CHAPTER 15 Care of Intraoperative Patients

Minimally invasive surgery (MIS)

A common practice and now is the preferred technique for many types of surgery, including cholecystectomy, cardiac surgery, splenectomy, and spinal surgery. It is even being used for cancer surgeries, such as the removal of a lung lobe (lobectomy) or even the entire lung (pneumonectomy) and colectomy. Benefits of MIS include reduced surgery time for some surgeries, smaller incisions, reduced blood loss, faster recovery time, and less pain. ne or more small incisions is made in the surgical area and an endoscope (a tube that allows viewing and manipulation of internal body areas) is used. Laparoscopes are used for abdominal surgery, arthroscopes are used for joint surgery, and ureteroscopes are used for urinary tract surgery. Endoscopes can be used for organ removal, reconstruction, blood vessel grafting, and many other procedures. Cutting, suturing, stapling, cautery, and laser surgery can all be performed through or with endoscopes. An important part of MISis injecting gas or air into the cavity before the surgery to separate organs and improve visualization. This injection is known as insufflation. An endoscopic surgical procedure has a chance for becoming an open surgical procedure.

laser specialty nurse or a laser nurse coordinator

A nurse specially trained in the use, care, and maintenance of the laser. A laser creates intense heat, rapidly clots blood vessels or tissue, and turns target tissue (e.g., a tumor) into vapor. All personnel must observe safety measures (e.g., wear eye shields, read door signs) during laser procedures to prevent injury.

General anesthesia

A reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system (CNS). General anesthesia depresses the CNS, resulting in analgesia (pain relief or pain suppression), amnesia (memory loss of the surgery), and unconsciousness, with loss of muscle tone and reflexes. The patient is unconscious and has no sensory perception. General anesthesia is used most often in surgery of the head, neck, upper torso, and abdomen.

operating room technicians (ORTs) or surgical technologists

A specially trained person who is not a nurse may perform the scrub role.

Surgical Attire

All members of the surgical team and all OR personnel must wear scrub attire while in the surgical suite. Scrub attire, provided by the hospital, is clean (not sterile). Basic surgical attire is a shirt and pants and a cap or hood. Shoe coverings may be worn only to protect the shoes. Staff change into clean surgical attire in the OR suite locker rooms, not at home. All members of the surgical team must cover their hair. Everyone must wear protective attire (mask, eyewear, gloves, and gown). Everyone who enters an OR where a sterile field is present must wear a mask. Surgical team members who are scrubbed and at the bedside during the surgery must also wear a sterile fluid-resistant gown, sterile gloves, and eye protectors or face shields. Team members who are not scrubbed (e.g., anesthesia provider, circulator) may wear cover scrub jackets that are snapped or buttoned closed and eyewear, as warranted.

Allergies and Previous Reactions to Anesthesia or Transfusions.

Allergies to iodine products or shellfish indicate a risk for a reaction to the agents used to clean the surgical area. Latex allergies are assessed with all patients because anaphylaxis can occur with latex contact during surgery. The patient's previous experience with anesthesia helps the nurse and anesthesia provider anticipate needs and plan interventions. The use of blood products during surgery may be influenced by the patient's history, religious beliefs, preferences, and past transfusion reactions.

Circulating nurses, or "circulators"

Are registered nurses who coordinate, oversee, and are involved in the patient's nursing care in the OR. This nurse's actions are vital to the smooth flow of events before, during, and after surgery. He or she coordinates all activities within that particular OR. The circulator sets up the OR and ensures that needed supplies, including blood products and diagnostic support, are available. All anticipated equipment is gathered and inspected. The circulator may also makes up the operating bed (OR table) with gel pads (to prevent pressure ulcers), safety straps and armboards, and either heating pads under the sheets or disposable warming blankets placed over the patient as needed to prevent hypothermia.

Advance Directives and Do-Not-Resuscitate Orders.

