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CHAPTER

26
Intraoperative Nursing
Krista Brecht With contributions by:
Krisna Ogerio Jane Ashley
Donna Stanbridge Kathleen Osborn
Danielle Vigeant
Suzanne Watt

Outcome-Based Learning Objectives


After studying this chapter, the learner will be able to:
1. Discuss the sequence of events for the patient from the beginning of surgery to arrival in the postanesthesia care unit.
2. Differentiate the roles of the surgical team.
3. Describe the interplay between each team member in the success of the surgical intervention.
4. Prioritize nursing interventions to maximize patient safety in the operating room.
5. Evaluate effective nursing measures for patient advocacy in the operating room.
6. Prioritize the nursing care of patients experiencing selected intraoperative complications.
7. Differentiate the role of the certified nurse and the anesthesiologist for the anesthetized patient.

THE GOAL of perioperative or intraoperative nursing practice a patient in pain, or supporting the patient’s view toward prolong-
is to assist patients and their families to achieve a level of well- ing life with extraordinary treatment or technology.
ness equal to or greater than that which they had prior to the
Surgical patients can be compromised by stress, disease
procedure (Association of periOperative Registered Nurses process, and sedation or general anesthesia, and they trust
[AORN], Perioperative Nursing Data Set (PNDS-2007). The that a perioperative nurse will advocate in their best interest
most important role of the perioperative nurse is to be a patient to ensure their privacy, dignity, rights, and safety.
advocate. The essence of the advocacy in the perioperative role
is defined as protection, communication (giving a voice), doing, The nurse must accept accountability for nursing actions that
comfort, and caring. safeguard the rights of the surgical patients. Perioperative nurses
Advocacy is described as an act of informing and supporting act as patient advocates by protecting, and they must be able to
the individuals so that they may make the best decisions possible quickly and accurately identify advocacy issues and be ready to
for themselves. It is also speaking up for someone who is unable to intervene on behalf of their patients. In recent years, the accep-
speak for himself. Advocacy is a critical issue for surgical patients tance of a conceptual model for patient care, published by
who are unconscious or sedated and unable to make decisions re- AORN, has helped to distinguish the relationship of various
lated to their care. Protecting patients from harm is the essence of components of nursing practice and the effect on patient out-
the advocacy role of nurses, and it is a critical component for pa- comes (Beyea, 2000) (Figure 26–1 䊏).
tients whose family members are not readily accessible and whose
only possible advocate is the nurse. This is often the case for the
patient having surgery. Many perioperative issues involve advo- Guidance for Professional Practice
cacy. These may include helping patients who are uninformed or The practice of perioperative nursing is guided by its own pro-
have not given adequate consent for surgical procedures, con- fessional organization, the Association of periOperative Regis-
fronting an incompetent colleague, pressing for more analgesia for tered Nurses, as well as the Centers for Disease Control and
618
CHAPTER 26 Intraoperative Nursing 619

a Joint Commission survey team at least every 3 years. A com-


plete discussion of the Joint Commission is presented in
Int Chapter 3 .

8
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nt es Nu e
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gn Surgical Team
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Int

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ut Successful surgery relies on the interplay of many individuals
rsi

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working as a team, complementing each other’s skills and respon-
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et sp
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sibilities. This multidisciplinary team includes the surgeon and

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assistants, anesthesiologist and assistants, the nursing team, and
Patient support staff. Each of these professionals is responsible for specific
Heal

functions and plays a role in supporting the other groups. This

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In ses l
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div :
idu
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ha overlap of responsibilities ensures the safety of patients while they


hS

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tem Re y &
are in a most vulnerable situation of not being able to give any

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De personal input. The roles of each member are described next.

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Ca d D
rt

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io
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s Surgeon
nt
ra

El Nu ve
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em er The surgeon heads the surgical team and is responsible for mak-
en
ts Int
ing decisions related to the surgical procedure. Depending on the
procedure, an assistant might be required. This assistant could be
another surgeon, physician, resident in a university teaching hos-
FIGURE 26–1 䊏 Perioperative patient-focused model. pital, or the registered nurse first assistant. The surgeon is respon-
AORN (2008). The PNDS Model. Retrieved on July 2, 2008 from http://www.aorn.org/Practice sible for performing the procedure and for coordinating the team.
Resources/PNDSAndStandardizedPerioperativeRecord/PNDSModel/.
An expanded role for perioperative nurses is that of registered
nurse first assistant (RNFA). The RNFA collaborates with the
Prevention (CDC) and the Joint Commission. AORN defines its surgeon and performs the role of first assistant during the oper-
mission as follows: “to promote safety and optimal outcomes for ation. This role includes handling tissue, providing exposure, us-
patients undergoing operative and other invasive procedures by ing instruments, suturing the wound, and providing hemostasis.
providing practice support and professional development oppor- The role of an RNFA is highly specialized and demanding. In
tunities to perioperative nurses.” AORN is composed of approxi- 2008, AORN approved a policy statement that defines the RNFA
mately 41,000 perioperative registered nurses in the United States role, scope of practice, and qualifications.
and abroad who manage, teach, and practice perioperative nurs-
ing; who are enrolled in nursing education; and who are engaged Anesthesia Care Provider
in perioperative research (AORN, 2007a). This professional orga- The anesthesiologist is a health care provider who specializes in
nization has developed a conceptual framework and vocabulary the administration of anesthetic agents and provides care to alle-
called the Perioperative Nursing Data Set (PNDS). The data set viate pain and promote relaxation. This professional is responsi-
addresses the domains of safety, physiological responses, behav- ble for maintaining the airway; monitoring and ensuring gas
ioral responses of the patient and family, and the environment of exchanges, respiration, and circulation; estimating and replacing
the perioperative setting within the health system. blood and fluid losses; administering medications to maintain he-
The CDC’s mission is to promote health and quality of life by modynamic stability; managing care in the event of a physiologi-
preventing and controlling disease, injury, and disability. It also cal crisis; and constantly communicating with the surgical and
influences perioperative practice. In 1999, the CDC issued nursing team. The anesthesiologist heads the anesthesia team and
guidelines for the prevention of surgical infection. Additionally, might be assisted by a respiratory therapist, anesthesia resident or
it reflected the mission statement of the Joint Commission to fellow in a university teaching hospital, or a certified registered
continuously improve the safety and quality of care provided to nurse anesthetist (CRNA). As Chapter 1 discussed, the CRNA
8

the public through the provision of health care accreditation is an advance practice nurse, educated with a master’s degree from
and related services that support performance improvement in an accredited nurse anesthesia educational program. CRNAs ad-
health care organizations (Joint Commission, 2007). The Joint minister anesthesia and anesthesia-related care in four gen-
Commission is an independent, not-for-profit organization that eral categories: (1) preanesthetic preparation and evaluation;
is the United States’ predominant accrediting body charged with (2) anesthesia induction, maintenance, and emergence; (3) post-
maintaining and improving health care delivery. The Joint anesthesia care; and (4) perianesthetic and clinical support func-
Commission’s comprehensive accreditation process evaluates tions. The CRNA works under the supervision of the
an organization’s compliance with its standards and other ac- anesthesiologist. In a large study examining morbidity associated
creditation requirements. Joint Commission accreditation is with anesthesia, researchers found several factors that signifi-
recognized nationwide as a symbol of quality that reflects an or- cantly reduce the risk of anesthesia. Among these are the direct
ganization’s commitment to meeting certain performance stan- availability of an anesthesiologist during surgery, the presence of
dards. To earn and maintain the Joint Commission’s Gold Seal a consistent anesthesia care provider throughout the case, and the
of Approval, an organization must undergo an on-site survey by presence of an anesthetic nurse (Arbous et al., 2005).
620 UNIT 5 Nursing Management of the Surgical Patient

Nurses patient general surgical unit. Once in the preoperative area, the
The perioperative nurse’s primary role in the operating room patient is normally anxious and stressed and assumes a passive
(OR) is that of the circulating nurse. Most states have taken legisla- role as the recipient of technical care. The perioperative nurse
tive measures in order to ensure the presence of a registered nurse performs the preoperative assessment of patients in the holding
in the circulator role in the OR for every surgical procedure. The area. The responsibilities of the perioperative nurse in this set-
circulating nurse’s duties are performed outside the sterile field ting are to verify the appropriate data have been obtained, assess
and encompass responsibilities of nursing care management the patient for readiness both physically and emotionally, and
within the OR. The circulating nurse observes the surgical team reinforce teaching as needed. This information is the basis for
from a broad perspective and assists the team to create and main- planning the patient’s individualized perioperative care.
tain a safe, comfortable environment for surgery. The circulating The use of the nursing process emphasizes a patient-centered
nurse communicates patient care needs to each member of the approach; health promotion in the perioperative arena has be-
surgical team, facilitating a united effort while being the patient come more evident as perioperative nurses have gained great
advocate whose actions are dedicated to ensuring that the patient’s satisfaction from knowing that they are part of a team commit-
rights and wishes are respected and carried out. ted to an individual patient with an individualized outcome. As
The scrub nurse works directly with the surgeon within the illustrated through the PNDS (p. 624), this framework enables
sterile field passing instruments, sponges, and other items perioperative nurses to shift from a task-oriented role to that of
needed during the surgical procedure. The sterile field is the area providing a holistic view of the patient. Therefore, even if the
closely surrounding the OR table. Surgical team members who nurse’s main role is still to ensure patient safety throughout a pa-
work within the sterile field perform a surgical scrub of their tient’s surgical experience, the nurse is now able to demonstrate
hands and arms with special disinfecting solution and, in addi- the caring aspect of perioperative nursing by participating in a
tion to the regular surgical attire, don a sterile gown and gloves. preoperative assessment of the patient.
This role can also be performed by other personnel than an RN,
in which case the person is then called a scrub technician. Other
roles for RNs are team leader, assistant head nurse, head nurse or
Surgical Areas
nurse manager, nurse educator, and clinical nurse specialist. Patients needing surgery go to the operating room for a surgical
As with any specialty, the perioperative nursing assessment is procedure after having been admitted to the hospital on the same
the first step in providing individualized care for perioperative day as surgery, unless an extensive work-up or in-hospital treat-
patients. The nursing process serves as a guide to make perioper- ments or tests are required prior to surgery. Patients also access the
ative nursing assessments comprehensive and holistic in nature. operating room emergently through the emergency department.
The focus is aimed at promoting and maintaining wellness as The practice of same-day admission has become popular for both
well as identifying and preventing illness (Hurley & McAleavy, financial reasons and because evidence suggests that surgical-site
2006). These assessments provide valuable information to the infection rates are reduced when the preoperative stay is reduced
entire perioperative team. The nursing care plans that are devel- (Nichols, 2001).
oped based on the assessment data are utilized to ensure conti- Prior to being admitted to the surgical setting, the patient dons
nuity of care during each phase of the individual’s perioperative a gown and cap. Surgical-site skin preparation includes a baseline
experience. The assessment provides a baseline against which in- assessment, cleaning of the surgical site and surrounding area,
formation about the individual’s stability can be measured and hair removal, and application of an antiseptic agent when re-
monitored at any stage of her perioperative experience. quired. Traditionally hair removal was extensive and often per-
formed the day prior to surgery. Research studies have revealed
Perioperative Nursing Education that hair removal does not reduce the incidence of surgical-site
Given that most nursing programs offer limited or no operating infections (SSIs). In fact, today, hair removal is instead performed
room experience in their curricula, nurses initiating a career in to improve access to surgical site, improve the field of view, or per
the OR get their perioperative education either at the hiring in- the institution’s policy or surgeon’s preference (Evidence-based
stitution or by enrolling in a postgraduate or fellowship periop- practice information sheets, 2003; Niel-Weise, Willie, & van den
erative program. It is estimated that a minimum of 3 to 6 Broek, 2005). Should hair removal be indicated, care needs to be
months of instruction is required to adequately educate nurses taken to maintain skin integrity and minimize injury. The re-
with no previous OR experience depending on the OR’s activi- moval is ideally done outside of the surgical suite as close to the
ties (AORN, 2007a). Programs may include the surgical envi- surgery time as possible (AORN, 2007b). There is some evidence
ronment, aseptic technique, perioperative assessment, that use of hair clippers is superior to use of a razor, but more re-
anesthesia, positioning the surgical patient, sterilization and dis- search is needed (Niel-Weise et al., 2005).
infection, surgical instruments, safety considerations, patient
teaching, teamwork, scrubbing and circulating, and wound Presurgical or Preoperative Holding Area
healing and hemostasis (AORN, 2007a). In addition to didactic
The surgical area typically has a presurgical or preoperative
modules, nurses are often instructed through a cognitive ap-
holding area next to the operating rooms. The preoperative
prenticeship model in the OR in which they take on increasingly
holding area is a semirestricted area usually just inside of the sur-
complex responsibilities over time.
gical area. This area provides a quiet, calm transition area for the
Health Promotion patient to wait immediately before surgery. It provides a shield
Patient teaching for the intraoperative patient is usually done in from the sights and sounds of the busy surgical suite and allows
a preadmission testing clinic or the day before the surgery in a personnel to interview the patient and verify the documenta-
CHAPTER 26 Intraoperative Nursing 621

