and radiology test results (e.g., x-rays, biopsy reports) need to be properly labeled and displayed.4
In addition, the NPSGs require that the surgeon mark the procedure site. If possible, the marking should be done with the patient’s involvement.4
Separation from caregivers just before surgery can produce anxiety for the patient. This anxiety can be reduced when the caregiver is permitted to wait with the patient in the holding area until the patient is transferred to the OR.
Operating Room
The traditional surgical environment, or OR, is a unique setting removed from other hospital clinical units. It is controlled geographically, environmentally, and bacteriologically, and it is restricted in terms of the inflow and outflow of staff (Fig. 19-1). It is preferable to have the OR located next to the postanesthesia care unit (PACU) and the surgical intensive care unit. This allows for quick transport of the postoperative patient and close proximity to anesthesia staff if complications arise.

Several methods are used to prevent the transmission of infection. Filters and controlled airflow in the ventilating systems provide dust control. Positive air pressure in the rooms prevents air from entering the OR from the halls and corridors. Ultraviolet (UV) lighting may be used because UV radiation reduces the number of microorganisms in the air. Dust-collecting surfaces such as open shelves and tables are omitted. Materials that are resistant to the corroding effects of strong disinfectants are used.
Overall safety and comfort are aided by the use of OR furniture that is adjustable, easy to clean, and easy to move. All equipment is checked frequently to ensure proper functioning and electrical safety. The lighting is designed to provide a low- to high-intensity range for a precise view of the surgical site (see Fig. 19-2). A communication system provides a means for the delivery of routine and emergency messages.5,6
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
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*
ABCs, Airway, breathing, circulation.
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
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 cardiopulmonary resuscitation
• Managing problems in pulmonary care
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).
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.
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
During room preparation and the surgical procedure, the scrub person performs surgical hand antisepsis, dons sterile gown and gloves, and touches only those items in the sterile field. The circulating nurse remains in the unsterile field and performs those activities that permit touching all unsterile items and the patient. This coordinated effort allows for smooth functioning throughout the procedure.
Transferring Patient
Once the patient’s identity has been verified and the OR has been prepared, the patient is transported into the room for the surgery. Each time a patient is transferred from one bed to another, the wheels of the stretcher must be locked, and a sufficient number of personnel should be available to lift, guide, and prevent accidental falling or injury to self, other staff, or the patient. Once the patient is on the OR bed, place safety straps snugly across the patient’s thighs. At this time the monitor leads (e.g., electrocardiogram [ECG] leads), BP cuff, and pulse oximeter are usually applied and an IV catheter is inserted if it was not done in the holding area.
Scrubbing, Gowning, and Gloving
Surgical hand antisepsis is required of all sterile members of the surgical team (scrub nurse, surgeon, and assistant). When the procedure of scrubbing is the chosen method for surgical hand antisepsis (often for the first case of the day), your fingers and hands should be scrubbed first with progression to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or detergent suds and water from draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers.6,22
Waterless, alcohol-based agents are replacing traditional soap and water in many facilities. When using an alcohol-based surgical hand-scrub product, prewash hands and forearms with soap and dry completely before applying the alcohol-based product. After application of the alcohol-based product, allow hands and forearms to dry thoroughly before donning sterile gloves.22,23
Once surgical hand antisepsis is completed, the team members enter the OR to put on surgical gowns and two pairs of gloves to protect patients and themselves from the transmission of microorganisms.24,25 Because the gowns and gloves are sterile, those who have scrubbed can manipulate and organize all sterile items for use during the procedure.

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