As a patient advocate, the nurse may have to intervene on behalf of the patient's rights and wishes. The nurse must be familiar with the advance directives and do-not-resuscitate (DNR) orders for each patient. The position statement of the Association of periOperative Registered Nurses regarding the care of patients with DNR orders states that automatically suspending a DNR or allow-natural-death order during surgery undermines a patient's right to self-determination.

Autologous Blood Transfusion.

Autologous blood transfusion (reinfusing the patient's own blood) may be used for surgery.

Intubation complications

Can include many problems (e.g., broken teeth and caps, swollen lip, vocal cord trauma). Difficult intubation may be caused by anatomic issues or disease presence (e.g., small oral cavity, tight jaw joint, tumor). Improper neck extension during intubation may cause injury. The surgeon should be in the OR during the intubation process in case a tracheotomy is needed when the endotracheal tube (ET) is placed. Intubation causes tracheal irritation and edema. Often the patient has a sore throat after surgery.

Overdose of anesthetic

Can occur if the patient's metabolism and drug elimination are slower than expected, such as with patients who are older or who have liver or kidney problems. Other drugs (e.g., antihypertensives) also alter metabolism, and interactions can occur between the anesthetic and the patient's regular drugs.

Complications of General Anesthesia.

Complications can range from minor (e.g., sore throat) to death. Malignant hyperthermia (MH), an inherited muscle disorder, is an acute, life-threatening complication of certain drugs used for general anesthesia. It is characterized by many problems, including poor thermoregulation. The reaction begins in skeletal muscle exposed to the drugs, causing increased calcium levels in muscle cells and increased muscle metabolism. Serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature. Manifestations are caused by increased muscle calcium level and the greatly increased body metabolism. These include tachycardia, dysrhythmias, muscle rigidity (especially of the jaw and upper chest), hypotension, tachypnea, skin mottling, cyanosis, and myoglobinuria (presence of muscle proteins in the urine). "The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation and tachycardia. Extremely elevated temperature, as high as 111.2° F (44° C), is a late sign of MH." Survival depends on early diagnosis and the immediate actions. Dantrolene sodium, a skeletal muscle relaxant, is the drug of choice along with other interventions.

Unrecognized hypoventilation

Failure of adequate gas exchange can lead to cardiac arrest, permanent brain damage, and death. Monitoring standards include the use of an end-tidal carbon dioxide monitor to confirm carbon dioxide levels in the patient's expired gas and a breathing system disconnect monitor to detect any break in the breathing circuit equipment.

Administration of General Anesthesia.

General anesthesia agents are administered by inhalation and IV injection. A combination of types of agents (balanced anesthesia) is used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function. Balanced anesthesia is safe and controlled anesthetic delivery, especially for older and high-risk patients. Hypnotics and opioid analgesics can be used for sedation before surgery, for IV moderate sedation for short procedures, and as an adjunct to general anesthesia during surgery. The neuromuscular blocking agents are used to relax the jaw and vocal cords immediately after induction so that the endotracheal tube can be placed.

Holding Area Nurses

Holding area nurses work in those operating suites that have a presurgical holding area next to the main ORs. The holding area nurse coordinates and manages the care while the patient waits in this area until the OR is ready. Responsibilities include greeting the patient on arrival, reviewing the medical record and preoperative checklist, verifying that the operative consent forms are signed, and documenting the risk assessment. This nurse also assesses the patient. If there is no holding area nurse, the circulator also assumes the responsibilities of that role.

Critical Rescue of Wrong Surgical Site

If the patient's description of the surgical site is different from that listed on the informed consent, form a time-out with the patient, yourself, and the surgeon to ascertain and mark the correct site.