tion. Equipment should be readily available in the preoperative attire that was donned in the surgery dressing room. This attire,
holding area for patient care and monitoring. This includes oxy- commonly referred to as “scrubs,” includes a shirt, trousers, cap,
gen, suction, electrocardiogram machine, pulse oximetry, and a shoe covers, and mask. Those directly involved in the surgical
blood pressure cuff; an emergency medical cart and defibrillator procedure will have scrubbed and will be wearing sterile gowns.
should be nearby (Bailey, McVey, & Pevreal, 2005; Sullivan, 2000). Surgical hand preparation, previously known as a “surgical
In the holding area, the nurse must verify that all the relevant scrub,” is performed prior to participating in a surgical procedure
documents and studies (films, scans, etc.) are available prior to in order to reduce the potential risk of SSI by reducing the num-
the start of the procedure, that they have been reviewed and are ber of microorganisms on intact skin of the hands and forearms.
consistent with each other, and with the patient involved. Team Hand preparation considerations include use of a broad-
consensus about the intended patient, procedure, and site and as spectrum, fast-acting, nonirritating, FDA-approved antiseptic
applicable implant is also needed. This verification should occur agent. Traditional scrub techniques with prolonged use of deter-
before the patient leaves the preoperative area and enters the gent, water, and brushes have contributed to the deterioration of
procedure/surgical room. skin, sometimes leading to undesirable changes of hand skin
When the operating room suite is ready to receive the patient, flora and colonization. Additionally, surgical facilities are exam-
the patient is asked to empty the bladder to prevent incontinence ining ways to improve the use of physical resources and health
or overdistention because an overly full bladder can hinder access care professionals’ time. Compared to the traditional surgical
to the surgical site and predispose the patient to inadvertent sur- scrub, waterless hand preparation boasts a reduction in micro-
gical bladder injury. Urinary catheterization is performed in the bial counts of hands, improved skin health, and reduced use of
OR as necessary (Iorio et al., 2005). The nurse accompanies the time and resources (Larson et al., 2001). Below is a list of recom-
patient to the operating room where the patient will be placed on mended surgical hand preparation practices (AORN, 2007b),
the operating table and prepared for surgery. and Chart 26–1 (p. 622) highlights the differences between a sur-
gical scrub and hand rub preparation method:
Preoperative Operating Room Checklist
The preoperative checklist is a tool for continuing the patient as- • Do not wear artificial nails.
sessment. On it, allergies are documented as per facility policy. • Keep skin free from open lesions and breaks.
Accurate documentation of height and weight is important for • Remove all jewelry from hands and forearms before per-
proper dosage calculation of the anesthetic agents. The periop- forming hand hygiene.
erative nurse ensures that the results of all laboratory, radi-
• Use only lotions that are approved by infection control staff;
ographic, and diagnostic tests are on the patient’s chart.
lotions must be compatible with the hand antiseptic and
Any abnormal results are documented and reported to the
gloves, and be stored in disposable, hands-free dispensers.
surgical team as well as any special needs, concerns, or instruc-
tions especially with regard to cultural or spiritual beliefs, phys- • Use a standardized hand scrub procedure that follows man-
ical impairments or limitations, and psychosocial conditions. ufacturer’s written guidelines and is approved by the health
For example, advise the surgical team whether the patient is a care facility.
member of Jehovah’s Witnesses and does not accept blood prod- Due to the rapid growth of surgical technologies and innova-
ucts or whether the patient is hard of hearing and does not have tion during the past decade, many operating rooms have been
his hearing aid (Hurley & McAleavy, 2006). Showing respect for renovated or reconstructed. This has been done in part to ad-
patients’ spiritual beliefs, psychosocial conditions, and physical dress the abundance of equipment needed in today’s operating
limitations facilitates rapport and trust that enable nurses to un- rooms as well as ergonomic issues. Recent trends in surgery in-
derstand the important role these factors play in how people clude the move toward less invasive techniques with shorter hos-
cope with fear and anxiety related to their perceived periopera- pital stays and faster recovery periods. One of the newest trends
tive experience. promising to transform surgery is the intelligent OR. The intel-
The perioperative nurse also notes the medical diagnosis, ligent OR incorporates advanced robotic surgical systems. A
previous surgical experience, patient’s physical appearance, speech recognition robot allows the surgeon to control the op-
visual skin assessment, medical devices accompanying the pa- erating bed, lighting, video displays, and other devices with sim-
tient or indwelling medical devices, and any prostheses, jewelry, ple voice commands. A robotic endoscopic camera facilitates
dentures, and/or capped teeth. The nurse also ensures that pre- optimal views of the surgical field, and the robotic surgical assis-
scribed preoperative medications have been taken by the patient tant enables the surgeon to control precise technical movements
and any medications that have been ordered to be given just of a robotic arm from a console station. Robotic systems are cur-
prior to surgery such as antibiotics are documented on the chart rently in use for certain cardiac procedures with plans for expan-
accompanying the patient. The NPO status of the patient is also sion on the horizon. Surgical robots make it likely that future
confirmed by the nurse to assess any potential risk of aspiration. surgeries could be performed at one facility with the surgeon
All relevant information is communicated to the surgical team. operating the console from a distant facility. One of the nurse’s
roles in robotic surgery is to assist the surgeon at the patient’s
Operating Room side during the operation.
Surgery may involve the removal, repair, drainage, replacement, In addition digital information is becoming the standard
or exploration of body tissue or organs. The operating room or format for accessing patient information and images, for com-
suite is where the surgery will be performed. This room is a municating with other areas of the hospital or consultants, and
restricted area where the team of health care professionals wears for conferring with other health care providers. The operating
622 UNIT 5 Nursing Management of the Surgical Patient

CHART 26–1 Traditional and Waterless Surgical Hand Preparation

Traditional Surgical Hand Preparation Waterless Surgical Hand Preparation


1. Wash hands with soap and water. 1. Wash hands with soap and water.
2. Use a disposable nail cleaner to clean nail beds under running water. 2. Use a disposable nail cleaner to clean nail beds under running water.
Discard nail cleaner after use. Discard nail cleaner after use.
3. Rinse. Wash hands, then forearms, using antimicrobial-impregnated 3. Rinse and thoroughly dry hands and arms. Apply alcohol-based
sponge. Use the counted stroke technique or the recommended surgical hand scrub product according to manufacturer’s instructions.
amount of time according to the manufacturer’s instructions. 4. Proceed to operating room.
4. Rinse.
Note: Step 2 is performed for the first scrub of the day or as required. Hand preparation time
5. Proceed to operating room. for step 3 generally requires 2 minutes.
Note: Step 2 is performed for the first scrub of the day or as required.
Scrub time for step 3 may vary according to product instructions from
3 to 5 minutes.

room requires convenient real-time access to these digital data successful adoption. The ultimate goal of surgical technology
and a way to manage the digital information acquired within adoption is to enhance patient care and improve patient out-
the operating room. OR design may be categorized into three comes.
major areas: physical, information and communication sys- Surgical table setup is specific to the procedure, facility, and
tems, and management. surgeon preference. Scrub tables are often standardized in order
To accommodate an optimal workflow and facilitate obser- to facilitate efficiency and changeover of staff. Instruments vary
vation of aseptic technique, certain physical considerations need according to specialty and type of procedure. Figure 26–3 䊏 dis-
to be taken into account, including the dimensions of the OR plays the contrast between traditional open surgery and endo-
suite, positions of exits and entrances, and location of support scopic instrumentation.
services. In addition, integration systems are available that per- Other perioperative nursing responsibilities include ensuring
mit the control of medical devices, lighting, and the OR bed; ac- proper instrument functionality intraoperatively through clean-
cess to images; and the routing of all this digital information to ing and inspection. Inadvertent patient injury may occur due to an
any particular monitor for display or to one or more recording instrument malfunction, resulting in an undesirable effect such as
devices for archiving, or to pathologists or radiologists via tele- tearing tissue, loss of small parts inside the patient, or improper re-
conferencing links. Control can be maintained from the surgical processing leaving a residue of bioburden that can result in post-
field by touch-screen or voice control interfaces, or from a nurs- operative complications. The use of protocols, checklists, and
ing station (Figure 26–2 䊏). detailed documentation of OR equipment is associated with a sig-
Intentional OR design considers the logistics of flow, main- nificant decrease in perioperative patient injury (Arbous et al.,
tains versatility, optimizes the use of resources, promotes com- 2005). The majority of surgical instruments are composed of
munication, synchronizes services, and adopts technological high-grade stainless steel, although advances in surgery such as ro-
advances while including all stakeholders in order to promote botics and minimally invasive surgery (MIS) have resulted in in-

SDA Unit DS

Holding Area

Operating room
suite (a)

Post Anesthesia
Care Unit

(b)
FIGURE 26–2 䊏 Layout of a typical surgical unit. (Note: SDA=Same
day surgery, DS=day surgery) FIGURE 26–3 䊏 Surgical instruments : (A) traditional versus (B) endoscopic.
CHAPTER 26 Intraoperative Nursing 623

novative discoveries of surgical materials and instruments. Surgi- concerns included performing surgery on larger patients and the
cal instruments are costly and require proper maintenance and spreading of cancer cells intraoperatively. The latter concerns have
care in order to preserve their longevity. been overcome through advances in equipment and instrumenta-
tion and adaptive surgical techniques that have enabled the use of
Patient Preparation laparoscopic gastric bypass surgery for bariatric patients. Study re-
ports confirm MIS to be oncologically safe (Bonjer et al., 2007).
Once they enter the surgical suite, patients are cared for by the
The laparoscopic cholecystectomy will be used to illustrate the dif-
anesthetist, surgeons, and nurses. Members of the team ask the
ferences between MIS and open surgery. Open surgery involves an
patient questions, apply electrocardiogram (ECG) leads, remove
incision under the rib cage on the right side of approximately 15
arms from gown, and so forth. Every effort should be made to
to 38 cm (6 to 15 in.) in order to allow surgeons access with their
limit activity with the patient until she has received a general
hands to perform surgery.
anesthetic or been given a relaxant if warranted. For example, a
Laparoscopic removal of the gallbladder involves several small
patient should have the bladder catheterized following the gen-
incisions, usually four, that are one-quarter to one-half inch in
eral anesthetic whenever possible. Also, patients should be kept
size. Trocars or ports (tubes with valves) are then inserted through
informed on an ongoing basis. This will prevent and limit anxi-
these small incisions in order to provide imaging through a tele-
eties created by the already stressful surgical experience. If re-
scope attached to a camera for viewing on a monitor while other
gional anesthesia is being used, the patient will remain awake;
ports are accessed for instruments used to perform the surgery. To
therefore, a screen is placed in front of the patient’s face. Seda-
provide space to view and perform surgery, the abdomen is in-
tives, hypnotics, or tranquilizers are administered in order to de-
flated with gas (usually carbon dioxide). Carbon dioxide is used
crease feelings of anxiety and provide sedation.
because it is readily accessible, inexpensive, does not support
The perioperative nurse greets the patient on arrival by first
combustion when using surgical energy sources, and is easily ab-
asking the patient his name and checks this with the patient’s
sorbed and excreted by the body through the circulatory and res-
identification bracelet, chart, and hospital card using at least two
piratory system. In addition, the smaller incisions available with
identifiers, for example, name and date of birth. The nurse re-
MIS require the use of finer instruments as shown in Figure
views the patient’s chart, the medical record, and preoperative
26–3b 䊏 (p. 622) resulting in less surgical trauma and immuno-
checklist, and ensures that the consent is signed and that all doc-
suppression than open surgery (Boo et al., 2007).
umentation, preoperative procedures, and orders have been
Advantages of a laparoscopic surgery over open surgery in-
completed. The nurse conducts the preanesthetic assessment by
clude less scarring, quicker recovery, shorter hospitalization,
looking at the patient from a holistic viewpoint. This means rec-
faster return to normal activities (work), fewer problems with
ognizing the individual person as a dynamic entity made up of
incisions, less pain, and less use of opioids, which reduces the
components that are continuously interacting with one another.
negative secondary effects associated with opioid use. Often pa-
The perioperative nursing assessment is the first step in provid-
tients undergoing laparoscopic surgery will be discharged the
ing individualized care to the perioperative patient. To harmo-
same day as surgery, whereas open surgery procedures can re-
nize care in all perioperative settings, the Perioperative Nursing
quire 3 to 5 days of hospitalization. The intraoperative cost of
Data Set vocabulary can be used as part of the data collection
MIS surgery is often more, but is offset by the reduced hospital
tool (Chart 26–2, p. 624). The PNDS describes the practice of
stay and quicker recovery (Noblett & Horgan, 2007).
perioperative nursing practice in four domains: safety, physio-
logical responses, behavioral responses, and health care systems. Many patients complain of discomfort similar to muscle ache
The first three domains reflect phenomena of concern to peri- in the shoulder area following laparoscopic surgery. This is a
operative nurses and are composed of nursing diagnoses, inter- referred pain and is due to the distention of the diaphragm,
ventions, and outcomes that surgical patients and their families which results from the insufflation of the abdomen with gas
that is required for laparoscopic procedures. The discomfort usually
experience. The fourth domain, the health care system, com-
subsides within 24 to 48 hours postoperatively.
prises structural data elements and focuses on clinical processes
and outcomes. The model is used to depict the relationship of
The Future of Surgery: Natural Orifice
nursing process components to the achievement of optimal pa-
Translumenal Endoscopic Surgery
tient outcomes (AORN, 2002).
Natural Orifice Translumenal Endoscopic Surgery (NOTES) is the
Comprehensively written nursing care plans have been
exploration of methods to perform surgery through any of the
specifically adapted to the perioperative environment as clinical
body’s natural orifices (e.g., oral, rectal, urethral, vaginal). NOTES
pathways. Because of the fast-paced environment of the OR, pa-
attempts to further minimize the effects of surgery through a to-
tients’ short lengths of stay, and the many routines, some proce-
tally noninvasive technique.
dures and protocols can be documented on a flow sheet.