Skin and tissue closures

Include sutures, staples, special tape, and tissue adhesive (surgical "glue"). Fig. 15-11 shows commonly used wound closures. They are used to: • Hold wound edges in place until wound healing is complete • Occlude blood vessels, preventing poor clotting and hemorrhage • Prevent wound contamination and infection Absorbable sutures are digested over time by body enzymes. Nonabsorbable sutures become encapsulated in the tissue during the healing process and remain in the tissue unless they are removed. Body enzymes do not affect nonabsorbable sutures. Retention (stay) sutures may be used in addition to standard sutures for patients at high risk for impaired wound healing (obese patients, patients with diabetes, and those taking steroids). The surgeon may inject a local anesthetic or instill an antibiotic into the wound. A gauze or spray dressing may be applied to protect the incision from contamination. A variety of dressings are used to absorb drainage and support the incision. A pressure dressing may be applied to prevent poor clotting and bleeding. One or more drains may be inserted to remove secretions and fluids around the surgical area.

Stages of General Anesthesia.

Induction of general anesthesia involves four stages: Stage 1 (Analgesia and Sedation, Relaxation), Stage 2 (Excitement, Delirium), Stage 3 (Operative Anesthesia, Surgical Anesthesia), Stage 4 (Danger). The speed of emergence (recovery from the anesthesia) depends on the anesthetic agent, the duration of anesthesia administration, and whether a reversal agent is used. Retching, vomiting, and restlessness may occur during emergence. Suction equipment must be available to prevent aspiration. During recovery, shivering, rigidity, and slight cyanosis may occur(thermoregulation disruption). The nurse provides warm blankets, radiant heat, and oxygen to decrease the effects of emergence.

Anesthesia

It requires the skill of an anesthesiologist, a certified registered nurse anesthetist (CRNA) working under the direction of an anesthesiologist or another physician, or an anesthesiologist assistant. Anesthesia is an induced state of partial or total loss of sensory perception, with or without loss of consciousness. The purpose of anesthesia is to block nerve impulse transmission, suppress reflexes, promote muscle relaxation. Use requires separate documentation. Selection of anesthetic is influenced by: • Type and duration of the procedure • Area of the body having surgery • Safety issues to reduce injury, such as airway management • Whether the procedure is an emergency • Options for management of pain after surgery • How long it has been since the patient ate, had any liquids, or had any drugs • Patient position needed for the surgical procedure • Whether the patient must be alert enough to follow instructions during surgery • The patient's previous responses and reactions to anesthesia The anesthesiologist assesses the patient and assigns him or her to one of six categories based on current health and the presence of diseases and disorders. The categories rank patients in a range from a totally healthy patient (P1 ranking) to a patient who is brain dead (P6 ranking). Anesthesia delivery begins with selecting and giving preoperative drugs. The most common forms of anesthesia used in North America include general, regional, and local anesthesia (Table 15-1). Less commonly used forms include hypnosis, cryothermia (use of cold), and acupuncture.

Local Anesthesia

Local anesthesia is delivered topically (applied to the skin or mucous membranes of the area to be anesthetized) and by local infiltration (injected directly into the tissue around an incision, wound, or lesion). Sometimes when the term local is used, it means any form of anesthesia that is not general or monitored anesthesia.

Local or Regional Anesthesia

Local or regional anesthesia briefly disrupts sensory nerve impulse transmission from a specific body area or region, thus reducing sensory perception in a limited area. Motor function may or may not be affected. The patient remains conscious and can follow instructions. The gag and cough reflexes remain intact, and the risk for aspiration is low. This type of anesthesia may be supplemented with sedatives, opioid analgesics, or hypnotics to reduce anxiety and increase comfort.