Surgical Approaches Anesthesia


Minimally invasive surgery became widespread when the laparo- Advances in anesthesia, such as improvements in airway devices,
scopic cholecystectomy became a standard of surgical care in the use of quickly reversible inhalation agents, and selection of
early 1990s. Initial reservations included the limitations of equip- short-acting anesthetic agents, have improved patient outcomes
ment, introduction of new instruments, and the ability of sur- (Arbous et al., 2005; Tarrac, 2006). Anesthesia needs to accom-
geons to adapt and acquire these new surgical skills. Other plish several things. It must produce sleep (hypnosis), lack of
624 UNIT 5 Nursing Management of the Surgical Patient

CHART 26–2 Perioperative Nursing Data Set

Code Diagnosis/Intervention/Outcome Yes No Comments


X29 Diagnosis: Risk of Injury related to transfer and transport
I26 Intervention: Confirms identity before the operative or invasive procedure.
I126 Intervention: Verifies operative procedure.
I60 Intervention: Identifies baseline tissue perfusion.
I65 Intervention: Identifies physiological barriers to communication.
I66 Intervention: Identifies physiological status.
I59 Intervention: Identifies baseline cardiac function.
I64 Intervention: Identifies physical alterations that may affect procedure-specific positioning.
Outcomes: Verbalizes comfort related to transfer/transport.
X4 Diagnosis: Risk for Anxiety related to knowledge deficit and stress of surgery
I13 Intervention: Assesses coping mechanisms based on psychological status.
I27 Intervention: Provides continuity of care.
I30 Intervention: Develops individualized plan of care.
I57 Intervention: Identifies and reports philosophical, cultural, and spiritual beliefs and values.
I85 Intervention: Minimizes the length of invasive procedure by planning care.
I101 Intervention: Provides care to each individual in a manner that preserves and protects the patient’s autonomy,
dignity, and human rights.
I106 Intervention: Provides instruction based on age and identified need.
I56 Intervention: Explains expected sequence of events.
I50 Intervention: Evaluates response to instructions.
Outcomes: Verbalizes/indicates decreased anxiety, ability to cope, understanding of procedure and sequence of
events. Questions answered.
X38 Diagnosis: Risk for Acute/Chronic Pain
I24 Intervention: Collaborates in initiating patient-controlled analgesia.
I51 Intervention: Evaluates response to medication.
I61 Intervention: Identifies cultural and value components related to pain.
I69 Intervention: Implements alternative methods of pain control.
I71 Intervention: Implements pain guidelines.
I108 Intervention: Provides pain management instructions.
I16 Intervention: Assesses pain control.
I54 Intervention: Evaluates response to pain management interventions.
Outcome: Demonstrates adequate pain management.
X28 Diagnosis: Risk for Infection
I3 Intervention: Administers care to invasive device sites.
I21 Intervention: Assesses susceptibility for infections.
I22 Intervention: Classifies surgical wound.
I94 Intervention: Performs skin preparation.
I31 Intervention: Dresses wound at completion of procedure.
Outcomes: Patient’s surgery performed using aseptic technique and in a manner to prevent cross contamination.
X29 Diagnosis: Risk for Injury
I11 Intervention: Applies safety devices.
I39 Intervention: Evaluates for signs and symptoms of injury to skin and tissue.
I72 Intervention: Implements protective measures to prevent injury due to electrical sources.
I73 Intervention: Implements protective measures to prevent injury due to laser sources.
I77 Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical sources.
I93 Intervention: Performs required counts.
I84 Intervention: Manages specimen handling and disposition.
I112 Intervention: Records devices implanted during the operative or invasive procedure.
Outcome: Patient is free from signs and symptoms of physical injury.
X40 Diagnosis: Risk for Injury: Positioning
I38 Intervention: Applies safety devices.
I39 Intervention: Evaluates for signs and symptoms of injury to skin and tissue.
I77 Intervention: Implements protective measures to prevent skin/tissue injury due to mechanical devices.
Outcome: Patient is free from signs and symptoms of physical injury.
CHAPTER 26 Intraoperative Nursing 625

CHART 26–2 Perioperative Nursing Data Set—Continued

Code Diagnosis/Intervention/Outcome Yes No Comments


X30 Diagnosis: Deficient Knowledge
I19 Intervention: Assesses readiness to learn based on physiological status.
I20 Intervention: Assesses readiness to learn based on psychological status.
I79 Intervention: Includes family and support persons in the preoperative teaching.
I103 Intervention: Provides information and explains Patient Self-Determination Act.
I67 Intervention: Identifies psychological barriers to communication.
I63 Intervention: Identifies individual values and wishes concerning care.
I30 Intervention: Develops individualized plan of care.
I104 Intervention: Provides instruction about prescribed medications.
I105 Intervention: Provides instruction about wound healing and wound care.
Outcome: Patient demonstrates knowledge of the physiological responses to the operative or other invasive
procedure.
Association of periOperative Registered Nurses. (2002). PNDS Resources. AORN. Retrieved June 29, 2008 from http://www.aorn.org/PracticeResources/PNDSAndStandardizedPerioperativeRecord/
PNDSResources/.

awareness and recall (amnesia), freedom from pain (analgesia), Nonbarbiturate drugs that depress the CNS may also be used
and muscle relaxation. A variety of anesthetic agents can pro- to induce anesthesia. Etomidate (Amidate) produces rapid hyp-
duce these effects. The anesthesia care provider considers the pa- nosis but with less effect on the respiratory and cardiovascular
tient and selects the agent or a combination of agents that will systems than the barbiturate drugs. This makes it an attractive al-
produce the best anesthesia with the fewest negative effects for ternative for use with high-risk patients. Etomidate suppresses
the patient. cortisol secretion causing hypotension. These effects are not sig-
nificant in short procedures but can be an issue in longer surger-
Inhalation Agents
ies. Etomidate is used primarily in short procedures. Ketamine
Inhalation agents are frequently used for anesthesia because
hydrochloride (Ketalar) is a fast-acting CNS depressant that
they are fast acting and easily controlled. Anesthetic agents pass
causes profound anesthesia but little skeletal muscle relaxation. It
through a vaporizer and are mixed with oxygen. The patient in-
is associated with a difficult emergence phase that is characterized
hales the vapors into the lungs. The gas crosses the alveolar
by hallucinations and disassociative feelings (feeling separate
membrane, dissolves in the blood, and is carried to body tissues
from the environment). The patient who is recovering from keta-
via circulation where it attaches to receptor sites on the cells to
mine will do better in a quiet, supportive environment. Propofol
produce its effects, primarily depression of the central nervous
(Diprivan) is a rapid-acting hypnotic that causes minimal excita-
system (CNS). Frequently, a mixture of gases is used to maintain
tion effects during induction. Risk of the patient’s vomiting or
anesthesia.
thrashing during induction is reduced. A test dose is initially given
A number of theories have been proposed to explain how in-
to test for allergy. Propofol is metabolized rapidly so it does not
haled anesthetic agents work, but no single theory explains the
accumulate in the blood when used to maintain anesthesia.
various effects seen with these agents (Hoffer, 1999). The effects of
Patients emerge from propofol quite quickly during the recovery
anesthesia diminish as the gas is washed out of the lungs with
period.
100% oxygen and the remainder is metabolized by the liver. The
Other IV medications used in anesthesia include benzodi-
Pharmacology Summary box (p. 626) lists the advantages, the side
azepines and opioid analgesics. Examples of benzodiazepines
effects, and implications of commonly used anesthetic gases.
include midazolam (Versed), lorazepam (Ativan), and di-
Intravenous Agents azepam (Valium). The benzodiazepines are antianxiety agents
A variety of intravenous (IV) agents are used to induce and that also have hypnotic, sedative, and muscle relaxant effects.
maintain anesthesia. The Pharmacology Summary box (p. 627) Midazolam is sometimes used to induce anesthesia but these
lists common intravenous medications used for anesthesia or as drugs are more commonly used as premedication to reduce the
adjuncts to anesthesia. Induction of anesthesia may be accom- patient’s anxiety because they have an amnesic effect. Benzodi-
plished with the administration of a sedative hypnotic or anxi- azepines are used in combination with other drugs to produce
olytic drug. Common drugs include barbiturates such as conscious sedation or as adjuncts to regional anesthesia to
thiopental sodium (Pentothal) and sodium methohexital produce sedation and muscle relaxation. Opioids are used in
(Brevital). These drugs cause rapid, short-acting depression of anesthesia for their analgesic effect. Common medications in-
the CNS (sedative hypnotic), but they have limited analgesic ef- clude morphine sulfate, fentanyl citrate (Sublimaze), sufen-
fects. A smaller test dose is initially given to make sure the patient tanil, and alfentanil. Fentanyl is more potent than morphine
tolerates the mediation without reaction. These drugs quickly and is the most commonly used analgesic in anesthesia. The
(within seconds) produce sedation and unconsciousness. Both opioid analgesics have good cardiovascular stability but cause
drugs can cause respiratory and cardiovascular depression. respiratory depression.
626 UNIT 5 Nursing Management of the Surgical Patient

PHARMACOLOGY Summary of Anesthetic Gases Used During Surgery


Agent Action and Advantages Disadvantages and Side Effects Nursing Responsibility
Desflurane (Suprane) Maintenance of anesthesia. Very Must be heated to vaporize. Monitor for hypotension.
rapid emergence. Causes increase in heart rate and
Good degree of muscle relaxation. decrease in blood pressure.
Has a strong odor precluding its use
for induction of anesthesia. May
cause coughing if used for induction.
Enflurane (Ethrane) Maintenance of anesthesia. May lower the threshold for seizures. Monitor for hypotension.
Good degree of muscle relaxation. Increases heart rate and decreases Contraindicated in patients with
blood pressure. seizure disorders.
Halothane Maintenance of anesthesia. Rapid Fair degree of muscle relaxation. Can cause hypotension. Monitor for
(Fluothane) induction and emergence but less Increases heart rate and triggers premature ventricular contractions,
than that of isoflurane. arrhythmias. ventricular tachycardia, and ventricular
Low incidence of postoperative Requires a higher degree of liver fibrillation with use of epinephrine.
nausea and vomiting. metabolization than other agents. Provide warm blankets during recovery
Causes postoperative shivering. period.
Isoflurane (Forane) Induction and maintenance of Causes increase in heart rate and Monitor for hypotension.
anesthesia. Faster induction and hypotension. Hypotension can be
recovery than enflurane or unpredictable and severe if
halothane. concomitant use of antihypertensive
Minimal metabolization by the liver. agents.
Weak stimulation of secretions.
Nitrous oxide Rapid induction and recovery of Does not produce muscle relaxation.
anesthesia.
When used with other inhalants, it
reduces the concentration of other
agent.
Sevoflurane (Ultane) Induction and maintenance of
anesthesia. Very rapid induction and
recovery (3–4 minutes faster than
Isoflurane).
Minimal metabolization by the liver.
Sources: Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: A pathophysiological approach. Upper Saddle River, NJ: Pearson Prentice Hall; Ebert, T. J. (2004). Physiology of
the cardiovascular effects of general anesthesia in the elderly. Retrieved April 26, 2004, from the ASA Syllabus on Geriatric Anesthesiology website: http://www.asahq.org/clinical/geriatrics/phy.
htm; Hoffer, J. L. (1999). Anesthesia. In M. Meeker & J. Rothrock (Eds.), Care of the patient in surgery (pp. 203–238). Philadelphia: Mosby; Thompson, A. M. (2002). Anaesthesia. In L. Shields & H.
Werder (Eds.), Perioperative nursing (pp. 79–105). San Francisco: Greenwich Medical Media.