Moderate Sedation

Moderate sedation (conscious sedation) is the IV delivery of sedative, hypnotic, and opioid drugs to reduce sensory perception but allow the patient to maintain a patent airway. The amnesia action is short, and the patient has a rapid return to ADLs. Etomidate (Amidate), diazepam (Valium, Vivol , Novo-Dipam ), midazolam (Versed), fentanyl (Sublimaze), alfentanil (Alfenta), propofol (Diprivan), and morphine sulfate are the most commonly used drugs. The physician determines whether the patient is a candidate. The nurse monitors the patient during and after the procedure for response to the procedure and the drugs. The airway, level of consciousness, oxygen saturation, capnography (measure of carbon dioxide level), ECG status, and vital signs are monitored every 15 to 30 minutes until the patient is awake and oriented and vital signs have returned to baseline levels. The patient receiving IV moderate sedation can be discharged to go home with a responsible adult if capnography indicates gas exchange is adequate and arousal from sedation is at an RSS 2 level. The patient is expected to be sleepy but arousable for several hours after the procedure. Oral intake is not permitted until 30 minutes after the patient has received the sedation or according to the physician's prescription. If the patient was intubated or had oral endoscopy, return of the gag reflex is required before oral intake.

Critical Rescue Signs of MH

Monitor patients for the cluster of elevated end-tidal carbon dioxide level, decreased oxygen saturation, and tachycardia related to malignant hyperthermia. If these changes begin, alert the surgeon and anesthesia provider immediately.

Action Alert for Patient

Once the patient has been moved into the holding area or the OR, do not leave him or her alone.

Perioperative Nursing Staff 1

Once the patient is moved into the OR, the circulating nurse, along with the OR team, assists the patient in transferring to the OR table. The nurse positions the patient, protecting bony areas with padding while providing comfort and reassurance. While observing the patient, the circulating nurse also assists the anesthesia provider with the induction of anesthesia by positioning the patient and applying cricoid pressure. The circulator then may assist with additional positioning, insert a Foley catheter if needed, apply the grounding pad, test equipment, and "prep" (scrub) the surgical site before the patient is draped with sterile drapes. Throughout the surgery, the circulating nurse: • Protects the patient's privacy • Ensures the patient's safety • Monitors traffic in the room • Assesses the amount of urine and blood loss • Reports findings to the surgeon and anesthesia provider • Ensures that the surgical team maintains sterile technique and a sterile field • Anticipates the patient's and surgical team's needs, providing supplies and equipment • Communicates information about the patient's status to family members during long or unique procedures • Documents care, events, interventions, and findings

TABLE 15-2 The Four Stages of General Anesthesia and Related Nursing Interventions

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Chart 15-1 Emergency Care of the Patient with Malignant Hyperthermia

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FIG. 15-8/9 Nerve block sites.

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TABLE 15-4 Ramsay Sedation Scale for Assessing Post-Sedation Consciousness

PG 249!!! Evaluation of consciousness for recovery sedation is performed using a sedation scale.

Chart 15-4 Prevention of Complications Related to Intraoperative Positioning

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Preparation of the Surgical Suite and Team Safety

Patient protection is provided by all members of the surgical team. The OR layout helps prevent infection by reducing contaminants through air exchanges in the room, maintaining recommended temperature and humidity levels, and limiting the traffic and activities. Safety straps are used for the patient, and the OR bed is locked. Blankets or warming units are used to prevent hypothermia and interventions are used to prevent skin breakdown. The nurse ensures electrical safety. All equipment used during surgery must be functional and in proper working condition. Equipment is cleaned and, when required, sterilized. The scrub and circulating nurses together ensure a correct count of surgical instruments, sharps, and sponges. Counts are performed before the procedure, during the procedure as items are added or when personnel are relieved from that assignment, at closure of the first layer of the surgical wound, and immediately before complete skin closure. All OR personnel work to prevent fire and complications from the use of hazardous or toxic substances. A cool room temperature (between 68° and 73° F [20° and 23° C]) with low humidity (30% to 60%) is optimal.

Regional Anesthesia.

Regional anesthesia is a type of local anesthesia that blocks multiple peripheral nerves and reduces sensory perception in a specific body region. It is often used when pain management after surgery is enhanced by regional anesthesia, such as after a total knee replacement. If the patient has eaten and the surgery is an emergency, it may be possible to perform surgery with the patient under regional anesthesia to decrease the risk for aspiration. Regional anesthesia includes field block, nerve block, spinal, and epidural (Table 15-3). The nurse's role in the delivery of regional anesthesia consists of: • Assisting the anesthesia provider • Observing for breaks in sterile technique • Providing emotional support for the patient • Staying with the patient • Offering information and reassurance • Positioning the patient comfortably and safely

Scrub nurses or scrub persons

Set up the sterile table, drape the patient, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Knowledge of the surgical procedure allows the scrub person to anticipate which instruments and types of sutures the surgeon will need(reduce anesthesia time). The scrub person (with the circulating nurse) maintains an accurate count of sponges, sharps, and instruments and amounts of irrigation fluid and drugs used.

Interventions: Infection

Surgical wound infections interfere with recovery, delay wound healing, contribute to rising health care costs, and are a source of nosocomial infections. ~30 days post-surgery. Assess the risk for infection by identifying patients with health problems such as diabetes mellitus, immunodeficiency, obesity, and kidney disease. The nurse performs the prescribed skin preparation, protects against cross-contamination, keeps traffic to a minimum, and administers prescribed antimicrobial prophylaxis. Surgery increases risk for wound complications (e.g., incisional tears, lacerations), infection, and loss of body fluids. When a wound is already infected or is at high risk for infection, antibiotics may be used directly in the wound before wound closure.

Robotic technology

Takes MIS to a new level. The robotic system consists of a console, surgical arm cart, and video cart (Fig. 15-5). The surgeon first inserts the required instruments and positions the articulating arms; he or she then breaks scrub and performs the surgery while sitting at the console. A three-dimensional (3-D) view of the patient's anatomy allows precise control and dexterity. The vision cart holds the monitors, cameras, and recorder equipment. This new technology requires a perioperative robotics nurse specialist. Mechanical trauma and thermal injury are two types of injury that a patient can incur during MIS and robotic surgery

Laboratory and Diagnostic Test Results.

The OR nurse reviews the most recent laboratory findings and test results to inform the surgical team about the patient's health and to alert them for potential problems. These results are usually obtained within 24 to 48 hours before surgery for hospitalized patients and within 4 weeks for ambulatory surgery patients. The nurse reports all abnormal findings or results to the surgeon and anesthesia provider.

Anesthesia Providers

The anesthesiologist is a physician who specializes in giving anesthetic agents. A certified registered nurse anesthetist (CRNA) is an advanced practice registered nurse with additional education and credentials who delivers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist, or podiatrist. The anesthesia provider monitors the patient during surgery by assessing and monitoring: • The level of anesthesia (i.e., by using a peripheral nerve stimulator or electroencephalogram [EEG] bispectral analysis) • Cardiopulmonary function (using electrocardiographic [ECG] monitoring, pulse oximetry, end-tidal carbon dioxide monitoring, arterial blood gases [ABGs], and hemodynamic monitoring via arterial lines and/or pulmonary artery catheters) • Capnography (monitors ventilation for non-intubated patients) • Vital signs • Intake and output

Perioperative Nursing Staff 2

The circulating nurse may record drugs, blood, and blood components given. Before the procedure is over, the circulating nurse completes documentation in the OR and nursing records, including the presence of drains or catheters, the length of the surgery, and a count of all sponges, "sharps" (needles, blades), and instruments. He or she notifies the postanesthesia care unit (PACU) of the patient's estimated time of arrival and any special needs.

Surgical positions

The dorsal recumbent (supine), prone, lithotomy, and lateral positions are most often used for surgery. When general anesthesia is used, the nurse positions the patient slowly to prevent hypotension from blood vessel dilation. Proper positioning is ensured by assessing for: • Anatomic alignment • Interference with circulation and breathing • Protection of skeletal and neuromuscular structures • Optimal exposure of the operative site and IV line • Adequate access to the patient for the anesthesia provider • The patient's comfort, safety, and dignity For example, patients in the lithotomy position may develop leg swelling, pain in the legs or back, reduced foot pulses, or reduced sensory perception from compression of the peroneal nerve. The nurse ensures proper padding and position changes at regular intervals. He or she continually assesses circulation adequacy by checking pulses and capillary refill below pressure points. Throughout surgery, the nurse prevents obstruction of circulation, respiration, or nerve conduction caused by tight straps, poorly placed pads and pillows, or the position of the bed.