Muscle Relaxants the muscles. The onset of paralysis is quick with intravenous ad-
Muscle relaxants (neuromuscular blocking agents) primarily af- ministration, 30 to 60 seconds, and the effects last up to 10 min-
fect skeletal muscle and they are used in surgery to facilitate en- utes. Often succinylcholine is used for intubation because it works
dotracheal intubation and to provide optimal operating very quickly and wears off quickly, but there are disadvantages to
conditions. A rapid-acting neuromuscular blocking agent is ad- the drug. The depolarization of muscle cells causes a transient in-
ministered before intubation to paralyze the muscles of the jaw crease in serum potassium that can produce cardiac dysrhythmia.
and vocal cords making placement of the endotracheal tube eas- Muscle fasciculation (twitching) leads the patient to complain of
ier. Muscle relaxation is used throughout the surgery to facilitate muscle soreness postoperatively. Succinylcholine is known to
dissection of tissue. During surgery, the anesthesia care provider trigger malignant hyperthermia in susceptible individuals. The
monitors the effects of muscle relaxant drugs with a peripheral drug is broken down by the plasma enzyme cholinesterase. Pro-
nerve stimulator. Recovery from neuromuscular blocking agents longed paralysis occurs in individuals with insufficient amounts
after surgery is evidenced by the patient’s ability to breathe on her of cholinesterase although this condition is rare.
own and hold her head upright as well as the presence of a strong Nondepolarizing agents work by blocking the depolarizing
hand grasp. There are two types of neuromuscular blocking action of acetylcholine at the motor end plate of the neuromus-
agents, depolarizing and nondepolarizing. cular junction, thereby producing muscle paralysis. Muscle fasci-
Succinylcholine is a depolarizing agent and the only one in culations do not occur with these drugs, eliminating
clinical use. The drug has a strong affinity for acetylcholine recep- postoperative myalgia. Another advantage is that these agents
tor sites and once it attaches to the site causes continuous depo- can be antagonized or reversed with the administration of
larization of the motor end plate. Continuous muscle neostigmine, edrophonium, or pyridostigmine. Use of reversal
contractions and fasciculations are followed by flaccid paralysis of agents reduces the risk of morbidity associated with anesthesia
CHAPTER 26 Intraoperative Nursing 627

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia


Used During Surgery
Agent Action and Advantages Disadvantages and Side Effects Nursing Responsibility
Intravenous Anesthetic
Etomidate (Amidate) CNS depressant used for induction Suppresses cortisol secretion. Good anesthetic for patients with
and maintenance of anesthesia for Postoperative nausea and vomiting. asthma or cardiovascular disease.
short procedures. Hypnotic effect but May cause transient skeletal muscle Used in neurosurgery because it
no analgesia. movements. causes a slight decrease in
Fewer respiratory and cardiovascular Metabolized in the liver. intracranial pressure.
effects than other agents. Monitor cortisol levels and blood
Onset is 60 seconds with duration of pressure.
3–5 minutes.
Diazepam (Valium) Benzodiazepine with hypnotic and May cause hypotension and Monitor sedation postoperatively.
amnesiac properties. tachycardia.
Used as adjunct drug in induction of Prolonged effect.
anesthesia and as a preoperative
medication to reduce anxiety.
Ketamine (Ketalar) CNS depressant used for induction of Increases salivary secretions. Premedicate with anticholinergic
anesthesia. Does not produce muscle relaxation. agent to reduce secretions.
May supplement nitrous oxide May increase heart rate and blood Provide a quiet, calm, reassuring
anesthesia. pressure. environment for recovery.
Fewer postoperative nausea and Depresses respirations and increases Monitor heart rate and blood pressure.
vomiting than other agents. intracranial pressure. Monitor airway to prevent aspiration.
Associated with emergence reactions
including hallucinations, dissociative
feelings, and irrational behavior.
Recovery can be prolonged.
Midazolam (Versed) Benzodiazepine with hypnotic, Slower induction than with Prepare patient for amnesia.
amnesiac, anxiolytic, and muscle barbiturates. Monitor for respiratory depression.
relaxant properties. May cause hypotension and
Used for induction of general tachycardia.
anesthesia and for conscious
sedation.
Propofol (Diprivan) CSN depressant used for induction Abnormal muscle movement. Monitor blood pressure.
and maintenance of anesthesia. May cause hypotension. Cautious use in patients with allergies
Rapid onset with minimal excitation to eggs.
during induction.
Sodium methohexital Barbiturate used for induction and May cause abnormal muscle Patient should be recumbent during
(Brevitol) maintenance of anesthesia. movements, coughing, and administration.
More potent and with a shorter onset laryngospasm. Monitor blood pressure.
and quicker recovery than Hypotension occurs in some patients.
thiopental. Hiccups may persist postoperatively.
Thiopental sodium Barbiturate used for induction and Depresses respiratory and circulatory Test dose given first.
(Pentothal) maintenance of anesthesia. function.
Depresses CNS causing sedation and Can cause anaphylaxis and
hypnosis. laryngospasm.
Ultrashort acting with onset in Metabolized by the liver.
10–20 seconds and duration of
20–30 minutes.
Opioid Analgesics
Alfentanil (Alfenta) Narcotic used for induction, Causes respiratory depression. Monitor vital signs.
analgesia, and balanced anesthesia. Can cause bradycardia and Report bradycardia.
Rapid onset and short duration make hypotension.
it a good choice for short surgical Bradycardia is more likely in patients
procedures. who are taking a beta-blocking drug.
Nausea and vomiting common.
(continued)
628 UNIT 5 Nursing Management of the Surgical Patient

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia


Used During Surgery—Continued
Agent Action and Advantages Disadvantages and Side Effects Nursing Responsibility
Fentanyl Narcotic used as adjunct for induction Causes sedation and respiratory Monitor vital signs.
(Sublimaze) to anesthesia and for analgesia depression. Watch for signs of respiratory
supplement. May also cause bradycardia and depression.
The drug of choice for epidural hypotension.
analgesia.
Short acting.
Causes less nausea and vomiting
than morphine.
Morphine sulfate Narcotic used as premedication and Causes respiratory depression. Monitor vital signs.
for postoperative analgesia. Histamine release causes peripheral
Long-lasting effect. vasodilation and hypotension.
Nausea and vomiting common.
Sufentanil (Sufenta) Narcotic used for analgesic Prolonged respiratory depression. Monitor vital signs.
supplement in balanced anesthesia. Watch for signs of respiratory
More potent than fentanyl. Has a depression.
quicker onset and shorter recovery
than fentanyl.
Not associated with histamine release
so there is less hypotensive effect.
Depolarizing Muscle Relaxants
Succinylcholine Depolarizing neuroblocking agent Causes muscle fasciculations, Monitor vital signs.
with high affinity for acetylcholine bradycardia, and respiratory Maintain airway and clear secretions.
receptor sites. depression. Patient may complain of muscle
Produces muscle relaxation and May precipitate malignant soreness postoperatively.
paralysis. hyperthermia in susceptible
Used to facilitate endotracheal individuals.
intubation and to produce skeletal
muscle relaxation for short surgical
procedures.
Short-acting agent with onset in
30–60 seconds and duration of
several minutes.
Nondepolarizing Muscle Relaxants—Intermediate
Mivacurium Intermediate, nondepolarizing muscle Transient hypotension and Monitor vital signs.
(Mivacron) relaxant used for endotracheal bradycardia.
intubation and to produce relaxation Metabolized by plasma
of skeletal muscles for surgery. cholinesterase.
Effect lasts 15–20 minutes.
Vecuronium Intermediate, nondepolarizing muscle Metabolized by the liver. Monitor for delay of recovery
(Norcuron) relaxant used for endotracheal Causes respiratory depression. postoperatively.
intubation and to produce relaxation Minimal cardiovascular effects.
of skeletal muscles for surgery.
Effect lasts 20–40 minutes.
Nondepolarizing Muscle Relaxants—Long Acting
Tubocurarine Long-acting, nondepolarizing muscle Causes histamine release with Monitor blood pressure and airway
relaxant used for maintenance of hypotension. until full recovery from drug.
relaxation during surgery. Increases bronchial and salivary Observe for residual muscle
Muscle relaxant effects last 30–40 secretions. weakness.
minutes.
Metocurine Long-acting, nondepolarizing muscle Hypotension, increased salivary Monitor blood pressure and airway
(Metubine) relaxant used for maintenance of secretions, and respiratory until full recovery.
relaxation during surgery. depression. May take several hours for complete
Muscle relaxant effects last 30–90 neuromuscular recovery.
minutes.
CHAPTER 26 Intraoperative Nursing 629

PHARMACOLOGY Summary of Intravenous Anesthetic Agents and Other Adjuncts to Anesthesia


Used During Surgery—Continued
Agent Action and Advantages Disadvantages and Side Effects Nursing Responsibility

Pancuronium Long-acting, nondepolarizing muscle Tachycardia, hypertension, and Monitor vital signs.
(Pavulon) relaxant used for maintenance of premature ventricular contractions.
relaxation during surgery.
Muscle relaxant effects last 30–60
minutes.
Anticholinergics
Atropine Anticholinergic agent used to Tachycardia, hypertension, urinary Monitor heart rate and blood pressure.
decrease salivary and respiratory retention, and dry mouth. Heart rate is best indicator of
secretions, to treat bradycardia May cause cardiac arrhythmias. response to the drug.
and/or hypotension, and to reverse
muscle relaxants.
Glycopyrrolate Anticholinergic agent used to Tachycardia, urinary retention, and dry Monitor heart rate.
(Robinul) decrease salivary and respiratory mouth.
secretions and to reverse Fewer problems with cardiac
neuromuscular block. arrhythmias than atropine.

Sources: Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: A pathophysiological approach. Upper Saddle River, NJ: Pearson Prentice Hall; Ebert, T. J. (2004). Physiology of
the cardiovascular effects of general anesthesia in the elderly. Retrieved April 26, 2004, from the ASA Syllabus on Geriatric Anesthesiology website: http://www.asahq.org/clinical/geriatrics/phy.
htm; Hoffer, J. L. (1999). Anesthesia. In M. Meeker & J. Rothrock (Eds.), Care of the patient in surgery (pp. 203–238). Philadelphia: Mosby; Thompson, A. M. (2002). Anaesthesia. In L. Shields & H.
Werder (Eds.), Perioperative nursing (pp. 79–105). San Francisco: Greenwich Medical Media.

(Arbous et al., 2005). Reversal drugs cause bradycardia, which is PeriAnesthesia Nurses, 2001). Some suggest that using a forced-
treated with atropine or glycopyrrolate. Nondepolarizing agents air warming blanket for 30 minutes prior to surgery helps pre-
are divided into intermediate acting and long acting. Intermediate- vent intraoperative hypothermia and improve patient outcomes
acting agents have a quick onset, 60 seconds or less, and last 25 to (Bitner, Hilde, Hall, & Duvendack, 2007).
40 minutes. Examples of intermediate-acting nondepolarizing
Malignant Hyperthermia
agents are vecuronium, atracurium, and mivacurium. Longer
Malignant hyperthermia (MH) is a rare but life-threatening
acting nondepolarizing muscle relaxants also have a rapid onset
complication of anesthesia. The predisposition for MH is genet-
but last 45 to 60 minutes. Examples include pancuronium,
ically transmitted by an autosomal dominant trait. It is thought
metocurine, and tubocurarine.
that MH is triggered by the medications or agents used in gen-
Complications of General Anesthesia eral anesthesia with the most common being succinylcholine or
The majority of patients experience general anesthesia without one of the inhalant anesthetics. Other factors such as stress,
problems except for the complaint of a sore throat from the endo- trauma, fatigue, or muscle injury may play a role in increasing
tracheal tube. Other problems that may occur with intubation are susceptibility to the condition or in modifying the patient’s re-
damage to teeth or dental work and trauma to the vocal cords. sponse to the condition. Malignant hyperthermia occurs most
Complications that arise from general anesthesia include hypoxia, commonly during induction of anesthesia although it may pre-
hypotension, hypertension, cardiac dysrhythmia, residual muscle sent anytime during the surgery or early postoperative period.
paralysis, hypothermia, and malignant hyperthermia. Malignant hyperthermia is not well understood. With MH,
A drop in body temperature is common during surgery. calcium levels within skeletal muscle cells increase, although the
Anesthesia interferes with the physiological mechanisms of reasons for this are not known. The elevation in intracellular
thermoregulation. This effect combined with environmental calcium activates muscle rigidity and spasm and a hypermeta-
factors such as the ambient temperature in the OR, the exposure bolic state. The increase in cellular metabolism leads to an in-
of body cavities, and the administration of cold solutions (e.g., crease in carbon dioxide production (hypercarbia) and a
blood products, IV fluids) or irrigants leads to a reduction in metabolic acidosis. As the process continues, the patient be-
core body temperature. Studies show the most significant drop comes hypoxic, hyperthermic, and develops dysrhythmias and
in body temperature occurs during the first hour of anesthesia hypotension. Muscle breakdown with the release of myoglobins
(Hasankhani, Mohammadi, Moazzami, Mokhtari, & Nagh- leads to myoglobinuria and an increased risk of renal failure.
gizadh, 2007; Sessler & Todd, 2000; Wagner, 2006). Monitoring Damaged muscle cells release intracellular potassium and crea-
body temperature and using warming devices during surgery tinine phosphokinase (CPK) into the circulation.
(e.g., blankets, thermal drapes, fluid warmers) is imperative The presentation of MH is variable. Early signs are masseter
(Hasankhani et al., 2007; Wagner, 2006). Research supports the spasm (contracture of jaw), sinus tachycardia, and an increase in
use of forced-air warming blankets as the most effective method expiratory carbon dioxide levels. The anesthesia provider first
of preventing or treating hypothermia (American Society of suspects MH by the rise in the patient’s expired CO2, which is
630 UNIT 5 Nursing Management of the Surgical Patient

monitored throughout the surgery. An end-tidal carbon dioxide Regional Anesthesia


level that is two to three times normal is the earliest and most de- Regional anesthesia is a general classification of anesthesia that
finitive sign of MH (Redmond, 2001). Other signs are rigor of includes spinal and epidural anesthesia, peripheral nerve blocks,
muscles, hypoxemia evidenced by a drop in oxygen saturation, Bier blocks, and local anesthesia. The common feature of all
and tea-colored urine, indicating the presence of myoglobins. types of regional anesthesia is the local injection of a medication
Laboratory blood tests results show metabolic acidosis and in- to block the transmission of sensory impulses from that area to
creases in serum calcium, potassium, and creatinine phosphoki- the brain, thus, effectively blocking the sensation of pain. Re-
nase. Hyperthermia is a late sign and temperature elevations can gional anesthesia has some advantages over general anesthesia.
be extreme with increases of 1 to 2 degrees every few minutes. Usually, regional anesthesia does not depress respirations so the
Other late signs are cardiac dysrhythmia and hypotension. patient is at lower risk of postoperative respiratory complica-
Malignant hyperthermia can be fatal. The key to treatment is tions. This makes regional anesthesia a good choice for patients
early recognition of the syndrome, immediate discontinuation with severe cardiopulmonary disease. Patients who receive a re-
of the triggering agent, administration of dantrolene sodium to gional anesthetic usually experience less postoperative nausea
produce muscle relaxation, and providing supportive care. Fol- and vomiting.
lowing emergency treatment, the patient is monitored in the in- Regional anesthesia can be used for any number of surgeries.
tensive care unit for 24 hours or longer because a small It is commonly used for repair of inguinal hernia, transurethral
percentage of patients experience a reoccurrence of MH (Red- resection of the prostate, gynecologic procedures, and arthro-
mond, 2001). Chart 26–3 summarizes the management of the scopies and other orthopedic surgeries including repair of hip
patient with malignant hyperthermia. fractures in the elderly. Typically, patients scheduled for regional
Other Complications anesthesia are premedicated in the holding area with an antianx-
Other adverse events or complications may occur in the oper- iety agent to produce mild to moderate sedation. Opioid anal-
ating room as a result of the surgical procedure. Examples in- gesics may be administered to reduce the pain associated with the
clude such things as bleeding with excessive blood loss or insertion of needles and the administration of numbing agents.
inadvertent injury to surrounding organs or tissues. Intraoper- Spinal Anesthesia
ative complication rates depend on the surgery, the type of Spinal anesthesia, also called intrathecal anesthesia, is the injec-
anesthesia, and the patient’s physical status. In studies of com- tion of a local anesthetic into the subarachnoid space and directly
plications associated with various procedures (e.g., abdominal, into the cerebrospinal fluid (CSF). The anesthetic blocks nerve
spinal, orthopedic, and urologic), 3% to 4% of patients experi- fibers (i.e., sensory, motor, and sympathetic) at the level of the
ence intraoperative complications (Rampersaud et al., 2006; spinal cord. Spinal anesthesia effectively blocks motor and sen-
Tarrac, 2006). sory nerves so that the patient cannot move the affected area
(temporary paralysis) or feel pain, touch, temperature, or pres-
sure. The spinal needle is inserted between the 2nd and 3rd lum-
Management of the Patient bar vertebrae (L2–L3) or the 3rd and 4th vertebrae (L3–L4). For
CHART 26–3
with Malignant Hyperthermia insertion, the patient is placed in a sitting position or in a side-
• Immediately discontinue triggering agent. lying position with their head and knees flexed (i.e., fetal posi-
• Stop surgery if possible. Otherwise, deepen anesthesia with opioids, tion). A spinal needle is inserted in the intervertebral space
sedatives, nondepolarizing muscle relaxants. through the dura mater and into the subarachnoid space. Special
• Hyperventilate with 100% oxygen. spinal needles called pencil point needles enter the dura mater by
separating the fibers rather than cutting them, reducing the risk
• Administer a bolus of dantrolene sodium (Dantrium) 2 to 3 mg/kg
of a CSF leak after the needle is removed.
intravenously with additional bolus doses up to 10 mg/kg until
decreased signs of hypercarbia. Commonly, spinal anesthesia includes the administration of
local anesthetics such as lidocaine, bupivacaine (Marcaine), or
• Administer cooling devices: Apply cooling blanket, use iced normal
chloroprocaine combined with an opioid analgesic such as fen-
saline intravenously, lavage open body cavities with iced saline.
tanyl or preservative-free morphine. The medication may be
• Hydrate with intravenous normal saline.
mixed with a dextrose solution to create a hyperbaric solution
• Maintain a urine output greater than 2 mL/kg per hour. Administer (i.e., a solution that is heavier than CSF). Once a hyperbaric so-
furosemide and/or mannitol if urine output is less than goal. lution is injected into the CSF, it travels by gravity. The anesthe-
• Treat metabolic acidosis with intravenous sodium bicarbonate if it siologist may have the patient sit for a few minutes to create a
does not self-correct with treatment. block in the lower extremities or place the patient supine with
• Treat hyperkalemia with intravenous sodium bicarbonate, 10 units of the head tilted slightly downward to create a higher block. After
regular insulin with dextrose intravenously. 10 to 15 minutes, the block sets and does not extend further.
• Treat cardiac arrhythmia if it does not self-correct with treatment. Do
Epidural Anesthesia
not use calcium channel blockers.
Epidural anesthesia is the injection of a local anesthetic into the
• Continue to monitor vital signs, oxygen saturation, electrocardiogram,
epidural space. The epidural space is located adjacent to the
urine output, arterial blood gases, and blood chemistry.
dura mater and contains fat, tissue, and blood vessels. Anesthetic
• Transfer to Intensive Care Unit for postoperative care. injected into the epidural space affects nerve roots as they leave
Redman, M.C. (2007). Malignant hyperthermia: Perianesthesia recognition, treatment, and the spinal cord and some medication diffuses across the dura
care. Retrieved on July 2, 2008 from http://www.aspan.org/EdCeMalHyper.htm#head11. mater into the subarachnoid space and the CSF. The anesthetic
CHAPTER 26 Intraoperative Nursing 631

spreads in both directions (i.e., cephalad and caudad) from the thetic blocks motor, sensory, and sympathetic nerves. Fre-
site of the injection, and positioning has less effect on movement quently, epinephrine is administered with the local anesthetic.
of the medication than it does with spinal anesthesia. Epinephrine causes vasoconstriction of the area and decreases
The same medications used in spinal anesthesia are used in vascular uptake of the medication, thus prolonging the effect of
epidural anesthesia, but the concentration of the drugs is greater the local anesthetic. The duration of the block depends on the
because they must diffuse across several layers of tissue. The on- choice of anesthetic, the volume and concentration of the drug,
set of epidural anesthesia is slower than that of spinal anesthe- and the site being injected. Frequently, nerve blocks are admin-
sia. A test dose of lidocaine with epinephrine is injected to make istered by anesthesia in the holding area because they may take
sure that the needle is correctly placed in the epidural space and anywhere from 5 to 30 minutes to take effect.
not in the subarachnoid space or in a vein. If the needle is mis- A nerve block can be performed in a number of different sites.
takenly in a vein, the test dose produces transient tachycardia; if For example, an interscalene or axillary block of the brachial
it is in the subarachnoid space, it produces mild numbness. Fre- plexus is done for surgeries on the shoulder, forearm, or elbow.
quently, an epidural catheter remains in place after the opera- Surgery on the lower leg may be accomplished using a femoral or
tion to provide postoperative pain control. Caudal anesthesia is sciatic block. Peripheral nerve blocks are used alone or in combi-
the administration of a local anesthetic into the epidural space, nation with general anesthesia. When used with general anesthe-
but the approach is through the caudal canal in the sacrum sia, the amount of general anesthesia can be reduced.
rather than through the lumbar vertebrae. Complications that can occur with nerve blocks include
hematoma at the site of the block, nerve damage, and toxicity
Complications of Spinal or Epidural Anesthesia Spinal anesthesia
from systemic absorption of local anesthetic. Other, specific com-
may be complicated by the development of headache, hypoten-
plications depend on the site where the block is administered.
sion, and meningitis. Spinal headache or post–dural puncture
Peripheral nerve blocks may be performed as outpatient sur-
headache (PDPH) is a common postoperative complaint. PDPH
geries. Patients are taught that recovery of motor function occurs
is caused by the leaking of CSF through the hole in the dura (e.g.,
first followed by recovery of sensation. Note that while the area is
the puncture site). The loss of CSF causes irritation of meningeal
numb, the patient is at risk for inadvertently injuring the area.
nerves and vessels (Hyderally, 2002). Because PDPH develops or
A Bier block is a specific type of peripheral nerve block that is
worsens when the patient moves to an upright position, patients
administered intravenously, but certain techniques are used to
may be restricted to bed rest for the first 8 to 24 hours postopera-
trap the anesthetic in the local area. Bier blocks may be used for
tively to reduce the incidence of spinal headache. When headache
surgeries on an extremity, usually the arm. An IV catheter is in-
develops, it is located in the occipital area and resolves in 1 to 3
serted in the extremity at the most distal site possible. A pneumatic
days. Patients who develop a headache are treated with hydration
tourniquet is applied proximal to the surgical site and inflated
and analgesics. The patient is placed on bed rest with the head of
higher than the patient’s systolic blood pressure. When the local
the bed maintained at less than 30 degrees to reduce CSF leak.
anesthetic (lidocaine) is injected intravenously, the obstruction of
PDPH that does not resolve quickly or that produces an intolera-
blood by the tourniquet prevents it from leaving the surgical area.
ble headache may be treated with a “blood patch.” The anesthesi-
At the completion of the surgery, the tourniquet is intermittently
ologist injects 5 to 10 mL of autologous blood into the epidural
deflated so that the lidocaine enters the patient’s general circula-
space at the site of puncture to seal the leak.
tion slowly, preventing a toxic reaction to the anesthetic.
Whereas PDPH occurs postoperatively, hypotension is more
likely to occur while anesthesia is still being administered. Hy-
potension is caused by vasodilation associated with the blocking Nursing Management
of sympathetic nerves. When sympathetic nerves are blocked by The verification process consists of information gathering and ver-
anesthesia, arteries and veins lose muscle tone and the ability to ification, which begins with the determination to do the procedure
constrict. This decreases venous return from the extremities and and continues through all settings and interventions involved in
reduces cardiac output. Hypotension can occur with both spinal the preoperative preparation of the patient, up to and including
and epidural anesthesia. Hypotension is avoided with the admin- the time-out (discussed later) just before the start of the procedure.
istration of fluid volume usually normal saline. Medications with
strong alpha-adrenergic stimulation effects, such as ephedrine or Assessment
phenylephrine, are used to prevent or treat hypotension.
The nurse asks the patient to confirm the procedure to be com-
Spinal anesthesia is associated with a low risk of aseptic
pleted, the surgical site, and the surgeon. The nurse verifies this
meningitis. When it does occur, signs develop within the first 24
information with the surgical consent form, a site verification
hours after surgery (Hyderally, 2002). The patient presents with
form per organization policy, and the operating room schedule.
the typical signs of meningitis, fever, headache, nuchal rigidity,
In some cases, especially when there is a left or right side in-
and photophobia.
volved in the procedure, the correct area for surgery is marked
Peripheral Nerve Blocks on the patient. Per the AORN (2008) correct site surgery posi-
A peripheral nerve block is the injection of a local anesthetic tion statement, a comprehensive approach is needed in each
into or around a nerve plexus to produce anesthesia of a selected health care delivery system to prevent wrong site surgery. In
area. The major advantage of a nerve block is that anesthesia is 2003 AORN and the American College of Surgeons developed
confined to the area of the surgery and does not have a systemic national guidelines that are to be used with every patient having
effect. Long-acting local anesthetics used in the nerve block pro- surgery to eliminate inadvertently operating on the wrong sur-
vide extended control of pain postoperatively. The local anes- gical site (see the National Guidelines box, p. 632).
632 UNIT 5 Nursing Management of the Surgical Patient

NATIONAL GUIDELINES AORN Guidelines for Eliminating Wrong Site Surgery


The following guidelines are supported by both AORN and the American College of Surgeons.
1. Verify that the correct patient is being taken to the operating room. This verification can be made with the patient or the patient’s designated
representative if the patient is underage or unable to answer for him/herself.
2. Verify that the correct procedure is on the operating room schedule.
3. Verify with the patient or the patient’s designated representative the procedure that is expected to be performed, as well as the location of the
operation.
4. Confirm the consent form with the patient or the patient’s designated representative.
5. In the case of a bilateral organ, limb, or anatomic site (for example, hernia), the surgeon and patient should agree and the operating surgeon
should mark the site prior to giving the patient narcotics, sedation, or anesthesia.
6. If the patient is scheduled for multiple procedures that will be performed by multiple surgeons, all the items on the checklist must be verified for
each procedure that is planned to be performed.
7. Conduct a final verification process with members of the surgical team to confirm the correct patient, procedure, and surgical site.
8. Ensure that all relevant records and imaging studies are in the operating room.
9. If any verification process fails to identify the correct site, all activities should be halted until verification is accurate.
10. In the event of a life- or limb-threatening situation, not all of these steps may be followed.