Evaluation: Outcomes

The expected outcomes are that the patient: • Is safely anesthetized without complications • Does not experience any injury related to surgical positioning or equipment • Is free of skin or tissue contamination and infection during surgery • Is free of skin tears, bruises, redness, or other injury over pressure points and elsewhere • Maintains normal thermoregulation and body temperature

History.

The holding area nurse or the circulating nurse greets the patient on arrival. As indicated in The Joint Commission's National Patient Safety Goals (NPSGs), correct identification of the patient is the responsibility of every member of the health care team. Check the patient's identification bracelet and ask, "What is your name and birth date?". The nurse then validates that the surgical consent form has been signed and witnessed. The nurse asks "What kind of operation are you having today?" to ascertain that the patient's perception of the procedure, the surgical consent, the surgeon's order, and the operative schedule are the same. When the procedure involves a specific site, validating the side on which a procedure is to be performed (e.g., for amputation, cataract removal, hernia repair) is the responsibility of each health care professional before and at the time of surgery. The Joint Commission now recommends that the patient and the licensed independent practitioner who is ultimately accountable for the procedure and will be present during the procedure (usually the surgeon performing the surgery) mark the surgical site. The nurse asks the patient about any allergies and determines whether autologous blood was donated. A special allergy bracelet on the patient's wrist and the medical record must be verified with what has been communicated. The nurse checks the patient's attire to ensure adherence with facility policy. Dentures and dental prostheses, jewelry (including body piercing), eyeglasses, contact lenses, hearing aids, wigs, and other prostheses are removed. Denture removal before anesthesia is controversial because, although the denture plate may come loose and obstruct the airway, the anesthesia provider may request that dentures be left in place to ensure a snug fit of the bag-mask. In some facilities, patients may wear eyeglasses and hearing aids until after anesthesia induction.

Complications of Local or Regional Anesthesia.

The nurse observes for central nervous system (CNS) stimulation followed by CNS and cardiac depression, which are indications of a systemic toxic reaction. The nurse also assesses for restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea, tremors, seizures, and increased pulse, respiration, and blood pressure. Interventions include establishing an open airway, giving oxygen, and notifying the surgeon. Usually a fast-acting barbiturate is needed for treatment. Cardiac arrest may occur as a rare complication of spinal anesthesia. Epinephrine is given to prevent cardiac arrest in patients who develop sudden, unexplained bradycardia. Local early complications include edema and inflammation. Abscess formation, tissue necrosis, and/or gangrene may occur later. Abscesses result from contamination during injection of the agent. Necrosis and gangrene may occur as a result of prolonged blood vessel constriction in the injected area.

Medical History and Physical Examination Findings

The nurse performs a final assessment for threats to patient safety, starting with the patient's age and general physical condition. Older patients and those who are thin or overweight are at greater risk for skin injury. Assessing mental status is important because confused patients and those who are unable to either follow instructions or communicate may not be able to tell you when a problem exists. Patients who have impaired sensory perception of any type are at increased risk for injury. Specific drugs, such as long-term steroid use (which increases capillary fragility and thins the skin), as well as limitations of range or motion, require modification during positioning and threaten patient safety. The OR nurse checks that the medical history and examination findings, including usual pulse and blood pressure, are recorded. Drugs taken before surgery may affect the patient's reaction to surgery and wound healing. For example, aspirin and other NSAIDs that can increase clotting time and the risk for hemorrhage. The nurse carefully monitors older patients and those with cardiac disease for potential fluid overload. After completing the medical record review, the nurse may insert an IV catheter and perform a surgical skin preparation. He or she provides emotional support and explains procedures to the patient.