Source: Carney, B. Evolution of Wrong Site Surgery Prevention Strategies. AORN, Volume 83, Issue 5, pp. 1115–1122.

Nursing Diagnoses other implants, previous anesthesia/surgery history, artificial or


The actual and potential nursing diagnoses related to surgery loose teeth, previous surgery, comorbidities, particular patient re-
include: quests, or any other information deemed crucial to intraoperative
patient care. Although this verification takes place in the same-day
1. Stress, Overload admission unit or the surgical unit, many ORs have developed a
2. Surgical Recovery Delayed presurgical checklist to ensure that all pertinent information is re-
3. Fear viewed and communicated.
4. Infection, Risk for
5. Pain, Acute. Preventing Wrong Site Surgery
When a procedure involves a left/right distinction, multiple
Planning structures (such as finger and toes), or multiple levels (such as
To provide the safest and least stressful experience for the patient, spinal procedures), the intended site must be marked so that the
planning is essential. Planning for the surgical experience typically mark will be visible after the patient has been prepped and
begins with the admission to the hospital. A comprehensive plan draped. The purpose is to identify unambiguously the intended
that organizes the care of the patient and family will facilitate the site of incision or insertion. The mark must be made using a
surgical process. The plan includes preoperative, intraoperative, marker that is sufficiently permanent to remain visible after the
and postoperative management and teaching. Communication is skin preparation. The Joint Commission (2004) recommends
as essential part of executing the plan. Each hospital has specific that the method and the type of marking should be consistent
forms that are used to guide the nurse through the process. throughout the organization and that the person doing the
Chapter 25 includes an example of a preoperative checklist. marking should be the one doing the procedure. Marking must
8

take place with the patient involved and aware.


Outcomes and Evaluation Parameters Exemptions to the marking procedure may include single-
The desired outcome for patients having surgery is that the pa- organ cases, interventional cases where the point of insertion
tient safely transitions through the entire process. Evaluation pa- is not predetermined (such as cardiac catheterization), teeth
rameters include: airway is maintained, oxygen levels are within extractions (although the involved tooth should be
normal limits, pain is managed and any postoperative complica- documented), and premature infants, for whom the mark may cause a
tions are effectively mitigated or controlled as much as possible. permanent tattoo.
As the patient’s advocate, the perioperative nurse should com-
Interventions and Rationales municate with all members of the surgical team to verify the cor-
The nurse must communicate pertinent information to the anes- rect surgical site. Individual facility policy should clearly delineate
thesia team. Information may include allergies, lab/test results, the role and responsibility of the health care provider and other
skin condition, NPO status, sensory/mobility impairments, phys- team members in marking and verifying the correct surgical site.
ical particularities, restrictions to jaw and neck range of motion, The 2006 statistics on sentinel events from the Joint Commission
history of drug use including herbal medication, anticoagulants identify wrong site surgery as the second most reported sentinel
held for number of days, implanted electronic devices (IEDs), event, accounting for 13% of reported sentinel events (Beyea,
CHAPTER 26 Intraoperative Nursing 633

2000). Although it is the surgeon’s role to diagnose a patient’s need Surgical Time-Out
for surgery and to delineate the surgical site, verifying the surgical Safety initiatives that address communication issues such as the
site at the time of surgery is the responsibility of perioperative time-out are designed to promote correct site surgery. The time-
nurses and every member of the health care team (AORN, 2008). out checklist has been adopted from the aviation industry
To this effect, the Joint Commission has issued regulations and is model and requires surgical team members to cease all other ac-
endorsing the Universal Protocol as part of the 2007 National Pa- tivities in order to actively, verbally, and mutually verify infor-
tient Safety Goals (Joint Commission, 2007). mation such as the correct patient, correct surgery, correct
site/side, correct patient position, and possibly additional infor-
The goal of the universal protocol is to prevent wrong site, mation such as prophylactic medications being administered at
wrong procedure, and wrong person surgery. The Joint
the appropriate time prior to surgery. Figure 26–4 䊏 shows a
Commission’s national guidelines to prevent wrong site
surgery are based on the consensus of experts from the
sample of a time-out checklist.
relevant clinical specialties and professional disciplines and is endorsed by Wrong site surgery may be the result of operating on the wrong
more than 40 professional medical associations and organizations. The patient or performing the wrong procedure, but most commonly
active involvement of the team and the patient or patient’s representative it is the result of operating on the wrong site/side; for example, the
and effective communication among all members of the operating room left hand is operated on instead of the right (Joint Commission,
team are important for success. 2007). Although rare, the consequences of wrong site surgery can

When marking the site


DO NOT USE:
The letter X or the word NO
Do NOT mark the Non-Operative Site
Guidelines for Implementing JCAHO Universal Protocol
To Promote Correct Site Surgery
According to AORN standards, the patient is
PREOPERATIVE VERIFICATION identified by the circulating RN when the patient
2 Patient Identifiers Must be Used (for example)* enters the OR suite. The procedure and surgical site
• Ask patient to state their full name. are validated at this time as well.
• Ask patient to state their date of birth.
• Ask patient to state their planned procedure and
document it in the patient’s own words. “TIME OUT”
• The patient’s room number is not an acceptable patient identifier: Takes place in the procedure/OR room, after the patient is
Confirm and Verify prepped and draped and it involves the ENTIRE TEAM.
• Patient’s name on their ID band, date of birth, and other
documents that correspond with the patient’s responses. All team members must verbally verify their agreement on:
• Medical record number. • The name of the patient.
• Consents. • The procedure to be performed.
• Availability of implant if required. • The site of the procedure, including laterality, implant to be used
• Availability of blood if ordered. and radiologic exams, if applicable.
• Radiologic exams (x-ray, CT scan, MRI, etc.). Validate site mark after draping or confirm ID band with the
procedure written on it if used in cases of exemption.
PATIENT RESPONSES MUST MATCH:
MARKED SITE * ID BAND * CONSENTS * RADIOLOGIC EXAMS *
DISCREPANCIES/ISSUES
Procedure does not start until patient verification & missing
SCHEDULED PROCEDURE
information is completed and agreed upon by all team members.
If a disagreement is not resolved, follow your facility policy and
In the case of pediatric patients and patients unable to verify notify your manager or administrator.
information for themselves, the RN identifies the patient’s All issues resolved are documented in the medical record.
legal guardian and verifies with them the following protocol.
DOCUMENTATION of “TIME OUT”
SITE MARK: Should indicate the following was verified:
• Use a permanent marker that is visible after skin is prepped and draped • Correct patient.
• Have operating physician/surgeon mark the site with his or her initials, • Correct site and side.
prior to patient entering the OR suite. *** • Agreement to procedure.
• Mark site(s) with patient participation (e.g., verbal confirmation or • Correct patient position.
visual pointing). • Implants and/or special equipment or special requirements available.
• Use an additional mechanism for identifying site(s) exempt from * Facility determined identifiers should be used.
marking according to facility policy and JCAHO guidelines (For ** Remove the mark at the end of procedure, especially for
example, an ID band with the procedure written on it is an alternative patients returning for subsequent procedures (e.g., trauma).
for site marking. When possible the ID band should be verified during
*** If operating physician does not mark site, an individual identified
the time out phase similar to the site mark). by facility policy with knowledge of the patient and planned
procedure to be performed may mark the site.

FIGURE 26–4 䊏 AORN guidelines for verifying the correct surgical site.
AORN. (2008). AORN position statement. Retrieved on July 2, 2008 from http://www.aorn.org/PracticeResources/AORNPositionStatements/PositionCorrectSiteSurgery/.
634 UNIT 5 Nursing Management of the Surgical Patient

AORN SAMPLE Patient Record Addressograph


(Facility Name and Address)
This record is a sample only. Clinical records should be customized to
incorporate data fields that represent the setting, facility, procedure, and patient. (Patient Information:
Reproductions and variations are encouraged, provided credit is given to AORN. name, age, gender, medical record number, date)

Structural Data:
Operating Room Progress Notes Surgeon 1: Circulating nurse 1:

Room #: ASA: Pt. in room: Anes. start:

Surgeon 2: Circulating nurse 2:

Procedure start: Procedure finish: Pt. out of room: Anes. finish:

Assistant 1: Circ. 1 relief:

Time in: Time out:


Anesthesia type:
Assistant 2: Circ. 2 relief:
General MAC Spinal Epidural
Time in: Time out:
Local block, Type: Other:
Anesthesia care provider 1: Scrub 1:

Op Dx:
Anesthesia care provider 2: Scrub 2:

Procedure(s):
Laser operator: Scrub 1 relief:

Time in: Time out:


Op Dx:
Other authorized personnel: Scrub 2 relief:

Time in: Time out:


Nursing Data Elements - Preoperative:
Preoperative checklist reviewed/evaluated Risk for anxiety related to knowledge deficit and
Risk for injury related to transfer and transport (X29): stress of surgery (X4):
ID confirmed Consent verified Site verified Psychosocial status:
Allergies verified Procedure verified Calm/relaxed Anxious Talkative
Latex allergy: Yes No NPO verified Crying Restless
Time: Other:
Alert/oriented Drowsy Sedated Provided instruction based on age and identified
Asleep Unresponsive Disoriented needs (I106).
Other: Communicated patient concerns to appropriate
members of health care team (I128).
Cool Warm Intact
Dry Moist Body jewelry removed Explained sequence of events and preoperative
Tattoos: routine (I56).
Evaluated response to instructions (I50).
Sensory impairment: No limitations Hearing
Language barrier Sight Risk for acute/chronic pain (X38, X74):
Instructed on use of pain scale
Musculoskeletal status: No limitations Paralysis Traction
Pain assessment (0-10):
Prosthetics/Assistive devices: Hearing aid Glasses Location:
AICD Outcomes:
Prosthetics:
Verbalizes/indicates decreased anxiety, ability to
cope, understanding of procedure and sequence of
Cardiopulmonary status:
events. Questions answered.
Peripheral edema: Yes Location:
Demonstrates adequate pain management.
No
Verbalizes comfort related to transfer/transport.
Transfer to suite via:
DVT/PE risk: High Med. Low
Respiratory: Tracheotomy Intubated Chest tube Stretcher W/C Bed
Regular Labored Other findings Isolette Crib

FIGURE 26–5 䊏 Sample of intraoperative nursing documentation.


CHAPTER 26 Intraoperative Nursing 635

Intraoperative Structural Data:


EKG Oximeter NIAPB Temp monitor OR medications: (other than those given by anesthesia care provider)
Implants/Prosthesis: Yes No Exp. Date: Time Medication Dosage Route Initials
Manufacturer:
Type:
Size:
Lot/Serial #:
Blood products: Yes No Blood band #: X-rays: Yes No Pathology specimens:
Unit #: Start time: Finish time: Site: Routine: Yes No
Unit #: Start time: Finish time: #:
Type:
Unit #: Start time: Finish time: Protective devices: Frozen section: Yes No
#:
Blood recovery: Yes No Unit #: Gonadal Thyroid
Cultures: Yes No
CCs reinfused: Other:
#:
Irrigation: Grafts: Yes No Comments:
Type:
Type:
Donor site:
Amount: Recipient site:

Intraoperative Nursing Data:


Risk for infection (X28): Risk for impaired skin integrity (X50):
Skin Pre-op intact Other: Position for surgery: Supine Prone Mod. lithotomy Jackknife
Surgical clippers: Lt. lateral Rt. lateral Other:
Area: Positioning devices: Chest roll Shoulder roll Axillary roll
Skin prep By: Pillow/wedge Stirrups Leg holder
Povidone-iodine Chlorhexidine
Other: Pad bony prominences: Elbows Heels Arms tucked/padded
Other:
Wound classification:
Positioned by:
1-Clean 3-Contaminated
2-Clean/contaminated 4-Dirty Risk for injury (X29):
Apply safety strap to:
Urinary catheter:
Apply grounding pad Site:
(size/type/site):
Electrosurgical unit #: Bipolar #:
OR output: Inserted by:
Setting: Coag: Cut:
Drains/tubes (size/type/site): Laser Type: Unit #: Settings: Time:
OR drainage amount: Safety measures implemented Operator:
Packing (size/type/site): Tourniquet checked & applied #: Site: Applied by:
Cast (type/site):
Inflated: Deflated: Pressure:
Dressing (type/site):
Sequential stockings: Yes No Other: Unit #:
Risk for hypothermia (X26): Counts: Sponge Needles Instruments
Apply warming blanket #: 1st count: Correct Correct Correct
Temp setting: 2nd count: Correct Correct Correct
Applied by: 3rd count: Correct Correct Correct
Unresolved Unresolved Unresolved
Warm IV fluid
N/A N/A N/A
Warm irrigation
Other: Surgeon notified of counts If counts unresolved, X-ray taken: Yes No
Signature: If no, explain:
Postprocedure Assessment/Evaluation:
Outcomes: Patient’s surgery performed using aseptic technique and in a manner to prevent cross-contamination (O10).
Skin remains smooth, intact, non-reddened, non-irritated, free of bruising (O5, O2, O8).
Core body temperature remains in expected range (O12).

be devastating and warrant improved systems that promote effec- position and accessories implemented, wound classification,
tive communication such as the time-out initiative. anesthesia classification, and monitoring devices to name a few.
Intraoperative Patient Record Protecting the Patient from Infection
Most facilities have an intraoperative patient record, like that Surgical-site infections are the third most frequently reported
shown in Figure 26–5 䊏, that is used to record intraoperative in- type of iatrogenic (hospital-acquired) infection (Engemann et
formation. In addition, perioperative nurses may chart informa- al., 2003). Preventing and minimizing associated risks of SSI are
tion in the nurse’s notes when warranted. For example, fundamental perioperative nursing diagnoses of the surgical pa-
information may include personnel involved, length of surgery, tient. According to Nichols (2001), the most critical factor in
636 UNIT 5 Nursing Management of the Surgical Patient

postoperative infection is the sound judgment and proper prac- in aseptic technique, and to correct any violation whether or not
tice of the surgical team in addition to the general health and anyone else is present or observes the violation. A surgical con-
disease state of the patient. It is for this reason that perioperative science mandates a commitment to aseptic practice at all times”
nurses have become quite expert in the areas of aseptic tech- (Spry, 2005). This allows personnel to function in a more efficient
nique and sterile conscience. Surgical aseptic practice is based and safe manner.
on the premise that most infections are caused by exogenous or- One of the strategies employed is the creation of the sterile
ganisms or organisms that are external from the body. field. The sterile field begins at the surgical site (incision), and
Asepsis is the absence of infectious organisms. In the OR asep- extends to the rest of the patient, OR table, surgical team, scrub
tic techniques are practices that minimize contamination due to table, and to a 1-foot parameter around the draped areas (Figure
microorganisms. Frequently aseptic techniques and practices 26–6 䊏). This principle is applied to application of prepping so-
are criticized for being ritualistic in nature and lacking in scien- lutions, patient draping, room setup, and so forth. It is com-
tific rigor, but until empiric evidence demonstrates a technique monly referred to as the clean to dirty principle.
is otherwise unnecessary or ineffective, basic aseptic principles Surgical attire, scrubbing, gowning, and gloving are all func-
should be observed. tions of OR aseptic technique. Figure 26–7 䊏 shows a nurse in
There are no sterilization processes that completely eliminate
all microorganisms. The best technologies to date can only limit
and reduce the presence of microbial life such as bacteria,
viruses, fungi, and spores to an acceptable sterility assurance
level. It is for this reason that nurses and surgical team members
in the OR need to continually monitor the surgical field and de-
velop strategies to minimize patient risk. An example may in-
clude inspecting sterile packaging, delivering items using proper
aseptic technique, and ensuring items have been appropriately
sterilized.
SSIs may also be predicted based on the surgical wound clas-
sification. The CDC publishes norms for SSI rates based on cer-
tain indicators, including wound classification (see the National
Guidelines box). The CDC data provide benchmarks for health
care professionals to evaluate their SSI rates so they can further
investigate the problem and implement initiatives should the
rates be unusually high.
The purpose of surgical wound classification is to track and
learn the cause of infections in order to prevent future
incidence. This information is generally recorded on the
patient’s intraoperative record.
Over time, surgical team members will in fact develop a surgi-
cal conscience. Surgical conscience is defined as “An inner com-
mitment to strictly adhere to aseptic practice, to report any break FIGURE 26–6 䊏 OR table.

NATIONAL GUIDELINES for Surgical Wound Classification


Clean wounds An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or
uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained
with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in
this category if they meet the criteria.
Clean-contaminated wounds Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled
conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina,
and oropharynx are included in this category provided no evidence of infection or major break in technique is
encountered.
Contaminated wounds Includes open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open
cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent
inflammation is encountered are included in this category.
Dirty or infected wounds Includes old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or
perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the
operative field before the operation.
Source: Devaney, L., & Rowell K. S. (2004). Improving surgical wound classification—why it matters. AORN Journal. Retrieved on July 2, 2008 from http://findarticles.com/p/articles/mi_m0FSL/
is_2_80/ai_n6159709.
CHAPTER 26 Intraoperative Nursing 637

surgical patients ranges from 4% to a high of 45% depending on


the study (Feuchtinger, Halfens, & Dassen, 2005; Price, Whitney,
& King, 2005). Researchers report conflicting data on risk factors
for the development of pressure ulcers. However, preoperative
risk factors commonly cited across studies include age (e.g., older
patients); presence of comorbidities particularly diabetes, hyper-
tension, and vascular disorders; and poor nutritional status as
measured by low serum albumin and anemia (Feuchtinger et al.,
2005; Price et al., 2005). Further research is needed to clarify in-
traoperative risk factors but those that are suggested include type
of surgery (e.g., higher risk with vascular, cardiac, thoracic, and
spinal surgery), length of operation (e.g., longer surgeries), care
taken during perioperative skin preparation to reduce unneces-
sary moisture collection under the skin, hypotensive episodes
during surgery reducing the blood available to tissues, and the
type of anesthetic used. Perioperative nurses need adequate
knowledge of anatomy and an understanding of the physiological
FIGURE 26–7 䊏 Correct surgical attire. effects of specific surgical positions. Appropriate positioning ac-
cessories and excellent communication between the anesthesia
proper OR attire and a surgical team member in scrub apparel, team monitoring physiological responses and the surgical team
highlighting important standards and principles. often requesting position changes is essential in order to prevent
patient injury.
Positioning the Patient to Prevent Injury
The primary objective of patient positioning for surgery is to
Patient positioning in the OR is chosen to accommodate surgi-
provide maximize exposure while ensuring patient safety.
cal access, staff ergonomics, and surgical view while maintaining For example, proper positioning can help maintain proper
the patient’s skin integrity. It is for this reason that OR tables are body alignment and access to intravenous and anesthesia
narrow (ergonomic for surgeon) and firm (limits movement support devices.
and allows for CPR). OR tables and accessories are designed to
accommodate a wide range of positions in order to allow for the Preventing the Retention of Foreign Objects
use of gravity to displace organs in order to provide additional Surgical counts are the responsibility of perioperative nurses and
working space, surgical access, enhanced ergonomics for profes- are performed in order to prevent patient injury due to the high
sionals, and prevent patient complications. risk of retained foreign body, which can include gauzes, needles,
Complications secondary to positioning include compro- or instruments. Retained foreign objects in patients have resulted
mised respiratory or circulatory responses, injury to nerves and in major injuries such as sepsis, bowel perforation, and death.
muscles, and the development of pressure ulcers. Chart 26–4 lists Most facilities follow a legal counting procedure based on the
common intraoperative positioning complications and potential AORN (2007b) recommended standards and practices. The de-
causes. Nurses may review patient’s intraoperative position via sired patient outcome is a patient free from injury related to ex-
the OR record and assess any relevant patient outcomes. Of these, traneous objects. It seems to be a much greater issue than
pressure ulcers have received much attention as a preventable in- reported, leading to an initiative by health care professional or-
traoperative complication. The incidence of pressure ulcers in ganizations, such as AORN, American College of Surgeons (ACS),

CHART 26–4 Intraoperative Positioning Complications

Potential Complications Secondary to Intraoperative Positioning Potential Intervention


Decreased lung expansion due to supine position resulting in Position bolsters correctly to minimize compression of thorax, facilitating full
compromised respiratory effects lung expansion.
Brachial plexus nerve injury Position arm correctly to ensure proper arm alignment of less than 90 degrees,
supinated, and adequately padded and protected.
Circulatory obstruction due to position resulting in increased risk of Apply antiembolic stockings and sequential compression leggings. Use
postoperative deep vein thrombosis appropriate prophylactic anticoagulant medication administration.
Integumentary injury resulting in pressure ulcers, abrasion, and Use OR table equipment that will minimize pressure and maximize capillary
blistering refill. Appropriate equipment includes gel mattresses. Ensure proper lifting and
securing of patient to prevent friction-related injuries.
Dislocation of acetabulum Ensure proper placement of stirrups and ensure that two health care
professionals simultaneously lift, support, and place legs onto stirrups
observing correct alignment.
638 UNIT 5 Nursing Management of the Surgical Patient

and the Joint Commission, to develop improved methods of ac- mated from their weight with 1 gram of weight being equal to
counting for surgical items. One technology that is currently be- 1 mL of blood. Blood-soaked sponges are collected in a plastic bag
ing tested is radio-frequency identification (RFID). This involves and weighed. The weight of the dry sponge(s) and plastic con-
RF tags being implanted in surgical sponges (Figure 26–8 䊏). This tainer is subtracted from the total weight to determine blood loss.
permits the surgical team to pass a wand over the patient follow- Whether or not the patient needs a transfusion during sur-
ing a procedure to verify that no sponges have been left in the pa- gery depends on blood loss as well as on other factors such as
tient (Medline, 2006). age, general level of health prior to surgery, history of cardiovas-
The presence of foreign materials in the body can lead to in- cular disease, how well the patient tolerates the blood loss, and
fection, abscess, and other serious problems. Multiple proce- the availability of autologous blood. Some religions, such as
dures are in place to prevent leaving an instrument or a sponge Christian Science and Jehovah’s Witnesses, restrict the adminis-
or other material in the patient when the wound is closed. tration of blood products.
Sponges, swabs, instruments, and sharps are counted many Adult patients who are generally healthy can tolerate surgical
times during the surgical procedure. Hospitals have written blood loss of up to 500 mL without the need for a transfusion.
policies describing what is counted, when it is counted, who Blood loss is treated with the administration of packed red blood
does the counting, where the counting is documented, and how cells. Chapter 23 provides a complete description of blood

8
to resolve a discrepancy in the count. To prevent a foreign object administration indications and procedures.
from being left behind:
Latex Allergy
• All items brought to the operating room are documented. There has been a significant increase in the number of latex aller-
• No items are removed from the operating room until the fi- gies seen in the hospital, including the operating room. Some sug-
nal count is complete and verified. gest the increase correlates with the adoption of universal
• Sponges, swabs, and other items are counted before surgery, precautions and the increased use of latex gloves. Patients are
before wound closure begins, and before skin closure begins. asked preoperatively about the possibility of latex allergy. A latex
sensitivity questionnaire can be used to identify those who have a
• The circulating nurse and scrub nurse count items in unison.
latex allergy or who are likely to develop the allergy. A high inci-
• The circulating nurse and scrub nurse document the count in dence of latex allergy is found in people with spina bifida, patients
the record. who have had multiple surgeries, those who work with latex prod-
If there is a discrepancy in the count, all personnel try to locate ucts (health care workers, dental industry workers, rubber work-
the missing item. If it cannot be found, the patient may be x-rayed. ers), and those with a genetic predisposition to allergies (atopy).
Surgical instruments can be seen by x-ray and soft materials, Patients who report allergies to kiwis, bananas, and avocados are
such as surgical sponges, have a radio-opaque stripe for x-ray also at an increased risk of latex allergies due to the cross reactiv-
identification. ity of the proteins present in these fruits and latex. Blood or skin
tests can detect latex-specific IgE antibodies and are performed
Estimating Blood Loss preoperatively when latex allergy is suspected. Latex allergy is dis-
The patient is monitored throughout the operation for blood loss. cussed in detail in Chapter 60 .
8

The calculation of blood loss is referred to as the estimation of It is virtually impossible to create a latex-free environment in
blood loss (EBL). Blood in suction containers, wound drains, the operating room—although it may be possible in the future
chest tubes, and nasogastric tubes is measured directly at frequent as more products are being manufactured without latex. For pa-
intervals during the surgery. If irrigating fluid is used, it is sub- tients with known allergy, a latex-reduced environment is cre-
tracted from the total amount of drainage to determine the ated. Elements of a latex-reduced environment in the operating
amount of actual blood loss. Blood in sponges can be approxi- room include (1) scheduling elective cases as the first cases of the

(a) (b) (c)