Interventions: Hypoventilation

The nurse, surgeon, and anesthesia provider monitor the patient according to official standards. These standards, adopted by both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists, include continuous monitoring of breathing, circulation, and cardiac rhythms; blood pressure and heart rate recordings every 5 minutes; and the constant presence of an anesthesia provider during the case.

Interventions: Injury

The patient cannot guard against nerve or joint damage and muscle stretch or strain. In addition, pressure ulcers often start to develop during surgery. Thus proper positioning is important. The circulating nurse pads the operating bed with foam and/or silicone gel pads and properly places the grounding pads. He or she coordinates the transfer to the operating bed and helps the patient to a comfortable position. The skin is assessed, especially of older patients, for bruising or injury, and extra padding is placed as indicated. The circulating nurse coordinates positioning of the patient for surgery and modifies the position according to the patient's safety and special needs. Factors influencing the timing of repositioning include: • The surgical site • The age and size of the patient • The anesthetic delivery technique • Pain on movement (conscious patient) Factors influencing the actual position include: • The specific procedure being performed • The surgeon's preference • The patient's age, size, and weight • Any pulmonary, skeletal, or muscular limitations, such as arthritis, joint replacements, emphysema, or implanted devices

Planning: Expected Outcomes for Hypoventilation

The patient is expected to be free of damaging events related to impaired gas exchange and hypoventilation as indicated by: • Maintenance of Sao2, Pao2, and blood pH within normal limits • Vital signs within normal limits • Return to presurgical level of cognitive function

Planning: Expected Outcomes for Injury

The patient is expected to be free of injury as indicated by: • Adequate capillary refill and peripheral pulses in all extremities • Sensory perception and motor function after surgery at the same level as before surgery • Absence of skin redness or open skin areas • Absence of bruising

Planning: Expected Outcomes for Infection

The patient is expected to have an uninfected surgical wound or wounds. Indicators include: • Wound edges are closed and not excessively red or swollen • Wound is free from purulent drainage • White blood cell counts remain at expected levels after surgery • Patient is afebrile

Analysis

The priority NANDA-I nursing diagnoses and collaborative problems for patients during surgery include: 1. Risk for Perioperative Positioning Injury related to improper positioning (NANDA-I) 2. Risk for Infection related to invasive procedures (NANDA-I) 3. Impaired Gas Exchange related to anesthesia, pain, reduced respiratory effort (NANDA-I)

Surgeon and Surgical Assistant

The surgeon is a physician who is responsible for the surgical procedure and any surgical judgments about the patient. The surgical assistant might be another surgeon (or physician, such as a resident or intern) or an advanced practice nurse, physician assistant, certified registered nurse first assistant (CRNFA), or surgical technologist.

Surgical Scrub

The surgeon, assistants, and the scrub nurse perform a surgical scrub AFTER putting on a mask and BEFORE putting on a sterile gown and gloves. The scrub does not make the skin sterile. Rings, watches, and bracelets are removed before scrubbing. Fingernails are kept short, clean, and healthy. Artificial nails are not worn. A surgical antimicrobial solution is used for the surgical scrub. Plain or antimicrobial soap is used for washing hands immediately before the surgical scrub. Vigorous rubbing that creates friction is used from the fingertips to the elbow. The scrub continues for 3 to 5 minutes, followed by a rinse. For rinsing, hands and arms are positioned so that water runs off, rather than up or down, the arms. After scrubbing, personnel enter the OR with their hands held higher than the elbows and thoroughly dry their hands and forearms with a sterile towel. This person is then assisted into a sterile gown ("gowning") and puts on sterile gloves ("gloving"). Operating room personnel wash and dry their hands with soap and water before applying the agent to their hands and forearms, rubbing thoroughly until dry. Gowns, gloves, and materials used at the operative field must be sterile. The surgical gown is considered sterile only on the front from the chest to the level of the sterile field. The entire sleeves of the gown are considered sterile from 2 inches above the elbow to the cuff. The back of the gown is not considered sterile because it cannot be seen. Only when they are properly scrubbed and attired do members of the surgical team handle sterile drapes and equipment.

Layout

The surgical suite is located near the PACU and support services (e.g., blood bank, pathology, and laboratory departments). Traffic flow is patterned to reduce contamination. The surgical area is divided into three zones—unrestricted, semirestricted, and restricted—to ensure proper movement of patients and personnel. Staff areas include locker rooms and staff lounges. Patient care areas include an admission or holding area and operating rooms (ORs). Support areas include ORs, cabinets for sterile supplies, separate utility rooms for clean and soiled equipment, and a clean linen room. A communication system links the OR with the main desk of the surgical suite and includes an intercom with separate systems for routine and emergency calls.

Members of the Surgical Team

The surgical team usually consists of the surgeon, one or more surgical assistants, the anesthesia provider, and the OR nursing staff. Perioperative, or OR, nurses include the holding area nurse, circulating nurse, scrub nurse or a non-nurse "scrub person," and specialty nurse.

Medical Record Review.

This record provides information to identify patient needs during surgery and allows the nurse to assess and plan specific care during and after surgery. It is the main source of information on the type and location of the planned surgery.

Health and Hygiene of the Surgical Team

To avoid transmitting organisms to the patient, policies and procedures for special health standards and dress must be followed. No one who has an open wound, cold, or any infection should participate in surgery. Good personal hygiene and frequent handwashing help prevent and control infection. Jewelry carries many organisms and should be minimal. All personnel must wash their hands between touching patients and performing procedures. Routine cultures of surgical teams' hands are usually obtained every 3 to 6 months. Surgical attire and the surgical scrub help prevent contaminations.

Patient: adequate body defenses related to infection

Vital signs: • Body temperature within normal range • No sweating or chills Physical assessment: • Skin color normal for ethnicity • Any drainage is not purulent • Urine is clear

Specialty nurse

may be in charge during some types of specialty surgery (e.g., orthopedic, cardiac, ophthalmologic) and provide specific nursing care during surgery. This nurse assesses, maintains, and recommends equipment, instruments, and supplies used in that specialty.

Key Points: Physiological Integrity

• Apply padding to the OR bed to maintain the patient's skin integrity. Evidence-Based Practice • Position the patient comfortably and safely. • Maintain the malignant hyperthermia cart. • Monitor the patient's airway, level of consciousness, oxygen saturation, ECG, and vital signs during and immediately after moderate sedation. • Assess the patient for tachycardia, increased end-tidal carbon dioxide level, and increased body temperature as indicators of malignant hyperthermia. • Assess all skin areas and document findings before transferring the patient to the postanesthesia care unit. • Communicate clearly and accurately information about the patient's surgical experience when handing off the patient to the postanesthesia care nurse.

Key Points: Psychosocial Integrity

• Communicate patient preferences or fears about anesthesia to the anesthesia provider. Patient-Centered Care • Preserve the patient's privacy and dignity by keeping body exposure to a minimum. • Stay with the patient during induction of anesthesia. • Communicate information about the patient's status to waiting family members. • Ensure that the patient's wishes, as expressed in the advance directives statement, are honored in the surgical setting.

Key Points: Safe and Effective Care Environment

• Review preoperative checklist and informed consent forms, including any allergies. • Highlight any known allergies. Safety • Ensure that all personnel entering the OR are wearing proper OR attire for their role. • Observe for and inform OR personnel of any break in sterile field or sterile technique. Safety • Use appropriate patient identifiers when administering drugs or marking surgical sites. Safety • Report to the surgeon any discrepancy between what type of surgery the patient says is going to be performed and what the informed consent form indicates. Safety • Apply grounding pads as needed. Safety • Complete any needed skin preparation. • Perform an accurate "sharps," sponge, and instrument count with the scrub nurse or surgical technologist. Safety