FIGURE 26–8 䊏 RFID technology: (A) RF tag implanted in surgical gauze; (B) wand to detect the RF tag in surgical gauze; (C) surgical RFID detection
console.
CHAPTER 26 Intraoperative Nursing 639

day to minimize contact with aerosolized allergen from latex Gerontological Considerations
gloves, (2) using vinyl gloves rather than latex gloves, (3) using
powder-free gloves to limit the aerosolization of latex antigens, Persons 65 years of age and older, require surgical interventions
(4) avoiding latex on the sterile field, (5) using a plastic anesthe- more often than younger persons because of age-related system
sia mask, (6) using a stopcock rather than the rubber port for in- changes and comorbid conditions. Degeneration of multiple
jection of intravenous drugs, (7) removing the rubber cap on systems such as the musculoskeletal, nervous, cardiovascular,
medication vials rather than drawing a medication through the respiratory, genitourinary, endocrine, and hematopoietic sys-
cap, (8) using nonlatex equipment such as blood pressure cuff, tems and hearing and vision can influence intraoperative and
stethoscope, and electrocardiogram leads, and (9) using nonla- postoperative outcomes. Changes in pharmacokinetics result
tex tape. Premedication of allergic patients with steroids or an- in changes in drug absorption, distribution, metabolism, and
tihistamines is not recommended. excretion by the body. At this stage of life, both physical and
Allergic responses to latex can range from mild cases of con- cognitive abilities may vary greatly. Appropriate age-specific
tact dermatitis evidenced by a rash and urticaria to serious cases interventions should be considered for the geriatric popula-
of anaphylaxis. When a latex allergy is suspected in the operat- tion taking into consideration both physical, cognitive, senso-
ing room, the source of latex in direct contact with the patient is rimotor, and psychosocial factors. The Gerontological
immediately removed. Follow-up treatment includes the ad- Considerations box highlights the special considerations for
ministration of 100% oxygen, intravenous fluids to support the the gerontological population.
blood pressure, and the administration of intravenous epineph- Assess the geriatric patient’s history and general health status,
rine. Diphenhydramine and steroids may also be given intra- in particular medications, previous surgeries, and comorbidi-
venously to attenuate the allergic response. ties. Promote patient warmth through warming devices and as-
sess range of motion prior to patient being anesthetized in order
to ensure correct positioning accessories are available. Addi-
Postanesthesia Care Unit tional padding may be necessary due to decreased adipose tissue
Once the surgery is completed, the anesthetist and the nurse will and circulation, predisposing the patient to the development of
accompany the patient to the postanesthesia care unit (PACU) pressure ulcers. Efforts should be made to diminish the use of
for further monitoring. Concerns along this route will focus on tapes that may lead to denuding of geriatric fragile thinner skin.
safety, infection control, medication, communication, position- Ensure adequate time is available to communicate clearly and
ing, and equipment. The PACU is where the patient will recover slowly, keeping in mind possible hearing impairment and need
from the anaesthetic he has received. This is an unrestricted area for additional processing and response time.
where the patient will no longer need to wear a head cover and Hyperglycemia is known to be associated with increased sep-
the nurses will wear regular uniforms. Visitors may be allowed sis, suggesting that careful monitoring of glucose levels may be
in certain parts of the PACU under certain circumstances. a way to reduce serious postoperative infections. Infections are
Poor communication is one of the top contributing factors a major concern for all hospitalized patients, but are especially
to medical errors. Therefore, nurses must strive to provide ef- dangerous for elderly persons. General risk factors for infection
fective and consistent information during patient handoff to a in elderly patients are known to include frailty, chronic under-
transition unit such as the PACU or Intensive Care Unit (ICU). nutrition, reduced muscle mass, and poor dentition. Other
It is important to give any pertinent information to the unit more general factors common to all age groups are diabetes, as-
members where the transfer of responsibility for the surgical piration, and the presence of an indwelling urinary catheter.
patient is occurring and provide an interactive communication Patients with postoperative cognitive dysfunction (POCD)
that is free of interruptions and includes a systematic process experience deterioration in cognitive function that persists for
of verification. Figure 26–9 䊏 (p. 640) shows a mnemonic that years after the operation. POCD may be related to brain oxy-
highlights the handoff principles and verification process. genation during anesthesia, anesthetic agents, and hospital en-
PACU is dicussed in detail in Chapter 27 . vironment (Prough, 2005).
8

GERONTOLOGICAL CONSIDERATIONS for Elderly Patients Having Surgery


Physical Factors Cognitive Factors Sensorimotor Factors Psychosocial Factors
• Decreased tolerance to heat • Decline dependent on pregeri- • Decreased visual acuity • Ego integrity important
and cold atric state and general health • Diminished hearing • Stressors: end of life, changes in
• Loss of skin tone and social involvement • Altered tactile sensation environment, increased cognitive
• Declining cardiac/renal • Decreased memory, inductive • Changes in taste and smell demands
function reasoning, and figural relations • Diminished response to • Death of loved ones
• Atrophy of reproductive may occur stress and sensory stimuli • Concerns for general health
organs • Cognitive tasks may require • Decreased mobility increase
• Increased incidence of more time to complete
preexisting health
conditions
640 UNIT 5 Nursing Management of the Surgical Patient

“I PASS THE BATON”


Handoffs and Healthcare Transitions
with opportunities to ask
QUESTIONS, CLARIFY AND CONFIRM

I Introduction Introduce yourself and your role/job (include patient)

P Patient Name, identifiers, age, sex, location

Presenting chief complaint, vital signs and symptoms


A Assessment
and diagnosis
Current status, medications, circumstances, including code
S Situation status, level of (un)certainty, recent changes, response to
treatment
Critical lab values/reports, socio-economic factors,
S SAFETY Concerns
alllergies, alerts (falls, isolation, etc.)

THE

Co-morbidities, previous episodes, past/home medications,


B Background
family history

What actions were taken or are required AND provide brief


A Actions
rationale

T Timing Level of urgency and explicit timing, prioritization of actions

Who is responsible (nurse/doctor/team)


O Ownership
including patient/family responsibilities

What will happen next? Anticipated changes? What is the


N Next
PLAN? Contingency plans?

FIGURE 26–9 䊏 Handoff protocol to improve communication when transferring a patient from the OR to another unit.
Source: Joint Commission (2008). National Patient and Safety Goals. Retrieved July 3, 2008 from http://www.jointcommission.org/NR/rdonlyres/ACA4DBF6-90FD-4400-BE7E-4C6F881E5DCD/0/
08_OBS_NPSG_Master.pdf.
CHAPTER 26 Intraoperative Nursing 641

Prevention of Infection
Clinical Problem setting nurses can use blankets and warming to maintain
Mild perioperative hypothermia, which is common during major normothermia. For maintaining normothermia in the OR policies and
surgery, may promote surgical-wound infection by triggering procedures could be implemented such as use of warming devices
thermoregulatory vasoconstriction, which decreases subcutaneous under the patient as well as the use of warm solutions. In addition the
oxygen tension. Reduced levels of oxygen in tissue impair oxidative temperature of the OR suite could be increased.
killing by neutrophils and decrease the strength of the healing wound Nurses also can coordinate the timing of preoperative antibiotic
by reducing the deposition of collagen. Hypothermia also directly administration. This will necessitate cooperation with both the
impairs immune function. surgeon and the OR staff to determine the optimal timing of antibiotic
administration.

Research Findings Critical Thinking Questions


Research was done testing the hypothesis that hypothermia both 1. What nursing interventions will decrease the risk of infection?
increases susceptibility to surgical-wound infection and lengthens
Answer:
hospitalization. Good et al. (2006) report that hypothermia itself may
a. Communication with surgical team for timing of antibiotic
delay healing and predispose patients to wound infections.
administration.
Maintaining normothermia intraoperatively is likely to decrease the
b. Institute measures to maintain normothermia throughout
incidence of infectious complications in patients undergoing colorectal
surgery & PACU.
resection and to shorten their hospitalizations.
c. Develop policies that ensure standards are used by all
Other research was done on prewarming of patients’ skin and its
members of the surgical team regarding warning
influence on core hypothermia (Cooper, 2006; Vanni et al., 2003).
procedures.
Camus et al. (1995) found that a single hour of preoperative skin
surface warming reduced the rate at which core hypothermia Answers to Critical Thinking Questions appear in Appendix F.
developed during the first hour of anesthesia.
References
Camus, Y., Delva, E., Sessler, D., & Lienhart, A. (1995). Pre-induction skin
Antibiotic Administration surface warming minimizes intraoperative core hypothermia.
Another measure to reduce infection in the operating room is proper Journal of Clinical Anesthesia, 7, 384–388.
timing for antibiotic administration. Antibiotic prophylaxis is being Cooper, S. (2006). The effect of preoperative warming on patient’s postop-
used in a variety of surgical procedures to reduce the incidence of erative temperatures. AORN Journal, 83(5) 1074–1076, 1079–1084.
surgical-site infections. Antibiotics should be chosen on the basis of Good, K. K., Verble, J. A., & Norwood, B. R. (2006). Postoperative
their effectiveness against the pathogens most likely to be hypothermia—The chilling consequences. AORN Journal, 83(5),
encountered. Skin floras (e.g., Staphylococcus organisms) are the 1055–1066.
usual target, so first-generation cephalosporins are most often Gordon, S. M. (2006). Antibiotic prophylaxis against postoperative wound
chosen. Preoperative prophylactic antibiotics should be administered infections. Cleveland Clinic Journal of Medicine, 73, S42–S45.
within 60 minutes before the initial incision is made to ensure that Olin, J. (2006). Multidisciplinary approach to optimizing antibiotic pro-
antimicrobial levels in the tissue are adequate and maintained for the phylaxis of surgical site infections. American Journal of Health-
duration of the procedure (Gordon, 2006; White & Schneider, 2007). To System Pharmacy, 63, 2312–2314.
comply with the recommendations of administration within 60 Vanni, S. M., Braz, J. R., Modolo, N. S., Amorim, R. B., & Rodrigues, G. R.
minutes of incision, the holding area was identified as the preferred (2003). Preoperative combined with intraoperative skin surface
location (Olin, 2006). warming avoids hypothermia caused by general anesthesia and sur-
gery. Journal of Clinical Anesthesia, 15(2), 119–125.
Implications for Nursing Practice White, A., & Schneider, T. (2007). Improving compliance with prophylactic
antibiotic administration guidelines. AORN Journal, 85(1), 173–180.
The latest research results have and will influence a change of practice
in the perioperative setting based on evidence. In the preoperative

NCLEX® REVIEW
1. A preoperative patient is taken into the holding area. The 2. A registered nurse first assistant is scheduled to assist a
nurse will utilize this time with the patient to do which of surgeon with a surgical procedure. This nurse will be
the following? responsible for:
1. Ensure surgical instruments are operational. 1. Administering anesthetic agents.
2. Clean and inspect surgical instruments. 2. Serving as the patient advocate.
3. Conduct an interview. 3. Providing the surgeon with instruments.
4. Insert an indwelling urinary catheter if necessary. 4. Collaborating with the surgeon and suturing the wound
closed.
642 UNIT 5 Nursing Management of the Surgical Patient

3. During the course of a surgical procedure, the patient’s heart 6. During a surgical procedure the patient begins to
rate increases and the blood pressure drops. The care demonstrate signs of malignant hyperthermia. Which of the
provider who would address these physiological changes to following should be done to support this patient?
the patient would be the: 1. Administer calcium channel blockers.
1. Surgeon. 2. Stop the surgery or deep the anesthesia.
2. Anesthesiologist. 3. Transfer to the PACU for postsurgical care.
3. RNFA. 4. Provide 21% oxygen.
4. Scrub nurse. 7. During a surgical procedure the anesthesiologist directs
4. While conducting a surgical time-out, the nurse says that the another care provider to change the oxygen mix being
site of surgery is the right knee whereas the left knee was provided to the patient. The care provider most likely to
marked as the site of the surgery. Which of the following make this oxygen change would be the:
should be done? 1. RN First Assistant.
1. Operate on the right knee. 2. Scrub nurse.
2. Operate on the left knee. 3. CRNA.
3. Ask a family member which knee is the site of surgery. 4. Respiratory therapist.
4. Stop all preparations until it can be verified which knee is the
site of surgery. Answers for review questions appear in Appendix 5

5. While an anesthetized patient is being moved to the


operating room table, the patient’s lower left leg drops and
hits the side of the table. Which of the following should the
nurse do?
1. Move the leg and place it on the table.
2. Examine the leg for possible or extent of injury and
document the event.
3. Nothing because this is considered an acceptable hazard of
surgery.
4. Elevate the leg on a pillow.

KEY TERMS
Bier block p.631 general anesthesia p.629 peripheral nerve block p.631
circulating nurse p.620 intraoperative p.620 regional anesthesia p.630
conscious sedation p.625 intrathecal anesthesia p.630 scrub nurse p.620
epidural anesthesia p.630 malignant hyperthermia (MH) p.629 spinal anesthesia p.630

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